“They would say that, wouldn’t they?” is the quote attributed to Mandy Rice-Davies giving witness in the Profumo affair. I think, it aptly highlights some of the issues related to conflicts of interest in health care.
These days, when a researcher publishes a paper, he will in all likelihood have to disclose all conflicts of interest he might have. The aim of this exercise is to be as transparent as possible; if someone has received support from a commercial company, for example, this fact does not necessarily follow that his paper is biased, but it is important to lay open the fact so that the readers can make up their own minds.
The questionnaires that authors have to complete prior to publication of their article focus almost exclusively on financial issues. For instance, one has to disclose any sponsorship, fees, travel support or shares that one might own in a company. In conventional medicine, these matters are deemed to be the most important sources for potential conflicts of interest.
In alternative medicine, financial issues are generally thought to be far less critical; it is generally seen as an area where there is so little money that it is hardly worth bothering. Perhaps this is the reason why few journals in this field insist on declarations of conflicts of interests and few authors disclose them.
After having been a full-time researcher of alternative medicine for two decades, I have become convinced that conflicts of interest are at least as prevalent and powerful in this field as in any other area of health care. Sure, there is less money at stake, but this fact is more than compensated by non-financial issues. Quasi-evangelic convictions abound in alternative medicine and it is, I think, obvious that they can amount to significant conflicts of interest.
During their training, alternative practitioners are being taught many things which are unproven, have no basis in fact or are just plainly wrong. Eventually this schooling can create a belief system which often is adhered to regardless of the scientific evidence and which tends to be defended at all cost. As some of my readers are bound to object to this remark, I better cite an example: during their training, students of chiropractic develop a more and more firm stance against immunization which in all likelihood is due to the type of information they receive at the chiropractic college. There is no question in my mind that creeds can represent an even more powerful conflict of interest than financial matters.
Moreover, this belief is indivisibly intertwined with existential issues. In alternative medicine, there may not be huge amounts of money at stake but practitioners’ livelihoods are perceived to be at risk. If an acupuncturist, for instance, argues in favour of his therapy, he also consciously or sub-consciously is trying to protect his income.
Some might say that this not different from conventional medicine, but I disagree: if we take away one specific therapy from a doctor because it turns out to be useless or unsafe, he will be able to use another one; if we take the acupuncture needle away from an acupuncturist, we have deprived him of his livelihood.
This is why conflicts of interest in alternative medicine tend to be very acute, powerful and personal. And this is why enthusiasts of alternative medicine are incapable or unwilling to look upon any type of critical assessment of their area as anything else than an attack on their income, their beliefs, their status, their training or their person. If anyone should doubt it, I recommend studying the comments I received to previous posts of this blog.
When Mandi Rice-Davies gave evidence during the trial of Stephen Ward, the osteopath who had introduced her to influential clients, the prosecuting council noted that Lord Astor denied having had an affair with her. Mrs Rice-Davies allegedly replied “Well, he would say that, wouldn’t he?” (Actually, she did not say these exact words but something rather similar) When I read the comments following my posts on this blog, I am often reminded of this now classical quote.
When chiropractors deny that neck manipulations carry a risk, when herbalists insist that traditional herbalism is based on good evidence, when homeopaths claim that their remedies are more than placebos, I believe we should ask who, in these debates, might have a conflict of interest.
Is there a circumstance of one party in the discussion where personal interests might benefit from the argument? Who is more likely to be objective, the person whose livelihood is endangered or the independent expert who studied the subject in depth but has no axe to grind? If you ask these questions, you might conclude as I frequently do: “they would say that, wouldn’t they?”
31 Responses to They would say that, wouldn’t they?
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this post was drafted before, but it can be seen as a direct continuation of the comments to my last one. funny how alt med practitioners seem to be bending over backwards to confirm my worst suspicions.
This post is very true in regards to how medical research is conducted, and given the fact that most CAM’s revolve around the use of a single therapy the goal of their research is to find support for their technique and more often than not it shows little to no benefits. In contrast, if a particular pharmacological therapy isn’t working correctly or has too many side effects, the pharmacy constructs a derivative of the compound and tries again.
So, in Low Back Pain what would happen to Western medicine if we took away the prescription pad for low back pain citing the dangers of continuous use of NSAIDS and opioids (liver failure, kidney failure, GI bleeding, Ulcers, addiction, over dose, death, etc).? There would be a similar reaction from the MD’s out there and more so from the pharmaceutical companies as they have more to lose.
The myriad of side effects and life threatening conditions from conventional pharmaceuticals for most mild to moderate pain control dwarf those of Chiropractic manipulation in every category from incidence, severe reactions, fatal events etc. Also taking into consideration total use of each method, the apparently rampant under-reporting of adverse events from chiropractic and pharmaceutical therapy.
As a Chiropractic Physician I personally feel that Vaccination is necessary and has been a huge tool in the eradication of life threatening diseases and aid in public health. That said I believe that the current vaccination schedule is a brutal attack on the bodies of our young children. 24 vaccinations in the first 15 months of life, its alot. The blame is not on the vaccine itself but the contents used to stabilize the dead/partially dead/alive virus, from formaldehyde to aluminum (which are the most common today) and mercury or thimerosal. Thimerosal-free vaccines have been made available since 2001 but that doesn’t mean they are always used. While there is no link between Autism and vaccines, mercury poisoning and autism have very similar signs and symptoms. I have no doubt that the public health benefit of vacccination is vital to our existence in such a dense population. I just think that the schedule should be re-worked and spread out. A 40 pound child is more likely to have less adverse effects from vaccination than a 8-25 pound infant.
Reasoning for the tight schedule lies in money and frequency of care. Infants are at the doctors more often and the older they get the less likely they are to have received all their vaccinations. And if I was a Business man looking to increase profits I can sell a lot more vaccines if we can get them while they young and visit the doctor more frequently. You don’t get to be CEO out of the kindness of your heart.
historically, the chiro anti-vax movement originated from the fact that chiros rejected the germ theory of disease, and this had nothing to do with stabilizers in the vaccines etc.
So your objections to chiropractic practices are largely based on its historical practitioners and their methods. This is true about the germ theory being the basis for anti-vax in the past. We are taught differently now, it is integral to public health to vaccinate. However, many of us now fear that more Vaccines are being pushed than ever before resulting in higher exposure to the toxic substances used in vaccines. Is it for public health or pharmaceutical profits? Stock holders love dividends.
My personal stance is to vaccinate appropriately and insist on Thimerosal-free vaccines. And no fish containing mercury should be eaten during vaccine treatment. (reducing fish intake has been show to alleviate some effects of autism in children)
A personal question Edzard, do you think that the current immunization schedule is just right or would there be no benefit to letting the child develop some natural immunity first say delay vaccination to 8-12months?
i did not write that my “objections to chiropractic practices are largely based on its historical practitioners and their methods”.
but i think it is good for readers of this blog to know the origins of the chiro-anti-vax nonsense.
The phrase you claim differentiates medicine from chiropractic ” if we take away one specific therapy from a doctor because it turns out to be useless or unsafe, he will be able to use another one” is true for chiropractic as well.
Two examples of changing treatment are discontinuing the “cervical lift” adjustment as well as eliminating the c-spine extension/rotation adjustment. They were replaced with safer neck adjustments.
The variations within the realm of manipulation are vast enough, but even if we call that point moot and throw those treatments out completely (akin to saying a MD can’t prescribe “drugs”), a chiropractor’s scope of practice still allows him to use every type of treatment that would be available to a physiotherapist, including: exercise and rehab; electrical modalities; manual soft tissue treatment; and acupuncture (should one be so inclined).
Many chiropractors I know do not perform adjustments at all. In fact a reasonable percentage of my own patients receive no adjustments at all, just because it is not part of their treatment plan I have designed.
I appreciate that chiropractic has been branded as spinal adjusters, but despite this picture our profession has projected in the minds of the public, the reality is not quite so simple.
On the bright side, I think this article enlightened me to “alternative” motivations for bias, we have to be aware of these unconscious tendencies. We are human, will we ever overcome them?
Excellent post, Edzard!
I completely agree that non-financial conflicts of interest can be at least as powerful as financial ones, and I suspect often more so. And while I agree with you that this is probably something to be particularly mindful of in the world of alternative medicine, I have no doubt that powerful non-financial conflicts of interest are also frequently at work in conventional medicine too. It’s true that the scientific method may be more generally accepted in conventional medicine, but that doesn’t mean that all doctors necessarily always have rational beliefs about everything.
Are you familiar with the classic study of Mahoney in 1977? I think that’s a fascinating insight into the world of non-financial conflicts of interest. If you (or any of your readers) need reminding about Mahoney’s study, I write about it here.
yes, of course, belief and irrationality are everywhere. if one reads some of the comments to previous blogs, one gets the imression, however, that alt med are especially plagued by them.
one point i wanted to make is the following: alt med it often portayed as being far les conflicted than conventional health care. IN MY EXPERIENCE, THIS IS NOT TRUE.
Indeed, and I totally agree it’s a very important point.
Blog posts have a tendency to be heated, people shrouded by anonymity with lowered inhibitions. I am not sure blog posts are the best way to judge a person, let alone a whole group of practitioners…lol. but I presume the “plague” you have experienced extends well beyond your blog.
Someone with your experience must have many interesting anecdotes.
Cui bono, and follow the money. Two good journalistic mantras.
As you rightly say, benefit is not just financial
It strikes me that individually cam practitioners/suppliers may not be big business, but added together it is quite a big industry. Has anyone identified how big in monetary terms, either U.K. or Worldwide?
one estimate is that, worldwide, alt med is worth 100 billion $ annually
In my country at chiropractic college/university we are taught:
– spinal adjustments/manipulation a carry an inherent risk & this material risk must be disclosed to patient
– immunisations are an essential Public Health Service that have reduced mortality & morbidity from certain infectious diseases. Anything to the contrary IS NOT taught in training unless from their own “learning” or seminar attendance.
when i once gave a lecture in the bournemouth chiro college, the discussion turned to vaccination. i asked for a show of hands and ~ 50% of UK chiro students seemed to be anti.
Whilst I agree with that an unfortunate anti-vaccination element does exist in many CAM I can’t help but pick you up on this.
You rightly suggest anecdote is not evidence in much of your commentary and posts but then use a conference at one school in the UK to point the views of the profession. I’ve seen you do this ‘show of hands’ for UK naturopaths in a Vaccine article too. The issue is far too complex to base on one data point in one country.
I would suggest persons with anti-vax views are attracted to CAM, not necessarily the other way (which partly explains why data suggests lay homeopaths are generally against vax, but medical homeopaths support it). The issue is more pronounced at different schools, different countries, and different professions. There is an issue but one show of hands at one UK chiro college does not represent an entire field, as you are implying.
Disclosure: I *do* have training as a CAM practitioner but also a MPH, PhD and Grad Dip Health and Med Law and fully support and promote public health vax (and even helped design vax strategies in a major Oz metro area). I am currently researching the anti-vax movement in CAM and ways to promote pro-vaccination views in these professions, the first article will be published in Journal of Law and Medicine in next few months.
you are right of course about the complexity of things. what is cause and effect?
i did mention the show of hands only in the comment, while in the post i cite an article which suggest that canadian chiros are educated to become anti-vax. i did not wish to imply much with this anecdote – it was meant as a supporting tale.
i do wish you luck with promoting pro-vax views in alt med [i have tried this for many years but was not very successful, it seems]
Pro-vaccination in CAM’s will come with the development of less toxic stabilizers and preservatives in vaccines.
see my comment above.
chiros originally believed that all disease is due to subluxation; this meant they had to reject the germ theory of disease.
today, a worrying number of chiros still adhere to palmers idiotic gospel.
From below: …palmer’s idiotic gospel.
Do you believe that CAM’s would be more willing to accept vaccination if the agents used in the vaccines were less toxic? You wouldn’t drink automotive anti-freeze so why would you inject propylene glycol into your body? Sure the public health benefit out weighs potential adverse effects of vaccination when looking at the big picture.
Edzard you seem to be clinging to Palmer’s view of chiropractic as if you depend on it to support your desire to prove chiropractic as useless. Seeing as you reject me and many of my contemporaries approach to chiropractic, an evidence based approach. *I know, I know there’s ‘no good’ evidence, yet.
@MedDC
How do you manage equate drinking anti-freeze and/or injecting propylene glycol into your body with getting vaccinated? Which particular vaccine do you think contains propylene glycol and in what quantity?
ah that proves it then.
Edzard,
I have been reading Ben Goldacres book ‘Bad Pharma’. In it, he speaks at length about both financial and non-financial conflicts as well as other factors at play that affect the the very foundation of EBM. He does not ask us to accept his opinion, he lays out the evidence to support his opinion. I understand that you have been an alt med researcher for many years, so perhaps you can give us some evidence of financial and non-financial conflicts of interest that plague alt. med.
the evidence is before you: read the comments to the previous posts.
Edzard,
You have asserted, based on your experience, that chiropractors, become anti-vaccination due to their teaching at chiro colleges/universities. You have also asserted that chiro’s believe that neck manipulation carries no risk. What I am after is some type of good evidence (not a show of hands at one college) that this is a systematic problem within the profession that is being taught throughout the universities/colleges.
I have to agree with Matt. I have attended chiro universities in Oz and can tell you that we were certainly taught about potential risks of neck manipulation and that this must be disclosed to patients (cue: BlueWode to chime in here with some dodgy stat about chiro’s not giving informed consent) and we are certainly not taught any anti-vaccination material. Infact just the opposite, we were taught that it was an important public health measure.
BASED ON EXPERIENCE????
have another look,please.
i have linked a canadian study which shows the phenomenon clearly [and then i added my own experience but only in the comments section].
Your missing the key word here. Canadian. You should qualify your statements. You make it seem as if it is all chiropractors are anti-vaccine. Not just the Canadian ones. For all your ‘research’ I would have expected to see polls of Chiropractors around the world in order to asses chiropractics distaste for vaccines. possibly including why they dislike them. Its not about Germ theory or having to rely on subluxation as the cause of disease, it has to do with what vaccines are made out of!
The anti vaccination movement isn’t limited to chiropractors. I know some pediatricians that are more anti-vaccination than I am, (I am pretty much neutral).
The Canadian study would be more complete if it was compared to such a study on medical students, as well as the general population.
Also, with only 1 (2 if you count the tiny UQTR), it is a relatively small sample size.
and a little bit more from the 2002 paper that this data comes from:
“Most CMCC students reported pro-vaccination attitudes, but there appeared to be an increase in anti-vaccination attitudes as students progressed through the CMCC program. This pattern was seen almost exclusively among students who relied primarily on informal sources of vaccine information rather than on core CMCC lectures or prior lectures at university.”
and
“In our survey, students who relied on such formal sources of vaccine information, including core CMCC lectures given by faculty, had a relatively positive attitude toward vaccination, regardless of year of study. ”
Busse, Jason W., et al. “Attitudes toward vaccination: a survey of Canadian chiropractic students.” Canadian Medical Association Journal 166.12 (2002): 1531-1534.
BadPharma does not criticise either EBM or SBM, it uses both to expose problems in the pharmaceutical industry. But why do CAM proponents hate the logical application of evidence and science to medicine?
A huge area of intentional conflict of interest is in the ‘professional line’ of supplements business model. Many big players in the ‘dietary supplement’ world only sell directly to licensed CAM providers (chiropractors, naturopaths, acupuncturists), and take great pains to enforce their Minimum Advertised Price and No-Internet policies. This is done to protect the profitability of clinical prescription/sales by making these brands artificially scarce in the marketplace and more expensive than they would be with normal competition. These supplements, only legal if marketed without disease claims, are also promoted to practitioners with literature that clearly makes strong drug-like claims to treat diseases. Of course most of them have had no real research to back up these claims, and many are outright implausible. However, even if they do work, the business model runs against the basics of medical ethics (patient autonomy, conflict of interest), which are why there is a pharmacy system independent of prescribing physicians. By motivating CAM practitioners to prescribe certain brands because they are more profitable, excess prescribing is encouraged. This is not in the patient’s best interest, financially or medically.
This concept is, as far as I know, completely ignored by most schools and practitioners of CAM. Edzard is correct in thinking that CAM enthusiasts live in a fantasy world where they think of CAM as more ethical than mainstream medicine.
Acupunk
Indeed. It’s not without good reason that many CAM practitioners are known as the ‘supplement sales force’.