MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The NHS tells us that our “choices include more than just which GP or hospital to use. You also have choices about your treatment decisions…”  In most other countries, similarly confusing statements about PATIENT CHOICE are being made almost on a daily basis, often by politicians who have more ambition to win votes than to understand the complex issues at hand. Consequently, patients and consumers might be forgiven to assume that PATIENT CHOICE means we are all invited to indulge in the therapy we happen to fancy, while society foots the bill. Certainly, proponents of alternative medicine are fond of the notion that the principle of PATIENT CHOICE provides a ‘carte blanche’ for everyone who wants it to have homeopathy, Reiki, Bach Flower Remedies, crystal healing, or other bogus treatments – paid for, of course, by the taxpayer.

Reality is, however, very different. Anyone who has actually tried to choose his/her hospital will know that this is far from easy. And deciding what treatment one might employ for this or that condition is even less straight forward. Choice, it turns out, is a big word, but often it is just that: a word.

Yet politicians love their new mantra of PATIENT CHOICE; it is politically correct as it might give the taxpayer the impression that he/she is firmly installed in the driving seat. Consequently PATIENT CHOICE has become a slogan that is used to score points in public debates but that, in fact, is frequently next to meaningless. More often than not, the illusion of being in control has to serve as a poor substitute for actually being in control.

To imply that patients should be able to choose their treatment has always struck me as a little naïve, particularly in the way this is often understood in the realm of alternative medicine. Imagine you have a serious condition, say cancer: after you have come over the shock of this diagnosis, you begin to read on the Internet and consider your options. Should you have surgery or faith healing, chemotherapy or homeopathy, radiotherapy or a little detox?

Clearly PATIENT CHOICE, as paid for by society, cannot be about choosing between a realistic option and an unrealistic one. It must be confined to treatments which have all been shown to be effective. Using scarce public funds for ineffective treatments is nothing short of unethical. If, for a certain condition, there happen to be 10 different, equally effective and safe options, we may indeed have a choice. Alas, this is not often the case. Often, there is just one effective treatment, and in such instances the only realistic choice is between accepting or rejecting it.

And, anyway, how would we know that 10 different treatments are equally effective and safe? After going on the Internet and reading a bit about them, we might convince ourselves that we know but, in fact, very few patients have sufficient knowledge for making complex decisions of this nature. We usually need an expert to help us. In other words, we require our doctor to guide us through this jungle of proven benefits and potential risks.

Once we accept this to be true, we have arrived at a reasonable concept of what PATIENT CHOICE really means in relation to deciding between two or more treatments: the principle of shared decision making. And this  is a  fundamentally different concept from the naïve view of those alternative medicine enthusiasts who promote the idea that PATIENT CHOICE opens the door to opting for any unproven or disproven pseudo-therapy.

To be meaningful, ethical and responsible, choice needs to be guided by sound evidence – if not, it degenerates into irresponsible arbitrariness, and health care deteriorates into some kind of Russian roulette. To claim, as some fans of alternative medicine do, that the principle of PATIENT CHOICE gives everyone the right to use unproven treatments at the expense of the taxpayer is pure nonsense. But some extreme proponents of quackery go even further; they claim that the discontinuation of payment for treatments that have been identified as ineffective amounts to a dangerous curtailment of patients’ rights. This, I think, is simply a cynical attempt to mislead the public for the selfish purpose of profit.

27 Responses to Why ‘patient choice’ does not apply to alternative medicine

  • It’s even worse here in the States because people pay for most CAM treatments themselves (although this is rapidly being altered and chiropractic has been covered in many states for some time now). Most people who still see a “mainstream” doctor end up wanting to do both CAM and standard treatment and now they are clamoring to get the CAM covered on insurance.They want it all in a package deal most recently referred to as “integrative medicine”. There are horrible proposals before Congress right now (some as part of the new “Obamacare”–Affordable Care Act–) to inject CAM into the Veterans Hospital system–at taxpayer expense, of course; to say nothing of none of it helping seriously damaged veterans beyond a placebo effect.

    Now I am also told that CAM is now a routine part of medical school, the only question being whether it will be something offered with skepticism for information purposes or as a “complementary” part of the curriculum!

    • unfortunately, in my experience, alt med is usually taught at med school by people who are simply not capable of critical thinking. thus the new generation of doctors will see it from an entirely wrong perspective. This has serious implications for tomorrow’s health care.

      • I’ve been reading the Science Based Medicine article series on quackademic medicine. Based on an extensive review of a large number of outputs from the “integrative” field, their conclusions exactly match yours. CAM is taught by true believers, med schools with integrative or CAM programmes do not seem to teach reality-based approaches to these interventions.

        • I know that for a fact regarding my own med school; long story, though. I will write it up as part of the book that I am presently working on.

  • I think everybody should be entitled to make their own informed choice, and healthcare providers should be required to provide full information if it’s requested, and to volunteer a certain minimum of information.

    Somehow I don’t think the quacks would enjoy this any more than they would enjoy a truly level playing field in regulation.

  • I know that homeopathy is available on the NHS but Reiki, Back Flower remedies and crystal healing – is that really true?

  • “To be meaningful, ethical and responsible, choice needs to be guided by sound evidence – if not, it degenerates into irresponsible arbitrariness, yes this is correct.

    Of course the taxpayer should not be paying for alternative therapies for which there is not sound evidence. Sometimes medical studies might demonstrate this evidence – or they might simply fabricate it – until they “discover” that the medication which was shown to be effective is not effective or it might be dangerous : In the US, I read that pharmaceutical companies themselves state that 45 percent of the medication work only for the 50 percent of the patients. This is a big number.

    So I m afraid that your argument against patient choice becomes very weak. Given the above reality – I have 50 percent chance my rejections to the established treatments to be actually very wise.

    But there are some forms of alternative therapy which the evidence is controversial : there are studies showing good results negative or inconclusive. If you ask me i tell you specific examples.

    Why patients should not have the right to choose among them as long there is some scientific literature showing to be effective?

    • perhaps you need to read my post again: I stated that patients should have the right to choose amongst treatments which have been shown to be effective.

  • Maria

    Q- What do you call an ‘alternative medicine’ that has been scientifically proven to work?

    A- ‘Medicine’

  • This discussion is really rather meaningless without a proper definition of what we mean by ‘alternative medicine’ which seems to be a blanket term to cover anything and everything that isn’t controlled by large corporations.
    ‘Alternative medicine’ is a broad spectrum term that includes everything from complete nonsense to some very effective and useful treatments.

    Where for example would be put osteopathy, chiropractic, or the Alexander Technique (the latter of which has been endorsed in a lead front cover article in the BMJ)? What about herbalism? Around two thirds of drugs are derived from plant remedies that were originally used by herbalists. And all the mainstream dietary advice I have heard originally came from nutritional therapists a couple of decades earlier.

    If we are going to argue from a scientific standpoint we need to be scientific and that means defining our terms with far greater precision

    • I agree, we would need to discuss this on a case by case basis; and that means not discussing herbalism but specific herbal remedies for specific conditions. my post was merely to say that PATIENT CHOICE is nonsense when it comes to choosing unproven or disproven treatments. somehow, one has to start from the general to get to the specific, I think.
      however, I do not agree with some of your statements, such as:
      1) all the mainstream dietary advice I have heard originally came from nutritional therapists a couple of decades earlier
      2) Around two thirds of drugs are derived from plant remedies that were originally used by herbalists [this may be roughly correct, but once an active ingredient is isolated, tested and put in a drug, it ceases to be herbalism]

      • Some treatments, although not yet proven, can be implemented if it has a plausible mechanism. Aspirin was used for about 70 years before the mechanism was understood. That is science for you. Some treatments will work and some won’t work- or some will work better than others. I am a chiropractor and chiropractic like other professions, such as teaching and psychology, is too often viewed as an art and not a science and practicioners often use what they feel or believe is the most effective treatment rather than keeping up with the latest research.

        • Aspirin is not a bad example. It was used because the clinical evidence demonstrated efficacy in the absence of knowing a mechanism. Chiropractic is used in the absence of both a plausible mechanism and the demonstration of clinical efficacy. One is good common sense, the other quackery.

          • I would keep in mind that chiropractic is a profession, not a specific treatment. In all honesty some chiropractic treatments don’t make any sense and have no plausible mechanism, or the postulated mechanism is counter to current scientific understanding. However spinal manipulation appears to be effective for certain types of acute low back pain and is also utilized by osteopathic doctors and physical therapists. Many chiropractors are also upset about some of the quackery that exists in the profession. I am sure that you are aware of the divide between the so called straights and mixers and the I.C.A vs the A.C.A. I would also like to add that I see some physical therapists and osteopaths doing quack treatments such as S.O.T where they claim to be adjusting the cranial bones. The problem is that quackery is more prevalent in chiropractic than in physical therapy and osteopathy. It may seem hard to believe that, despite being a chiropractor, I am able to look at matters objectively. Most chiropractors are unable to do this. They often become brainwashed during an intense medically oriented chiropractic curriculum that they can serve as primary care physicians. Or they become indoctrinated with the idea of vitalism and innate intelligence in a straight chiropractic college program. Both of these forms of indoctrination are dangerous.

          • take the woo out of chiropractic, and what remains is essentially physiotherapy. so why should we have chiropractic?

        • could this be related to the fact that physios are taught things which by and large are demonstrably true, while chiros are brain-washed with mystical concepts like THE INNATE and SUBLUXATION?

          • Despite the overabundance of quackery in chiropractic, the majority of treatments that chiropractors deliver and bill for are mainstream treatments which include spinal manipulation, exercise, electrical muscle stimulation, ultrasound, exercise therapy, massage, and neuromuscular re-education. You may be surprised to learn that a lot of chiropractic colleges are now downplaying concepts like innate and subluxation. Many chiropractors, however, still rely on these concepts as a powerful way to generate business. Since the profession doesn’t appear to be going anywhere anytime soon it may be best to concentrate on the chiropractic colleges changing the way they teach and chiropractic boards changing the way they regulate.

  • I am a chiropractor who believes in patient choice regarding which licensed practitioner patients may choose. It is hard to refute your contention of not paying for treatments which are not proven or are scientifically unsound. I just wish that if, for example, someone who has back pain can have equal access to see a physical therapist, a medical doctor, or a chiropractor. Chiropractors employ such treatments as exercise , modalities, massage, and manipulation to relieve back pain and obtain results similar to physical therapists. Often insurance companies don’t reimburse chiropractors as much as physical therapists for the same treatments. This economic disincentive to seek chiropractic care is an unfair obstacle to seeing chiropractic care. Our training to treat back pain is at least as extensive as that of a physical therapist.

  • I am a middle aged surgeon who was previously rather open minded about alternative therapies with plausible mechanisms of effect like acupuncture and chiropractic.
    I have had many bouts of lower back pain after entering “middle life”. In one of them, several years ago, tough but not the worst one mind you, I was advised to see a very popular chiropractor in town. I read up on the matter and found that uncomplicated LBP was considered a valid indication for this kind of therapy even in the US. My friend said he had saved his back several times so I allowed him to contact the CP for me that same evening on his private number. I went there full of positive expectations and certainly got a royal treatment. He even skipped family dinner to attend to my emergency after hours. He spent a good hour on a very thorough examination of the vertebral areas, took X-ray’s and stroked over the spinal column with an apparatus that purportedly indicated affected areas. I got plausible explanations of the nature of the affection and the mechanism of how manipulation could help relieving it. Then I was laid up on a couch, twisted up like a pretzel and this very muscular man literally and unexpectedly thumped his whole weight upon me, or so it felt. Well, I was flabbergasted and laughed hysterically so for a moment I guess I forgot about the pain. That was it! I was then told I had to come back regularly for an indefinite amount of necessary repeat treatments if this was to have a lasting effect.
    I went at least weekly for manipulations for some months and was also coerced into attending a lecture about the effects of spinal manipulations. That was when I started too that these people were not so sensibly endowed as I had hoped. We were told that literally all the more mystical and hidden bodily functions were more or less connected to the vertebral column and its appendages or whatever and that adjustments of the column would simply do wonders to our health so long as we met up regularly. The re-visits were very effectively organized using a simple “conveyor belt” system, which allowed for a five minute turnaround time. A money making system all right! A five minute session cost about $40-50 at today’s rate.

    I can honestly say that despite my really open minded and positive expectations throughout, his manipulations never did anything more for me than other less costly or free methods. We exchanged a good amount of money but the revenue was low for my part. The back pain did not go away sooner than usual. Probably the opposite because in retrospect I relied too much on the CP and did nothing much else for the problem at that time.
    After the first brief effect I never found any convincing relief from his manipulations. I have had much better results from sensible pain killers, exercises like walking, back strengthening calisthenics on a floor mat and good (non-gentle) massage. To avoid problems the best is to do regular walks and strengthening exercises, especially if you have an otherwise sedentary or ergonomically difficult job. Terrain and uphill is best.
    If I find a bout coming on I try to go out and work manually in some way. A few times it has done wonders to go and cut the grass if the back starts to act up!
    The only benefit for me of seeing a CP was making me realize that I had to learn to deal with these things myself. I have also learned how to avoid lumbago with free exercise.
    My glands and inner organs also work fine even if my spine is not regularly adjusted by a well paid chiropractor.

    • Although chiropractic manipulation may be effective for some people the fact that the chiropractic boards allow chiropractors to use pseudoscience and metaphysical concepts to “educate” patients makes the profession look bad(rightfully so) to educated individuals like yourself. I am a chiropractor and I am now thinking this: Someone goes to see a medical doctor and has a negative experience with the doctor this person will then just blame it on the individual doctor, not the whole medical profession. If someone, however, has a negative experience with a chiropractor, they blame the whole profession. I am a chiropractor who doesn’t preach/teach any of these metaphysical pseudoscientific concepts.

      • “Although chiropractic manipulation may be effective for some people… ” Interesting statement coming from a member of the profession. What is your srate of success?
        If manipulation only works for some, what do you have to offer those who do not respond to manipulation?

        In my line of work everything[sic] about our procedures and follow up results is registered in a comprehensive national database We cannot hide anything from the public eye. Our results are analyzed annually and published.

        As they seem to be under increasing critical scrutiny, perhaps Chiropractors should team up, start central registries and perform regular audits so we can all know what their complication and success rates are? ( I do not think we need to be told what problems such a venture will encounter).

  • In response to your comment f that if we take the woo out of chiropractic, we have physical therapy, so why even have chiropractic? I suppose the profession could be eliminated and the country would not experience a healthcare tragedy, as would be the case by eliminating physical therapy, medicine, or nursing. The profession, however, isn’t likely to be eliminated anytime soon. So when choosing a chiropractor people have to be extra careful. But some people do love their chiropractors and chiropractors are far and away the most skilled practitioners of spinal manipulation. If someone wants to undergo spinal manipulation from the most skilled practitioner, chiropractic is usually the way to go. I have a very successful chiropractic practice. I suppose it comes from building relationships with people. I believe people will choose to see me, a chiropractor, regardless of their views of the profession because they like and trust me. They choose the doctor, not the profession.

  • Hmm…
    My patient choice has been paid for BY ME. As much as you are complaining in your article, most alternative medicine is paid for out of patient pocket. It’s amazing how much patients are willing to do this, despite the cost.

    I chose TCM (chinese herbs) for my psoriasis. (At the point where my psoriasis was going from moderate to severe). All the AMA approved choices just didn’t seem safe enough for me (drugs or therapies that depress the immune system, increase the rate of cancer, cause serious birth defects, or destroy the skin through thinning of it). Also, speak of expense! Some of these therapies run into thousands and thousands of dollars. I am happy to say that my experience with TCM has been excellent, with my psoriasis symptoms greatly reduced. Yes, it cost me money, but the TCM dermatologist that I see charges me much less than a traditional doctor would.

    You list treatment with crystals, reiki, bach flower remedies and homeopathy. All of those appear bogus to me, as well. I chose TCM after reading a number of studies online that seemed to suggest that giving it a try might be worth it. I didn’t choose any TCM. Acupuncture didn’t seem like it would be effective, but herbs did. The biggest thing I checked to see was whether there might be any dangerous risks. I was cautious enough to spend six months doing research on it. Yeah, I’m not a doctor, not a scientist, but I do have enough of a brain to worry about side effects like increased cancer risk and depressed immune function or spending a lot of money on something with no evidence behind it at all. Since I found a number of studies done in China, yes, I know, China, but that’s where they are doing them, and because I couldn’t find any red flags with the TCM herbal approach (except that I should go through a legit TCM doctor who uses a professional compounding pharmacy), I gave it a try. Using myself as my own control, I can tell you that definitely this treatment has a large degree of efficacy for me. (When I use the herbs the psoriasis starts to clear up after about two months. When I stop, the psoriasis starts flaring up after about a month–that exact pattern has happened several times, so, for me, I’m PRETTY convinced.)

    CAM is not black and white. CAM is not one thing. CAM is whatever the AMA and FDA doesn’t accept. Supposedly this is all based on research and evidence. However, there aren’t many research dollars being put into more natural / nutrition based therapies. The profits for big pharma aren’t there. Once I looked through the studies for psoriasis on PubMed to see if I could find any relating to diet or herbs. Out of 75 plus studies, I could not find ONE that fit that description (except one that seemed to be studying a chemical derivative of an herb, although I could not tell if it was a synthetic version of the herb or the actual herb itself). That was a real eye opener for me.

    As far as tax dollars go, I have to pay my tax dollars for approved expensive drug treatments that are only partially efficacious with side effects even though I don’t want to use them! So me, the patient, is stuck paying MY tax dollars for treatments that I don’t want while having to pay out of pocket for one that works.

    Yes, I can’t research which hospital is best for me while enroute. Yes, I want doctors who are qualified. But in your article you just lump everything together, just perfectly annoying! Even in the world of medicine a treatment might change over ten years. Doctors don’t always agree, etc. Yeah, CAM is the wild west. The good mixed up with the bad. The better for some and the worse for some, the sublime and the stupid. You have to really research it, think about it, and then give it a try. That’s just the way it is because the government isn’t doing its job.

    Also, the alternative therapies you list for cancer are just a bit sarcastic, and don’t really fit what I’ve seen in the alternative medicine world (having had several friends with breast cancer and looking at alternative therapies because of that). What I sense is that in general most people who suddenly get a cancer diagnosis ask for prayer (“faith healing”) AS they are getting surgery and chemo. Then when the second round of chemo comes, they think, “Geez, why didn’t it work the first time? Is this the only way? Are there any other ways?” Then they might try a hybrid approach, chemo with CAM (paying for the CAM, which is generally cheaper than the chemo but still a lot for a person to pay, out of their own pockets). Then, when the third time comes around, the death sentence… well, hmm… CAM just looks a bit more appealing to some people, doesn’t it? The fact is that chemo isn’t nearly or always as effective as patients hope it will be, and it has some nasty side effects beyond nausea and losing hair.

    How about healthy diet to compliment traditional cancer treatment? How about vitamin D3 supplements? (There’s a good deal of research there!) How about meditation? There is some scientific evidence for these treatments. However, no insurance is going to help a patient who maybe can’t afford another penny, to pay even a small sum of money towards these things. Many patients aren’t looking at forgoing the chemo or radiation or surgery. Rather, they are looking for help with treatments that might make the chemo more effective, etc.

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