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Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? — No

While the answer to the question in most situations is a definite “no”, the issues associated with the need to ask the question are important and troublesome. In this most scientific of ages, when orthodox medicine is committed to embracing an ever more evidence-based approach to clinical practice (and still has a long way to go), consumers of health care are increasingly exposed to a plethora of nonsense (non-science) claims that waste their money, distance them from effective care strategies and, not infrequently, cause harm. More than half the population will partake of some form of alternative or complementary therapy each year, spending more than two billion dollars to do so! Of course it is important to understand why this is so. A reporter from The New Yorker magazine contacted me a few years ago after I had discussed health care fraud in an article for Reader’s Digest. “You don’t seem to understand”, she told me, “that in this postmodern age, people are yearning for simplicity, panaceas and a little bit of magic in their lives”. This is surely a dangerous romanticism given that it is people’s health, and therefore happiness and productivity, we are discussing. Many patients have told me that “alternative practitioners” are likely to give you an hour of their time, a bit of a massage, and send you away with a cocktail of therapies from their shelves. In orthodox medicine, we rightly regard prescribing and dispensing medicines for financial gain an unacceptable conflict of interest. However, we know that enough time with a general practitioner to allow patients to vent their concerns satisfactorily is very often unavailable. Consumers, of course, are bombarded with fraudulent advertising telling them vitamins cure stress and provide energy, weight loss is guaranteed with this herbal preparation, glucosamine will take you from your wheelchair to the golf course, foot vibrators will cure your ankle oedema, and detoxification will cleanse your body of all those accumulated poisons compromising your health. The list is virtually endless. How often do we hear consumers being assured that “natural is best” when exactly the opposite is true. Significant numbers of doctors are advertising their practice of “integrative medicine”, a mixture of the best treatments available from the orthodox and alternative medical universes! I know of no scientific study exploring the motivation for such an approach, so some may believe they are offering superior care while others are, no doubt, responding to commercial opportunities to capitalise on the popularity of complementary approaches. To do so, however, is to abandon scientific medicine — which strives for evidence, rejects the “therapeutic” use of the placebo effect and addresses the psychological nature of many symptoms — for an approach that does not believe in testing, is happy to exploit the placebo effect and rejects a psychological influence on health. Pick up any copy of an alternative health care magazine and you will see doctors and nurses advertising intravenous vitamin therapies for a range of problems, and “chelation” therapy for everything from cancer to heart disease. Our profession should be worried by these trends, which see many doctors practising a form of medicine that would be rejected by most of their peers. To see how professional standards can be consumed by the attractions of less scientifically rigid approaches, one has only to look at what has happened to the scientifically trained men and woman of pharmacy, whose shelves are stacked with useless products they knowingly promote to trusting customers. The scientific study of many of alternative medicine’s claims is taking place in many universities. This is important because, of course, there is really only “good” medicine and “bad” medicine. Scientific studies that determine that an approach, supported previously only by anecdote, has evidence-based merit, should be embraced by orthodox medicine if it fills a therapeutic gap. Claims about therapies that turn out to be inaccurate when studied, would, if they are still propagated, represent bad medicine, and prescribing such therapies would be unethical. Science is the key to converging the approaches we have been discussing. However, we don’t need to wait to warn the public in the strongest terms that many alternative strategies are already known to be useless. Homoeopathy, iridology, reflexology, healing touch, and many of the claims made for acupuncture are some examples. Private insurance funds that “cover” a number of these totally unacceptable practices give them a totally undeserved imprimatur, and so do doctors who prescribe alternative and complementary procedures. In our national health scheme, Medicare dollars are precious, and it is surely unethical to ask the taxpayer to foot the bill for unproven, highly suspect or useless treatments. In this era of the endless information highway, the community should be able to depend on their doctors for education on just how people should seek out for themselves the evidence supporting proposed care plans. Doctors also need to impress on their patients the importance of divulging what alternative preparations they may be using, as severe complications from chemical interactions may occur. Finally, doctors need to avoid supporting the alternative “lastresort” approach that may be suggested by desperate patients, because the extraordinary expense, false hope and removal from skilled end-of-life care can add so much to suffering.