Arianne Shahvisi is a lecturer in Ethics and Medical Humanities at the Brighton & Sussex Medical School. She has long had an interest is so-called alternative medicine (SCAM) – see here, for instance. Now she has published another most intriguing paper.
In it, she explains that scientific medicine (SM) neglects the needs of women relative to those of men. Subsequently she discusses the many limitations of SCAM and describe concerns about its use. Despite SCAM’s shortcommings, it is the domain of women who not only use it more frequently than men but also tend to be the practitioners practising SCAM. Arianne Shahvisi argues that, despite being chosen by women in reaction to the shortcomings of SM, SCAM cannot offer greater patient autonomy and is more liable to be exploitative.
Here conclusions are unusually long and I provide them here in full (after changing her abbreviation ‘AM’ to mine ‘SCAM’):
Within this paper I have made the following argument: SM is patriarchal and under-serves women; women dominate SCAM, both as users and service providers; women who choose SCAM often cite dissatisfaction with SM and the desire for greater autonomy and personalization within the clinical encounter. Based on these premises, it is likely that women use SCAM because it promises to offer greater autonomy and personalization than SM. This segues into a second argument: autonomy in healthcare requires informed consent; informed consent is not possible for SCAM therapies since mechanisms are either not known or not plausible, and there is no evidence base. These premises entail that SCAM cannot help patients to realize autonomy. Combining these two conclusions, it seems that SCAM does not offer the control and autonomy that is sought. Whilst it may be argued that SCAM offers personalization and a satisfactory therapeutic encounter, it must also be noted that forfeiting an evidence base, plausible mechanisms, and the ability to make autonomous decisions is a heavy loss to patients and one for which SM must take some responsibility.
I have attempted to motivate each of the above premises in the preceding sections. In this section I reflect on the implications of these conclusions and make recommendations to ensure that women’s health needs are more adequately met.
First, to the extent that rejection of SM may be seen as a form of resistance, the cost of that resistance is borne largely by the resistors themselves. Those who begin witha sense of dissatisfaction with SM—in many cases stemming from SM’s failure to provide them with adequate healthcare or to inspire trust in its own decency—end up with healthcare that is on many counts less adequate.
With the ascendance of a post-factual culture, arguments relying on evidence, reproducibility, and consistency are liable to have ever less traction. By corollary, the features that have typically worked against SCAM—its lack of an evidence base—are likely to pose less of a barrier to its uptake. This ought to be a grave public health concern, since the well-being of entire populations depends on medicine earning and retaining the trust of all. To see this, one need only consider how easily herd immunity is lost when trust in vaccination is undermined, putting entire populations at risk of disease outbreaks (Casidayetal.2006). Recommending against vaccination is common amongst SCAM practitioners (especially within chiropractic, homoeopathy, and naturopathy) whose philosophies so often rely on emphasizing, and in many cases overstating, iatrogenic risk (Ernst 2001).
Not much can be done now to atone for medicine’s history except to openly accept its shortcomings and under take particular effortS to re-engage marginal health populations. While it is easy to suggest that researchers should be devoting more time to women’s health issues and their treatments, the bench-to-bedside timeline is long, and more immediate efforts are also necessary. As Ernst (2010) has noted, concentrating on the therapeutic relationship within SM seems like the most constructive way forward. Although patients often look to SM for the ‘science of medicine’, clearly many are turning to SCAM for the ‘art of medicine^ (Ernst 2010, 1473)—for a compassionate clinical encounter in which patients are humanized and power differentials are flattened. While SM may have the upper hand in terms of mechanisms, an evidence base, and social capital, there are inadequacies in the patient–practitioner relationship, and in this respect there is much to learn from SCAM modalities, where the therapeutic relationship is key to their appeal. Even the most resolute SCAM user inevitably encounters SM professionals on occasion. Provided broader pressures on health workers permit them the time and space, those encounters present the possibility of demonstrating that SM can be person-centred, equitable, and sensitive to the differential needs of marginalized patient groups.
As I described in section 4, many of those who choose SCAM do so following a long period of unsatisfactory encounters with medical professionals as they pursue the treatment or resolution of long-term chronic ailments (Furnham and Vincent 2000; Cant and Sharma 2004). The majority of these patients are women. While SCAM practitioners are unlikely to offer therapies that are effective beyond placebo, they are able to offer consultations which are longer, more participatory, and more personalized. It is likely that most of the placebo effect is interpersonal and stems from the ritual of healing within encounters with practitioners, rather than from any specific therapy (Miller et al. 2009). There is some evidence that open label placebos still confer a placebo effect, which suggests that the therapeutic relationship plays a significant role (Kaptchuk et al. 2010). In light of these insights, Blease (2012) suggests that the placebo effect instead be referred to as the ‘positive care effect’. Given the importance of communication and autonomy amongst patients choosing SCAM, it is interesting to note that a surgical study shows that the extent of the positive care effect is contingent on the quality of the clinical encounter, with communication skills aimed at empowering patients being predictive of better clinical outcomes (Trummer et al. 2006).
Focusing on the U.K. healthcare system, I therefore recommend that general practitioners, who are the gatekeepers of the medical profession, make efforts to address the inadequacies in the clinical encounter, specifically for those with long-term health conditions or medically unexplained symptoms. As it stands, general practitioners in the United Kingdom spend ten minutes with each patient and are encouraged to focus on a single health issue. It is therefore unsurprising to note that dissatisfaction with the clinical encounter is shared by clinicians. In a recent survey, 55 per cent of general practice surgeries in the United Kingdom reported concerns about the quality of care they could provide and described their workload as unmanageable most of the time; 13 per cent reported that it was unmanageable all of the time (Iacobucci 2016). In another study, 68 percent of general practitioners expressed the view that care could be improved by longer, higher-quality consultations, while 67 percent felt that patients with long-term conditions should be afforded longer consultations (Rimmer 2015). It has been demonstrated that longer consultation times correlate with a greater likelihood of taking a thorough medical history and conducting examinations in accordance with good practice, a lower prescribing rate, a greater likelihood of offering advice about preventative healthcare, and fewer follow-up consultations (Wilson and Childs 2002).
General practitioners are currently able to make referrals to specialists in various clinical disciplines. In addition to lengthening standard consultation times, the option of making general referrals may be a constructive way forward, i.e. arranging for the patient to have a lengthier consultation with a general practitioner rather than being siloed into a specialist referral (which is liable to be an even less holistic encounter) or sent away. Given the importance of the therapeutic encounter, it is also worth considering increasing the number of talking therapies referrals for long-term physical health problems. As it stands, talking therapies are recommended within the U.K. National Health Service for a range of social, mental, and physical conditions. This could be broadened, so that those whose physical symptoms are not being satisfactorily resolved within the biomedical paradigm are able to benefit from a personalized therapeutic relationship which does not rely on implausible mechanisms (NHS Choices 2016).
That women may be less likely to benefit from medicine and therefore more likely to spend time and money seeking therapies whose claims are questionable, whose benefits are negligible, and whose potential for exploitation is considerable, is a grave matter. Researchers and clinicians must take responsibility by consciously modernizing biomedicine to ensure that its goods are accessible to all and that the benefits of a positive therapeutic encounter are acknowledged and prioritized in the delivery of care.
One does not need to be a feminist to see that Arianne Shahvisi is correct in her line of arguing. Her insights are important and very well-put. Yet, they represent merely one aspect of SCAM, and there are many others. For instance, many consumers are not motivated to try SCAM by a disenchantment with SM. In fact, most of the research shows that this is not the main reason for becoming a SCAM proponent.
But, whatever the reason, it seems clear to me that those who subscribe to SCAM are getting a poor bargain. Arianne Shahvisi is therefore entirely correct in demanding that SM has to get its act together to avoid this from happening. I must have written and said it hundreds of times: whatever SCAM is, it is a poignant criticism of SM which must be used constructively for improving SM.
All I can say to S&M CON-MEN (CONventiional MEdiciNe) is good luck with trying to change your clinical experience, while the insurance companies or NHS is/are breathing down your neck. Come on over to CAM on the other side if you want to enjoy your practice and help your patients. Trust your own experience if you want to see if alternative therapies are effective or not.
How clever of you Roger to find the secret code of the terrible murderous medical lizzard people ???????
It’s an interesting paper. In recent researches looking at links between anti-vacccination and UK homeopathy I came across the paper The body, health, and healing in alternative and integrated medicine: An ethnography of homeopathy in South London which does mirror some of Shahvisi’s findings. Unfortunately, because of the way that it is formatted, it’s not exactly easy to read.
There is considerable irony in certain CAM pracitices having mostly female practitioners yet the instructors etc with the really bad ideas are male.
Shahvisi states “While SCAM practitioners are unlikely to offer therapies that are effective beyond placebo”. Placebo has only been demonstrated to help some of the symptoms of chronic disease while the patient is taking the placebo and the benefits wear off after they stop.
I cant speak for other forms of alternative medicine but homeopathy has a well-documented 200 year history of long-term cures of chronic disease of all varieties. Homeopathy has thrived, because of its well deserved reputation of curing. If it didnt it would have died out long ago; bad news travels fast.
Shahvisi recommends “it is also worth considering increasing the number of talking therapies referrals for long-term physical health problems.” Nothing pisses of patients more than having their doctor imply that their symptoms are psychosomatic. Good luck with that advice. That will send even more patients to alternatives. A psychosomatic illness is defined by S&M doctors as any illness that S&M doctors cant cure.
“Placebo has only been demonstrated to help some of the symptoms of chronic disease while the patient is taking the placebo and the benefits wear off after they stop”
PERHAPS, BUT ADMINISTERING AN EFFECTIVE THERAPY WITH COPASSION GENERATES A SPECIFIC EFFECT PLUS A PLACEBO EFFECT AND IS THEREFORE PREFERABLE.
“homeopathy has a well-documented 200 year history of long-term cures of chronic disease of all varieties. Homeopathy has thrived, because of its well deserved reputation of curing. If it didnt it would have died out long ago; bad news travels fast.”
THIS IS NOTHING BUT A FALLACY – READ UP: APPEAL TO TRADITION
I thoroughly enjoyed this article. Thank you for signposting Edzard!
What I still find confusing is the ethics around using a placebo/CAM in a hypothetical (sometimes not) situation where there is no/any longer an effective therapy but there is a medical (scientific) diagnosis made.
For example in chronic fibromyalgia (I do understand that diagnosis is very difficult in this case but let’s assume it isn’t for this hypothetical)
Assuming, duloxetine, pregabalin, exercise therapy and education have all been tried to no avail (I have recently seen this in GP!), would it be ethical to use a CAM therapy such as acupuncture as a placebo for symptom relief if it satisfied these conditions:
– The intentions of the physician must be benevolent, and her only concern the well-being of the patient.
– The placebo cannot be given in place of another medication that the physician reasonably expects to be more effective.
– Administration of placebos should be considered when a patient is refractory to standard treatment, suffers from its side effects, or is in a situation where standard treatment does not exist.
– The placebo can be named for what it is, but this is not required. It is then sufficient to make a statement along the lines that the substance provided has been found to be effective for the problem at hand, even though the mechanism is uncertain.
– Placebos should only be used where research has provided empirical evidence to expect them to have the potential of providing relief (eg, for pain, depression, etc).
– When proved ineffective the placebo should be withdrawn.
– The physician should not lie. She should respond honestly when asked about nature and expected effects of the placebo treatment she is offering. In addition, an explanation of top-down interventions is appropriate and may serve as an educational corrective to dominant chemo-centric tendencies in medicine.
we are in a grew zone in such cases, I think.
I never had a MD offer me a placebo, not even a mention of it.
Come to think of it, nobody I’ve ever known has ever been offered or prescribed a placebo… that they’ve told me.
I think you’re missing my point RG.
Ahhhhh yes…. the point is a hypothetical, who cares what happens in the real world.
Ok…. I’ll play the game. Let’s talk about a hypothetical situation you suggested.
No, in my view it’s not unethical or illegal for a MD to prescribe CAM OR other placebo treatment, IF they notify the patient first. Personally I’d rather subject myself to placebo treatments that much of SBM.
Do not assume there will be no placebo effect if the patient is aware of receiving placebo treatment.
In clinical trials patients might be aware they could be receiving a placebo. However, data suggest that even if the patient knows they ARE receiving a placebo, the placebo effect is still effective.
“Placebos often work because people don’t know they are getting one. But what happens if you know you are getting a placebo?
A 2014 study led by Kaptchuk and published in Science Translational Medicine explored this by testing how people reacted to migraine pain medication. One group took a migraine drug labeled with the drug’s name, another took a placebo labeled “placebo,” and a third group took nothing. The researchers discovered that the placebo was 50% as effective as the real drug to reduce pain after a migraine attack.”
So in such an event that the patient knows, you can throw all those illegal and unethical cautions out the window.
Shavisi, do you know if any one any evidence whatsoever that any homeopathic remedy has ever had any effect on anything?
And are there any randomised controlled clinical trials of a placebo remedy (a ‘pure’ sugar pill) for one group and the other group receiving ‘genuine’ individualised remedies – and all going through the prescribed ritual (pillule containers with genuine labels, instructions not to touch the pillule etc.). Double if not triple blinded of course.
If there was a demonstrated difference between the two groups – intensive serious scientific research would be indicated.
If no difference was demonstrated, homeopaths would have to give up on their remedies, but continue developing their counselling skills – which is how they get the results they claim.
‘Homeopathy’ would continue.
Homeopathic remedy manufacturers would have to stop trading in that field.
Tough, but that’s what integrity demands.
Psychosomatic illnesses are ‘physical’ – how do you think thoughts occur?
A vital force no one has ever identified?