Detroit is my hometown, and three and a half years ago, after nearly twenty years away wandering between residency, graduate school, fellowship, and my first academic job, I found myself back in Detroit minted as surgical faculty at Wayne State University and practicing and doing research at the Barbara Ann Karmanos Cancer Institute. One thing that I had forgotten about while I was away for so many years is just how intimately southeast Michigan interacts with Canada. This closeness is not surprising, given that Detroit and Windsor are separated by only about a half mile of Detroit River. Indeed, a there are a lot of Canadians who cross the border on a daily basis to work in the Detroit area, many of them in the medical center within which my cancer center is located. The reason I point this out is not to wax nostalgic for trips to Windsor or for the occasional trip to Stratford to see plays but to point out that Ontario is right next to us. What happens there is of concern to me because I know quite a few people who live there and because it can on occasion influence what goes on over here on the U.S. side of the border.
I recently learned that the College of Physicians and Surgeons of Ontario (CPSO) has been working on updating its policy on the use of nonconventional medical therapies. The wag in me can’t help but wonder why such a policy would need to say anything other than that, if it isn’t science- and evidence-based, the CPSO doesn’t support using it, but in a less sarcastic moment I realized that such a policy is probably not that bad an idea, as long as it doesn’t legitimize pseudoscience, which is, of course, the biggest pitfall to be avoided when writing such a policy. Not too long ago, the CPSO released its draft policy and has asked for public comments, with the deadline being September 1. I was happy to learn that I had not missed the deadline, because there is much to comment about regarding this policy, but it’s definitely true that time’s short. Unfortunately, I wasn’t so happy when I read the title of the draft policy, namely , with a subtitle of “Formerly named Complementary Medicine.” The full policy in PDF form can be found at .
“Allopathy” versus everything else?
Regular readers of SBM will probably notice one thing right away, even before clicking on either of the links and reading the draft policy. The problem is right there in the title and, in fact, I was floored when I first read the title. My jaw dropped, and dropped hard. Basically, I couldn’t believe that the CPSO had decided to use the term “allopathic” to describe science- and evidence-based medicine. True, that wasn’t the only problem, but it gave me a sinking feeling to see such a term right there in the title. So what’s the problem?
“Allopathic medicine” was a originally coined by Samuel Hahnemann, the inventor of homeopathy to contrast homeopathy with the medicine of the time, namely that of 200 years ago. Hahnemann, as you may recall, believed in what he called the Law of Similars, which states that “like cures like,” or, to be more clear, that medicines that cause the same symptoms as a disease should be used to treat the disease. Doing this would stimulate the “vital force” and lead to resolution of the symptoms. Of course, this is nothing more than the principles of sympathetic magic transmuted (if you’ll excuse the term) into a different element, namely that of medicine; there has never been any convincing evidence—or even much in the way of evidence at all—that “like cures like” (or, using the Latin that Hahnemann favored, similia similibus curentur) is a general principle in biology or medicine. According to Hahnemann, “allopathy,” as opposed to homeopathy, is medicine that violated the law of similia similibus curentur and treats disease using remedies whose effects differ from those produced by that disease, the term meaning “other than the disease.” From its very origin, in fact, “allopathy” has been a derogatory term for medicine that is not homeopathy. Indeed, you can even find quotes to that effect documented in—of all places—the . For instance, points out in his book :
One form of verbal warfare used in retaliation by irregulars was the word “allopathy.” Coined two hundred years ago by Samuel Hahnemann, founder of homeopathy, it was taken from Greek roots meaning “other than the disease” and was intended, among other things, to indicate that regular doctors used methods that were unrelated to the disharmony produced by disease and thus were harmful to their patients. “Allopathy” and “allopathic” were liberally employed as pejoratives by all irregular physicians of the nineteenth century, and the terms were considered highly offensive by those at whom they were directed. The generally uncomplaining acceptance of [the term] “allopathic medicine” by today’s physicians is an indication of both a lack of awareness of the term’s historical use and the recent thawing of relations between irregulars and allopaths.
The other aspect of the term “allopathy” is that it was consciously used by practitioners of “unconventional” medicine to relegate “conventional” medicine to nothing more than another “competing” school of medicine. The term thus serves the simultaneous purpose of bringing “allopathic medicine” down to homeopathy’s level and elevating homeopathy to the level of conventional medicine. Far better, albeit still imperfect, characterizations could be:
- Science-based medicine versus nonscientific medicine
- Conventional medicine versus unconventional medicine
- Medicine versus unproven medicine
Other possibilities come to mind. Of course, my preferred one (reality-based medicine versus magic) is probably a bit too stark. Be that as it may, I would contend that accepting the language of practitioners of unscientific medicine and using it in an official policy statement is not a good idea. Language has power and meaning. No one knows that better than promoters of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) or whatever it is that quacks decide to call it next. While the use of language in the CPSO draft is disturbing enough in and of itself, there are more substantive problems with the draft that need to be discussed.
Beyond “allopathic medicine”
The opening of the CPSO statement does not begin any more auspiciously than the title, after which the statement quickly devolves into meaningless platitudes that accept many of the false equivalencies promoted by CAM practitioners when arguing for pseudoscience. For example, check out how the draft opens:
In increasing numbers, patients are looking beyond allopathic medicine to nonallopathic therapies for answers to complex medical problems, strategies for improved wellness, or relief from acute medical symptoms. Patients may seek advice or treatment from a range of health care providers, including Ontario physicians.
The College supports patient choice in setting treatment goals and in making health care decisions, and has no intention or interest in depriving patients of non-allopathic therapies that are safe and effective. As a medical regulator, the College does, however, have a duty to protect the public from harm. Thus, the object of this policy is to prevent unsafe or ineffective non-allopathic therapies from being provided by physicians, and to prohibit unprofessional or unethical physician conduct in relation to these therapies.
Right from the beginning, all the buzzwords and false equivalencies are right there. There’s the appeal to popularity in the form of the unreferenced, unsupported statement that more patients are embracing non-science-based medicine. That’s rapidly followed by the platitude assuring us that the CPSO supports patient “choice,” which implies by contrast that those who might not be as open to “non-allopathic” medicine are somehow against “patient choice.” particularly given the line of how the CPSO has “no intention or interest” in “depriving” (note the word choice) of their woo. Of course, one wonders what these “non-allopathic” treatments are that are both safe and effective might be. After all, if they were both safe and effective they wouldn’t be “alternative.” I’m tempted to repeat that old trope that alternative medicine that is proven to be safe and effective ceases to be “alternative” and becomes simply “medicine.” Never mind. I just did. So did the CPSO:
The categorization of specific therapies as non-allopathic is fluid: as clinical evidence regarding efficacy is accumulated, certain non-allopathic therapies may gain broad acceptance and thus be accepted in allopathic medicine.
I’ve tried to think of an example of any such therapies that have made the leap from “non-allopathic” to “allopathic” medicine and am hard-pressed to do so. Be that as it may, just because this is an old trope doesn’t mean it isn’t true. Substituting the term “non-allopathic” medicine for term “alternative” medicine or CAM in this draft statement not-so-subtly equates what was once called CAM or “alternative medicine” with “allopathic medicine.” Again, language matters, and the CPSO knows it. Its choice of the the term “non-allopathic” was deliberate:
Different operative terms have been adopted that were deemed to be value-neutral: ‘Allopathic medicine’ refers to traditional or conventional medicine (as taught in medical schools) and ‘non-allopathic therapies’ refer to complementary or alternative medicine.
Notice also how the CPSO chooses to characterize patients looking for CAM as “looking beyond” allopathic medicine, which implies that CAM modalities are somehow ahead of or superior to “allopathy.” A more appropriate way to phrase this concept would be to say that patients are looking “outside of” science-based medicine or “elsewhere than” science-based medicine. But, no. Patients are “looking beyond” that tired, old, hidebound scientific medicine.
Imagine my relief that the College is committed to preventing unsafe or ineffective “non-allopathic” therapies from being provided by physicians. You know, ineffective like homeopathy.
Platitudes mixed with disturbing statements
If there’s one thing about this draft that impresses me about the CPSO draft policy is the sheer number of meaningless platitudes the CPSO packed into it. Mixed in with these platitudes are statements that range from disturbing to just plain puzzling. For instance, one puzzling aspect of the draft occurs where the CPSO points out that physicians should “refrain from exploitation” and abusing his power over patients and avoid conflicts of interest. No one, least of all I, would argue that physicians should exploit their patients or engage in activities that represent a blatant conflict of interest, but nowhere in the draft is this principle related to the use of “non-allopathic” medicine by patients or physicians. At least for the other principles the draft at least takes a stab at trying to relate them to patient autonomy, which, of course, the CPSO supports. The CPSO also expects physicians to:
- Act in patients’ best interests, in accordance with fiduciary duties;
- Respect patient autonomy with respect to health care goals, and treatment decisions;
- Communicate effectively and openly with patients and others involved in the provision of health care;
- Maintain patient trust through a commitment to altruism, compassion and service.
As opposed to, I suppose, advocating not acting in patients’ best interests, not respecting patient autonomy, not communicating effectively and openly, and not being committed to altruism, compassion, and service. I know, I know, I’m being a bit curmudgeonly, and I realize that these sorts of principles have to be repeated and emphasized, but it’s about the specifics of how physicians will adhere to such principles “where the rubber hits the road,” so to speak that such a policy should provide guidance. I would argue that it is a physician’s responsibility always to be honest with his patients and to pull no punches when it comes to giving his professional opinion. That is the very essence of acting in the patient’s best interest and communicating effectively and openly. What, then, am I to make of some of the statements in this draft that sound suspiciously like advocating pulling punches? For instance:
The College expects physicians to respect patients’ treatment goals and decisions, even those which physicians deem to be unfounded or unwise. In doing so, physicians should state their best professional opinion about the goal or decision, but must refrain from expressing non-clinical judgements.
I can’t help but wonder whether calling, for example, homeopathy “quackery” would be viewed as a “non-clinical” judgment by the CPSO. The language used smacks of the CAM-enabling sort of language that demands that we physicians above all remain “nonjudgmental.” Personally, I would counter that it is our professional responsibility to be judgmental when it comes to evaluating the evidence for a treatment. It is our duty to judge what treatments are safe and effective and which are not; that’s what our patients come to us for.
Here’s another problematic passage:
When providing non-allopathic therapies, physicians are expected to demonstrate the same commitment to clinical excellence and ethical practice, as they would when providing allopathic care.
The problem here is that providing “non-allopathic” care that is not evidence- and science-based (in other words, virtually all of it) is inherently unethical and represents anything but “clinical excellence.” This is a rather amusing conundrum to me. Consider this example. If a physician (and, make no mistake, there are a fair number of physicians who do this) offers homeopathy, which is nothing more than magical water supposedly imbued with mystical healing caused by the “memory of water” remembering whatever remedy that was in it before and forgetting, as Tim Minchin puts it, all the poo that’s been in it. How can any physician ethically offer homeopathy, for example, to a patient? Similar arguments construct themselves for other “non-allopathic” therapies, such as reiki (which is faith healing that substitutes Eastern mysticism for Christianity as its basis) or acupuncture, which postulates that sticking needles into “meridians” that have no detectable anatomic counterpart somehow “unblocks” the flow of vitalistic mystical life energy to healing effect. Yet, the CPSO goes on to state:
Physicians must always act within the limits of their knowledge, skill and judgement9 and never provide care that is beyond the scope of their clinical competence.
This expectation applies equally to treatments or therapies that the physician proposes and those that may be requested directly by patients. Where patients seek care that is beyond the physician’s clinical competence, physicians must clearly indicate that they are unable to provide the care. Physicians should consider whether a referral can be made to another physician or health care provider for care the physician is unable to provide directly.
While this is simply a restating of basic physician ethics when it comes to science-based medicine, I can’t help but wonder: Does this policy in the context of emphasizing patient autonomy and choice somehow obligate or imply an obligation for an Ontario physician to refer to a “non-allopathic” practitioner if that is what the patient wants? Shouldn’t there be a clear statement that a physician is not obligated to support the use of “non-allopathic” medicine if he believes it—and correctly so—to be quackery? The whole thing is a muddle, particularly given the statements elsewhere in the policy about how diagnosis and treatment should be based on the principles of “allopathic” medicine?
A brief policy statement
It’s obvious from the wishy-washy approach to the scientific basis of medicine, the waffle words when it comes to whether an “allopathic” physician should support “non-allopathic” therapies, and the apparently inadvertent use of language favored by quacks that there were far too many “alternative” practitioners involved in drafting this policy. Similarly, the are dominated by believers, although I must admit that one of them does point out the conflict inherent in this policy, as the CPSO tries to have it both ways:
“To act in accordance with the standards of allopathic medicine, physicians providing non-allopathic care must reach an allopathic diagnosis”
This doesn’t make sense! If I want non-allopathic care, then that includes a non-allopathic diagnosis. Allopathic labelling is only useful for determining which prescription to write and has no business in non-allopathic medicine!
This would be a bit of a problem in traditional Chinese medicine, where the diagnoses are based on “imbalances” in heat, moisture, etc., and some diagnoses come about by mapping organs to locations on the tongue. Similarly, in homeopathy, diagnoses are not necessarily based on physiology and treatments are based on homeopathic “provings.” Yes, this believer nailed the conundrum that the CPSO is trying to dance around.
To that end, let me propose a much briefer policy statement for the CPSO to consider in a few bullet points:
- Medicine should be science- and evidence-based. “Alternative” and “evidence-based,” “allopathic” and “non-allopathic,” “conventional” and “unconventional” are all false dichotomies. If a treatment is not evidence- and science-based, it is not medicine. Such a treatment becomes “medicine” only when it is demonstrated to work by science.
- Competent adults have every right to seek out non-science-based medicine if that is what they desire. However, informed consent mandates that physicians who encounter such patients provide an honest professional assessment of such treatments based on science.
- Physicians should always inquire about the use of non-science-based medicine when evaluating their patients, so that they can take into account possible interactions with medical treatments.
- Physicians are in no way obligated to refer patients to “alternative medical” practitioners. For many forms of “alternative medicine” doing so is unethical because such modalities are not science- or evidence-based.
I’m sure readers can come up with their own versions or suggest modifications and/or additions to the bullet points above.
In the meantime, there is still more than a week left before the September 1 deadline for supporters of science-based medicine to let the CPSO know the problems in its draft policy by e-mailing [email protected] or filling out CPSO’s . It’s clear from the comments that are there now that more input from supporters of science-based medicine is needed.