MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Who – apart from quacks – would not want to get rid of all quackery, once and for all? It would be a huge improvement to medicine, save thousands of lives, and reduce our expenditure for health care considerably.

But how? How can we possibly get rid of something that is as ancient as medicine itself?

Simple!

All we need to do is to employ the existing ethical imperatives. I am thinking in particular about INFORMED CONSENT.

Informed consent is a process for obtaining permission from a patient before treating him/her. It requires the patient’s clear and full understanding of the relevant facts, implications, and consequences of the treatment. It is a ‘condition sine qua non’; no health care professional must commence a treatment without it.

And how would informed consent get rid of all quackery?

This is perhaps best explained by giving an example. Imagine a patient is about to receive a quack treatment – let’s take crystal healing (we could have chosen any other implausible non-evidence based therapy, e. g. homeopathy, chiropractic, Bach Flower Remedies, faith-healing, etc.) – for his/her condition – let’s say diabetes (we could have chosen any other condition, e. g. cancer, asthma, insomnia, etc.). Informed consent would require that, before starting the intervention, the therapist informs the patient about the relevant facts, implications and consequences of having crystal healing for diabetes. This would include the following:

  • the therapy is not plausible, it is not in line with the laws of nature as we understand them today,
  • there is no evidence that the treatment will cure your condition or ease your symptoms beyond a placebo-effect,
  • the treatment may harm you in several ways: 1) it might cause direct harm (unlikely with crystal healing but not with chiropractic, for instance), 2) it will harm your finances because the therapist wants to be paid, 3) most importantly, if you believe that it could help you and therefore forego effective therapy for your diabetes, it could easily kill you within a few days.

It is impossible to dispute that these facts are true and relevant, I think. And if they are relevant, the practitioner must convey them in such a way that they are fully appreciated by the patient. If the patient comprehends the implications fully, he/she is unlikely to agree to the treatment. If most patients refuse to be treated, the market for crystal healing quickly collapses, and crystal healers move into other, more productive jobs. This might even help the general economy!

But quacks are not in the habit of obtaining fully informed consent, I hear you say. I agree, and this is why they must be taught to do so in their quack colleges. If informed consent was taught to all budding quacks, they would soon realise that quackery is not a viable business and go to a proper school where they lean something useful (this too might help the economy). If that happens, the quack colleges would soon run out of money and close.

Meanwhile, one could remind the existing quacks that they break the law, if they neglect informed consent. In the interest of the patient, one could closely monitor the consent giving process, and even think of increasingly heavy finds for those who break the law.

As we see, almost all the means for rendering health care quack-free already exist. All we need to do is implement them. That shouldn’t be difficult, should it?

AND NOW I STOP DAY-DREAMING AND DO SOMETHING USEFUL.

37 Responses to The end of quackery…it’s amazingly easy!!!

  • Back in reality, here’s how one quack justifies what she’s doing: I subtly confronted a homeopath friend by saying that she won’t catch me recommending alternative treatments anymore, since I deeply regret doing that when the person then had to go to the emergency ward for taking my advice to dump her psych meds for aromatherapy. My homeopath friend said I shouldn’t feel bad, since it was the person’s decision to do that and heck, that person could just as easily have gone on the internet and found the instructions to do what she did. So all is right!

    I was pretty shocked at her easy defense of recommending woo and having it turn out badly. And it’s not as if she just casually recommends alternatives to people as a friend, like I did. She hangs out her shingle to sell people woo treatments in place of real medicine.

    After our conversation, I could tell she was still chewing on the concept of regret for bad outcomes. I suspect this subject will come up again, and I look forward to it.

    • Wow. Paraphrasing: “If I don’t give terrible and possibly harmful recommendations to people, they may just end up finding the same bad advice on the internet anyway. At least this way I make some money at it.”
      This rationale probably provides solace to many of the quack misinformation sites too; if they stopped, their customers would just buy quackery from, or generate clicks on, some other appalling site.

      • Yeah, can you believe it? And sure, the profit motive is involved for her but moreso, she truly believes she’s a medical practitioner who works at the level of doctors. (Though she says she tells people that she’s *not* a doctor, and tries to work with her clients’ doctors/psychiatrists on a treatment; I don’t know how that goes.) It’s an identity thing that I don’t think will be easy to crack.

  • Nice idea, but — I suspect — no cigar. The problem lies with the nature of the consent form details. Who decides them? One senses the inputs from the ‘woo-d be medics’ will dilute and weasel away the good intentions you suggest. You’re right to stop daydreaming. In real medicine we have consent forms for surgical procedures and consent forms by proxy for pharmaceuticals (the package inserts; you read them then decide whether you want to take the product). Big Snakeoil is unlikely to follow.
     
    Your post comes close to formally raising a point implicit also in the comment from Linnie Mae. The underlying problem is the tug of war between treatment a patient wants and treatment a patient should ideally receive. In very many cases clinicians are equivocal about the latter. They may be unsure of the precise diagnosis or of the best therapeutic approach; or they may recognize a patient’s problem can’t realistically be treated effectively with what’s currently available. That adds weight to the idea that the patient is entitled to choose their own treatment, and bang goes the end of quackery, with or without consent forms.
     
    In any case, even if a woo-minded patient reads, say, your example of consent for crystal therapy, they’re free to argue “I don’t believe a word of this” and sign anyway. There’s no shortage of information available to explain to patients why the many snakeoil therapies have no rational basis and no proven efficacy, yet still they queue up for it, with religious subjective conviction that it offers benefits. Gullibility comes in a wide variety of colours.

    • Franko

      You said “In real medicine we have consent forms for surgical procedures and consent forms by proxy for pharmaceuticals (the package inserts; you read them then decide whether you want to take the product)”

      How practical do you suppose that is? How ethical do suppose that is? Do you really think that’s good practice?

      Do you think patients fully read and understand? I’m sure it legally qualifies as “informed consent”, but it’s not good medical practice. Linnie Mae’s friend would not have “dumped” her psych meds if her doc had made sure she understood that you can’t do that on a whim. But I’m sure that’s in the fine print, somewhere.

      It certainly takes extra time to make sure the patient understands procedures, medications, etc. But if you don’t have the time to educate your patient…you don’t have time to practice medicine. Informed consent isn’t a legal checkbox – it’s part of the treatment.

      • @jm
        I don’t disagree with a word you say. The context of my remark was the original post of this thread: altmed offers no form of honest consent advice. Revise my first line to “In real medicine we have at the very least consent forms etc.” and the context becomes clear.
         
        Your last paragraph is perfect. I’ve never experienced a doctor who doesn’t take the time to explain procedures and medications and their risks. I’ve never experienced a doctor who says “read the package insert: it’s all in there”. But altmed practitioners seem to be happy to talk pseudoscientific gobbledygook as explanation for what they’re doing. Just as Edzard Ernst says in his post, if there were a legal requirement for them to give the same unbiassed explanations we expect of medical practitioners, perhaps patients would be less easily bamboozled.

      • Franko

        Yes, the addition of “at the very least” helps. And, you’re quite fortunate that docs explain meds – the vast majority of my clients get little more than “it will help with ___”. Most med info comes from the pharmacist, and that info centers around interactions, etc – not what it’s doing for you. Many of my clients on multiple meds don’t really know which is doing what – they just know they were told to take them. It’s sad.

        We’ve also had to send a few folks to the ER, after they decided one day that they didn’t like the side effects of their meds…and just quit taking them. All were surprised that you couldn’t just do that.

        On the other hand, I’ve never been to someone you’d consider an altmed practitioner (acu, massage, chiro, feldenkrais, etc) who didn’t have a consent form, and explain what they were doing and why – and making sure you understand. I’m not sure if it’s legally required (it’s not for massage), but it’s good practice. (for hopefully obvious reasons)

  • It seems that there is an inexhaustible supply of nonsense, unfortunately.

    Only today I was recommended http://www.livestrong.com/article/119278-kundalini-yoga-ocd/.

    This suggests that OCD, a psychiatric disorder, can be treated with yoga. The basis for this claim? That “Kundalini yoga strives to access and raise dormant, cosmic energy, or Kundalini, through sequences, or kriyas, that combine physical exercises, meditation and structured breathing techniques.”

    “Dormant, cosmic energy” is not a concept I find particularly credible, but apparently others, in search of a cure, do!

    Sometimes I despair.

  • And as for this, the biggest assembly of woo on the planet?

    http://abundantenergysummit.com/

    “The Abundant Energy Summit is based on the world-renowned psychologist and philosopher Ken Wilber’s “Integral Theory,” and therefore provides the most radically inclusive, comprehensive roadmap to dealing with the true root causes of fatigue in existence today. Whether you are in the midst of a health crisis or committed to having abundant levels of endless energy, this summit will be exceptionally useful to you and your goals.”

    What’s even more disappointing is that the line up includes ‘proper’ medical practitioners, apparently happy with the company they are keeping, where claims are made about “How earthing, structured water, circadian rhythms and similar factors control our biology.” and “80,000 chemicals are in the environment with 2000 added every year”!

    *Sigh*

  • How is a deluded practitioner backed up by mountains of studies from quackademia to be faulted when they give out misinformation? The information studies may be from an alternate reality, but because of them, true believer can consider themselves completely ethical. Most alt-med professional organizations exist for promotion rather than honest criticism. There has been precious little in the way of discussion of ethics from these groups. Mainstream medicine has so far reacted by accepting double standards or actually bringing in new integrative profit centers. In many cases alt-med practitioners are as misinformed as their clients. Without better recognition of the different standards being allowed all round, “informed consent” has no real meaning.

    • In many cases alt-med practitioners are as misinformed as their clients.

      Probably even more misinformed. The above-mentioned homeopath recently said she never gets colds but she had caught one. Wouldn’t know where she’d have picked it up, so she figured she must’ve gotten it from a spider bite. This is what terrifies me about homeopaths and other alt-med quacks presuming to diagnose *anything*, let alone treat it.

  • Apologies if this is too far off topic, but another danger of quackery was demonstrated yesterday here in Germany — 30 homeopaths and “Heilpraktiker” are in hospital after experimenting with amphetamines at a seminar. Why the hell they did it no one knows, because they’re all still under the influence. All are expected to fully recover, but the people who run the seminar house where they did it were deeply shocked by the whole thing — 30 people suddenly staggering about and collapsing, and incapable of responding. 150 emergency responders were required to treat them and get them to a hospital. Poosibly they were trying to “experience” some kind of illness from the patient’s perspective, according to one homeopath in the comments. Another homeopath commented that amphetamines have “already been proved (tested)”, so who knows why they did it. Whatever the case, they were out of their depth and didn’t realise it.
    Article in German–
    https://www.ndr.de/nachrichten/niedersachsen/lueneburg_heide_unterelbe/Nach-Drogen-Experiment-Ermittlungen-dauern-an,handeloh104.html

    (Again, apologies if this is too far off topic.)

    • Thank you @Yakaru for this very interesting link.
      Here an english news item: http://abcnews.go.com/Health/wireStory/germany-30-apparently-suffer-amphetamine-poisoning-33540828
      For those who do not read German, your link can be helpfully enjoyed using the Google Chrome Browser with its translating function.
      It will be very interesting to hear if and when any information becomes available as to what these nitwits were doing. Perhaps Prof. Ernst will tell us in a future post?
      I will use this as an example of what the “health-freedom” ideology can have for consequences when amateurs get to pay with dangerous substances or herbs.

      • @Bjorn and @Yakaru
        It’s a relief to find these links here. I thought I was hearing things when this story was covered on yesterday lunchtime’s BBC radio news. By the time I tried to look up details on their website the story had disappeared, never to be repeated there or on air, and googling things like ‘homeopath conference/convention’ produced no results. (Does Clarence House regulate our news media?)
        I notice that your links don’t mention the people were homeopaths/altmeds. This one is more explicit: http://www.ctvnews.ca/health/dozens-suffer-apparent-amphetamine-poisoning-at-german-homeopathic-conference-1.2548502.
        Thank goodness nobody succussed the amphetamines to 30C: everyone would probably have died at that potency!

        • The drug they apparently took was 2C-E, so maybe they thought it would be far less potent than 30C-E ???

          Still no news about why they did it — police still can’t get any sense out of them. They might face charges and will probably have to pay for the 160 (!!!) emergency responders and helicopter crew.

      • @Alan
         
        Broadcaster NDR described the 29 men and women “staggering around, rolling in a meadow, talking gibberish and suffering severe cramps”.
        The “talking gibberish” may not have been attributable to the hallucinogenic drug.
         
        “Unfortunately, the conference in Handeloh has severely damaged the image of the alternative medicine profession…”. More than it damages itself normally? Has no-one considered the event might have been a homeopathic proving?

        • true!
          this is a possibility

        • Indeed. I mentioned the possibility it was a proving in the comment I left under the article this morning. 🙂

          • @Alan
            Apologies: no comments at all show when I link to the article!

          • The doctor in this report (video in German) says that they were psychotic, screaming and hallucinating in the hospital and at times had to be tied to the beds. The earlier article now has over 100 comments, quite a few from homeopaths insisting that it is a personal sacrifice and medical duty to “prove” various substances. Other homeopaths complain that acid has already been well “proved” by homeopaths, so what the heck were they doing….

            It’s not a crime to take it in Germany, but whoever handed it out will be in trouble. They might all face some professional disciplinary action, especially any doctors. And also, all the assumptions that it was 2C-E were based on the symptoms. They won’t know what it really was until the blood & tests come back at the end of the week. It might be something else altogether. I mean they take dogsh*t to “prove” it (in healthy people it causes dislocated hip and unemployment — sounds accurate enough to my mind). It could have been anything. The police might be in for a surprise.

          • @FrankO

            Odd. Do you have cookies blocked – that frequently stops comments appearing.

          • @Alan
            Nope, no blocking of cookies. Perhaps the comments lie behind a paywall? I can’t see comments on any article on the Independent site.

          • I can’t see comments on any article on the Independent site.

            I can (including Alan’s), and I am not a paying reader, so there must be something else going on. One does not even have to be a registered member to see comments, I just tried to make sure.
            At the risk of asking the irritatingly obvious: could you have an active adblocker or popup blocker? (I doubt this has anything to do with your problem, but one never knows).

  • In my experience the first bullet point in far too many and most cases becomes moot. The very lack of understanding of natural sciences (as interpreted meaning of “laws of nature”) seem to be one of the reasons patients and practitioners deal in quackery from the outset…

  • I would submit that informed consent, while an excellent idea, is a bit redundant. One may not make false claims about a product. Quacks do, that’s what makes them quacks in the first place. This should be enough for ‘the authorities’ to put them out of business permanently. The only factual problem I can see, is that ‘the authorities’ simply don’t have the sheer numbers of personnel available to do exactly that.

    Second, to the best of my knowledge, only certified/qualified medical professionals are allowed to give medical advice. One may agree or disagree with that, one may – or not – question the quality of these qualifications and the relative capabilities of those so certified, but this essentially seems to be the fact in most relatively developed countries.

    Most quacks are – at the most – qualified in quackery, not medicine. What they do, is therefore illegal, and this should be enough to shut them down permanently. Again, the only genuine obstacle against this is the deplorable lack of personnel to do exactly that.

  • Quacks may be able to fool patients, but registered medical practitioners must have higher ethical standards. For millennia patients were expected to do as their magi, priests and physicians told them – now the days of medical paternalism have passed. Today patients expect to understand what is proposed for them and to be involved in decision making.

    ‘The doctrine of informed consent’ was first formalised by Justice Bray in the California Court of Appeals in 1957. Taking the term from a brief submitted by the American College of Surgeons, he opined: ‘A physician violates his duty to his patient and subjects himself to liability if he withholds any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment….In discussing the elements of risk a certain amount of discretion must be employed consistent with the full disclosure of facts necessary to an informed consent.’

    Medical practitioners are expected to deal with colleagues whose practice seems at odds with established ethics. The General Medical Council requires: ‘If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay…’ Although few members of the Society of Homeopathy are medically qualified, this year’s conference is on the topic of homeopathy’s role in diagnosing and treating autism spectrum disorder. Should we be concerned? What does the Faculty of Homeopathy, most of whose members are GMC registered, think of using homeopathic remedies to treat children with autism?

    GMC Guidance tells registered doctors: ‘You must be prepared to explain and justify your decisions and actions (paragraph 4); You must take part in systems of quality assurance and quality improvement to promote patient safety. This includes…taking part in regular reviews and audits of your own work and that of your team, responding constructively to the outcomes (22.1a); You must give patients the information they want or need to know in a way they can understand (32);You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability (54); The investigations or treatment you provide or arrange must be based on the assessment you and your patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options’ (57).

    The GMC’s Guidance on obtaining consent states, inter alia: ‘You should not make assumptions about: the information a patient might want or need; the clinical or other factors a patient might consider significant; a patient’s level of knowledge or understanding of what is proposed. You must give patients the information they want or need about the diagnosis and prognosis: options for treating or managing the condition, including the option not to treat; the potential benefits, risks and burdens, and the likelihood of success, for each option. You should check whether patients have understood the information they have been given.’

    Given the GMC injunctions, how should the profession respond to colleagues who fail to comply? In August 2015 Mark Baker, Director of the Clinical Centre for Practice at the National Institute for Health and Care Excellence suggested UK doctors could be reported to the GMC for inappropriate antibiotic prescribing. But why only anti-microbials? Surely, such stringencies should be applied to prescriptions of all medicines, including those prepared homeopathically.

    What if a group of doctors were to devise a treatment by extracting sunbeams from cucumbers, and then claimed their patients benefited from the ‘healing energy’. Should they be taken seriously? Would they not merit ridicule? Deserve to be satirised? Dr Jonathan Swift thought so. But satire is not enough. Vulnerable and gullible patients are deserving of better care and intellectual integrity from all those who profess to manage health, wellness and disease.

    Ethical camists (who practice CAM) should tell patients “I am going to provide a treatment which is controversial and not endorsed by most doctors. I have no plausible scientific evidence the treatment itself will have any beneficial effect for you greater than would be achieved by a placebo, but some patients tell me they do benefit and in the context of our constructive therapeutic relationship I am prepared to try. I ask you to give informed consent to have treatment on that basis.”

    In ‘Placebo’ (2004), Dylan Evans suggests that just as cigarette packets have statutory health warnings attached, so too should alternative medicines:
    ‘Homeopathic remedies should be sold with a label reading: “Warning: this product is a placebo. It will work only if you believe in homeopathy and only for certain conditions such as pain and depression. Even then, it is not likely to be as powerful as orthodox drugs. You may get fewer side effects from this treatment than from a drug but you will probably also get less benefit.”’

    Next step: Identify doctors who fail to obtain fully informed consent and ask the GMC whether they are fit to practice. I’m on the case!

  • I’ve been truly shocked this morning by this: https://www.youtube.com/watch?t=669&v=RWbkvCMuU5A. I thought the US Office of Alternative Medicine at the National Institutes of Health (NIH) had fizzled at the end of the 1990s, when millions of research dollars had failed to produce evidence of efficacy for any form of CAM. I had no idea that the opposite was true; that the funding has increased massively (and the ‘Office’ has changed its name) so that now snakeoil is being taught and practised even at the most prestigious medical schools in the USA: Mayo Clinic, Johns Hopkins, MD Anderson, Vanderbilt, Stanford, Duke, Memorial Sloan Kettering and scores more.
     
    This is unbelievable. There is no conceivable end to quackery when a major government is sufficiently populist and gullible to vote billions of public dollars to support it. Those fans of woo and witchcraft who post on this blog, please refrain from ever again telling us there is insufficient money to do decent research on CAM!

  • This Oglaf comic represents the mindset of alt med:

    ***WARNING*** site is NSFW ***WARNING***
    http://oglaf.com/nostrum/

  • The informed consent question is problematic because most of the people who practise CAM do actually believe in the ‘therapy’ they offer. So we are unlikely to see them saying to a patient that ‘this is a placebo’. No, I have no idea how they can believe in the tosh most of them peddle, but many seem utterly sincere. So maybe it is a question of making each one individually justify their beliefs to a committee of rational people. Not very practical. I despair of those among my acquaintance who go to chiros, acupuncturists etc, and say, well it made me better. None of them will accept that they would have got better anyway, or that they were just getting a placebo effect.

    Has anyone got a reliable way of persuading the gullible that theya r ewasting their money and their time?

    • Mr (or Mrs or Miss or Ms) Barton asks:
      “Has anyone got a reliable way of persuading the gullible that they are wasting their money and their time?”

      In a liberal free democracy – no.
      But we should have regard for the gullible and more importantly, vulnerable.
      This latter group includes cancer and chronic disease patients (who become desperate and disillusioned with orthodox medicine) and particularly the elderly who are all to susceptible to scams and fraud.

      Camists (who practice camistry) may be sincere, but for the umpteenth time of asking: “How do we tell a sincere CAM practitioner from a fraudulent quack?”

      Can L. Barton offer any evidence at all that: “…most of the people who practise CAM do actually believe in the ‘therapy’ they offer”? Do they really?

      As for a ‘committee of rational people’ – well, where registered medical practitioners are concerned, the GMC is obliged to asess whether any practitioner referred to its Fitness to Practice procedures is indeed FtP.
      At least if it could be established that RMPs who do not obtain informed consent, and do not advise their patients that homeopathic remedies are placebos (in the face of having no evidence otherwise), are not FtP, some progress might be made.
      It would become much easier to tell patients “Caveat emptor’, if you go to an unlicensed practitioner be careful what you wish for.” And their carers/children/relatives simply: “Avoid quacks.”

      I am preparing referrals to the GMC on these lines.
      Any comments?

      • Actually, no, I haven’t really got proper proof that camists are totally sincere, or indeed that their patients are. I am going from my own contact with such people, few of whom seem to be what I would call obvious fraudsters or idiots. I am excluding the bubble-headed ones (always female) who go in for just whatever the latest fad may be (usually cooked up from a women’s magazine – they really have a lot to answer for), and looking at the ones who have high street practices and apparently mainstream businesses. I’ve no idea what proportion of the cam community they are, so another reason I am not providing proper proof.

        I support your move in referring RMPs to the GMC. One of the big arguments put forward by the CAM community is that ‘doctors use/recommend this’. If that was stopped, it would help a great deal. The problem there is that even today most patients are too scared/impressed by a doctor, any doctor, to look rationally at what they are told, or ask any questions at all. It must be all right, the doctor said so. My own GP is a model of excellence here. He not only failed the ‘illegible handwriting’ exam, he also knows how to answer questions and explain things, and realises he has to persuade me of his argument. I suspect many GPs would not want me as a patient. Neither would any cam practitioner. Asking questions is not encouraged by them as far as I can see, not even the apparently genuine ones. Are they trained to discourage questions? Perhaps, then, we need a campaign to demand proper explanations.

        I realise this would not help many of the vulnerable, especially the ones with little education, but if a large chunk of patients disappeared so would many practitioners, I suspect.

  • L Barton says: I realise this would not help many of the vulnerable, especially the ones with little education, …

    The problem, at least here in the U.S., is that it’s the well educated ones who think they’re too smart or too enlightened to listen to doctors, and can “take control” of their own health care with whatever mix of woo they believe in. I come from a working-class town where a lot of people aren’t the best educated; their common sense prevents them from falling for any of this crazy stuff. If I’d go off quoting Deepak Chopra to any of my family, they’d at least roll their eyes or if it was excessive, they might have me put away where I couldn’t injure myself.

    That’s the conundrum: Education seems to only hinder people’s ability to think logically, when it comes to modern health care.

    • So many people believe in the myth that “better education” means “more education”. The truth is that the quality is far more important than the quantity.

      • Good point. Education must be about critical thinking to be valid. While studying the intricacies of the impact of Doraemon and Sazaesan on Japanese culture or studying how art changed in Liechtenstein during the second world war or studying the differences between Chinese and Duch grammar may be very interesting and rewarding, they seem somewhat unlikely to teach anything at all about how to think critically and how to evaluate scientific (sounding) claims.

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