Letters
Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? TO THE E DITOR : The commissioned article by Pirotta, dealing with the ethics of prescribing alternative complementary treatments that may lack an evidence base,1 contains a number of statements which, if the article had been subjected to peer review, might well have finished up on the cutting-room floor. For example, the statement “it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence” is not backed up by the only monograph cited in support of it.2 Whatever relevance a lack of level-1 evidence may have to the practice of dermatology (for which it is claimed), it plays little part in either modern medicine or the revolutionary advances in surgery, few being the result of a systematic review of multiple well controlled randomised trials. Having said that, the reference to complementary or alternative treatments that lack any evidence base as “medicine” gives a misleading legitimacy to practices that may be — and frequently are — based on cultural, historical or spiritual beliefs, or even just plain wacky approaches to healing. Regrettably, Pirotta adds nothing new to the (uncited) definitive 2004 article by Kerridge and McPhee.3 How times have changed. Not only are doctors now expected to
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the reference to complementary or alternative treatments that lack any evidence base as “medicine” gives a misleading legitimacy
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Gerber
have sufficient knowledge of complementary and alternative medicine to be able to advise their patients of therapeutic alternatives, but we may well have reached the stage where a failure to alert patients of such alternative treatment options may constitute negligence at common law. The New South Wales case of McGroder v Maguire4 is instructive. In that case, the plaintiff, a truck driver, had suffered a neck injury in the course of his employment. Despite a lengthy period of treatment, he continued to suffer from tingling in his arm. The defendant, a general practitioner retained by the plaintiff’s employer, although not having examined the patient, nevertheless referred him to a chiropractor. This referral was held to have been negligent, not because of the referral per se, but because of the patient’s condition. This came to light in the evidence given by a neurosurgeon and orthopaedic surgeon at the trial of the action, both of whom agreed that this case was not one for chiropractic manipulation of the plaintiff’s neck and back. Despite subsequent neurosurgery, the plaintiff became totally incapacitated for work. In the result, both the referring GP and the chiropractor were held to be liable in negligence. Paul Gerber Honorary Reader in Legal Medicine Faculty of Health Sciences, University of Queensland, Brisbane, QLD.
[email protected] Competing interests: No relevant disclosures. doi: 10.5694/mja11.10923 1 Pirotta MV. Is it ethical for medical practitioners
to prescribe alternative and complementary treatments that may lack an evidence base? — Yes. Med J Aust 2011; 195: 78. 2 Abeni D, Girardelli CR, Masini C, et al. What proportion of dermatological patients receive evidence-based treatment? Arch Dermatol 2001; 137: 771-776. 3 Kerridge IH, McPhee JR. Ethical and legal issues at the interface of complementary and conventional medicine. Med J Aust 2004; 181: 164-166. 4 McGroder v Maguire [2002] NSWCA 261. ❏
TO THE E DITOR : We read with interest the commentaries by Pirotta and Dwyer on complementary and alternative medicines (CAMs).1,2 This debate has a long history, spanning more than two decades,3 and the pessimism continues to ignore good science.2
Letters Firstly, integrative medicine (IM), which combines alternative and conventional medical practices, is not and never has been synonymous with CAMs. IM is a global paradigm shift that expands the conventional model of medical care with evidence-based laboratory and clinical research. IM embraces the foundations of medicine, such as (i) the critical role of the doctor–patient relationship, (ii) the importance of lifestyle, and (iii) improving the wellbeing and promoting the natural healing potential of people afflicted with disease.4 Secondly, a thinly disguised commentary on the ineffectiveness of CAMs,2 while dismissing a large body of scientific clinical evidence, is broadly misleading. This is significantly remiss, failing to cite the value of prebiotics and probiotics in digestive diseases,5 the effect of omega-3 essential fatty acids on endothelial function,6 the efficacy of acupuncture for some forms of pain,4 mindfulness-based stress reduction and mindfulness-based cognitive therapy for mental health,7 and emerging modalities such as yoga for menopausal symptoms4 and tai chi for fibromyalgia,4 and many more.4 Moreover, such deliberate carelessness serves only to confuse researchers and clinicians, as well as the public. Evidence-based medicine is critical in expanding the medical model of care; of this there can be no doubt. Adhering to biologically plausible mechanisms of action is the key foundation that will always guide scientific evidence, including that for CAMs. As an example, we have recently scientifically challenged the validity of the antioxidant effect to abrogate free radicals that are purported to contribute to the development of chronic diseases.8 Therapies that deviate from the conventional medical model still elicit an unhealthy cynical response2 that hinders the progress of scientific and medical investigations. If Florey and Fleming had adopted such cynicism and dismissed the biologically farfetched notion of an antimicrobial mould in a Petri dish (Penicillium notatum), they most probably would not have pursued and contributed to the discovery of the antibiotic penicillin. Thus there is no place in
science and medicine for the imprimatur of distrust and scepticism that is levelled without respite at novel concepts, even those with scientific plausibility. Luis Vitetta Associate Professor and Director1 Shoshannah L Beck Research Assistant 1 Samantha Coulson PhD Scholar 1 Avni Sali Director 2 1 Centre for Integrative Clinical and Molecular Medicine, University of Queensland, Brisbane, QLD. 2 National institute of Integrative Medicine, Melbourne, VIC.
[email protected] Competing interests: Luis Vitetta and Avni Sali have research collaborations with nutraceutical companies in Australia. doi: 10.5694/mja11.10916 1 Pirotta MV. Is it ethical for medical practitioners
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to prescribe alternative and complementary treatments that may lack an evidence base? — Yes. Med J Aust 2011; 195: 78. Dwyer JM. Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? — No. Med J Aust 2011; 195: 79. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998; 280: 1569-1575. Kotsirilos V, Vitetta L, Sali A. A guide to evidencebased integrative and complementary medicine. Sydney: Churchill Livingstone Australia, 2011. Yan Y, Polk DB. Probiotics: progress toward novel therapies for intestinal diseases. Curr Opin Gastroenterol 2010; 26: 95-101. Egert S, Stehle P. Impact of n-3 fatty acids on endothelial function: results from human interventions studies. Curr Opin Clin Nutr Metab Care 2011; 14: 121-131. Fjorback LO, Arendt M, Ornbøl E, et al. Mindfulness-based stress reduction and mindfulness-based cognitive therapy — a systematic review of randomized controlled trials. Acta Psychiatr Scand 2011; 124: 102-119. Linnane AW, Kios M, Vitetta L. Healthy aging: regulation of the metabolome by cellular redox modulation and prooxidant signaling systems: the essential roles of superoxide anion and hydrogen peroxide. Biogerontology 2007; 8: 445-467. ❏
TO THE E DITOR : I am concerned that the viewpoints by Dwyer1 and Pirotta2 were published without establishing a clear definition of “complementary and alternative medicine” (CAM). The term CAM is not ideal as it groups many non-evidence-based therapies that have little in common, such as iridology and homoeopathy, with more evidence-based complementary therapies such as acupuncture, nutritional medicine, meditation and some herbal medicines that have demonstrated efficacy. To date there is a growing body of research, including Cochrane
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Therapies that deviate from the conventional medical model still elicit an unhealthy cynical response that hinders the progress of scientific and medical investigations
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reviews, to support the use of some complementary therapies (Box). The fact that many complementary therapies have not been tested and subjected to high-quality research does not necessarily mean they do not work.3 For other complementary therapies, there are mixed findings (negative trials balanced by positive trials, as seen in Cochrane reviews), so one needs to ask why the differences in results? Were there differences in dosage, the quality of the substance or method of the therapy tested? Would you argue with patients who find symptomatic relief for troublesome symptoms of menopause from herbs when they are intolerant to hormone replacement therapy, or relief from osteoarthritic pain from complementary medicines and acupuncture if non-steroidal antiinflammatory medications are contraindicated because of a peptic ulcer? Demand for complementary therapies in Australia is actually coming from consumers. If they found the therapies unhelpful, why would they continue with them? A better term for complementary and alternative medicine is integrative medicine (IM), defined as: the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.4
Vitetta et al
Sources of evidence supporting the use of some complementary medicines Topic
DOI
Cranberry for prevention of recurrent urinary tract infections in young women
10.1002/ 14651858.CD001321.pub4
St John’s wort in major depression
10.1002/ 14651858.CD000448.pub3
Pygeum africanum for benign prostatic hyperplasia
10.1002/14651858.CD001044
Herbal medicines for treatment of irritable bowel syndrome
10.1002/ 14651858.CD004116.pub2
Acupuncture for tension-type headache
10.1002/14651858.CD007587
Acupuncture for migraine prophylaxis
10.1002/ 14651858.CD001218.pub2
Garlic for hypertension
10.1186/1471-2261-8-13
DOI = digital object identifier, which can be used to locate the relevant articles at http://www.doi.org or http://www.crossref.org.
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Letters The aim of IM is to find common ground and respect for the patients who choose to use complementary therapies and to understand their use. General practitioners have been shown to be very interested in learning about complementary therapies, with one study finding that about 30% of Australian GPs identified themselves as practising IM and most (more than 80%) requesting more education and research in complementary therapies.5 It is important that doctors balance clinical decisions between the risks associated with any therapy, the evidence and the therapeutic clinical outcome (effectiveness) to inform patients appropriately. Vicki Kotsirilos General Practitioner Whole Health Medical Clinic, Melbourne, VIC.
[email protected] Competing interests: I was the Founder and Founding President of the Australasian Integrative Medicine Association. doi: 10.5694/mja11.10877 1 Dwyer JM. Is it ethical for medical practitioners
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to prescribe alternative and complementary treatments that may lack an evidence base? — No. Med J Aust 2011; 195: 79. Pirotta MV. Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? — Yes. Med J Aust 2011; 195: 78. Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ 1995; 311: 485. Consortium of Academic Centers for Integrative Medicine. Definition of integrative medicine (adopted May 2004). http:// www.imconsortium.org/about/home.html (accessed Aug 2011). Brown J, Morgan T, Adams J, et al. Complementary medicines information use and needs of health professionals: general practitioners and pharmacists. Sydney: National Prescribing Service, 2008. http:// www.nps.org.au/__data/assets/pdf_ file/0020/66620/CMs_Report_-_HP_-_Apr_ 09.pdf (accessed Sep 2011). ❏
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