Media Advisory: Ontario Doctors Given the Green Light to Promote Quackery

August 12, 2011

Toronto, ON (August 12, 2011) – Ontario’s doctors could soon be pushed to promote unproven, ineffective, and potentially dangerous therapies, if a policy proposed by the College of Physicians and Surgeons of Ontario (CPSO) is approved. This is the conclusion reached by the Committee for the Advancement of Scientific Skepticism (CASS), a division of the Centre for Inquiry Canada, after reviewing the CPSO’s draft policy on Non-Allopathic (Non-Conventional) Therapies in Medical Practice. The Policy is the most recent attempt by the CPSO to address the growing popularity of alternative medicine. Unfortunately, the draft policy is more politically polite than scientifically supportable, and could put Ontario’s patients at risk.

One of the stated aims of the updated policy is to respect patient autonomy, but patient choice has little meaning if it is not informed by expert medical advice based on sound scientific evidence. The policy is heavily slanted in favour of alternative medicine and the language used even suggests equivalence between conventional and non-conventional medicine. Given the woefully unscientific nature of most of these therapies we find the suggested equivalence completely misguided, and bordering on irresponsible. As well, the use of the pre-scientific word “allopathy,” also suggests undue influence over the CPSO of the alt-med community who have a vested interest in selling these treatments.

“The policy also moves toward muzzling doctors to keep them from expressing concern about these practices if such opinions are “non-clinical,” even if the alternative therapy is completely implausible,” said Iain Martel, a CASS member and lead author of CASS’s response, “and yet at the same time no such constraint is put on alternative practitioners to keep them from impugning conventional medicine and speaking out against successful, safe, and vital public health programs like vaccination.” What is even more striking is the contrast between the CPSO policy and the British Colombian version: the CPSBC considers it unethical for a physician to prescribe a non-conventional therapy if there is no good evidence of the therapy’s effectiveness.

With the large increase in public fascination with alternative medicine it is an imperative for Ontario physicians to educate their patients about the pros and cons of these treatments. If a non-conventional treatment is supported by evidence to the same standard as a treatment used in conventional medicine, then the non-conventional treatment may also be considered, but given the unscientific nature of most “alternative” modalities, this is not likely to happen. “Ontarians look to their physicians for sound advice, based on solid medical knowledge, but under this policy, they may instead be directed to such magical nonsense as reiki and homeopathy, or prescribed dangerous chelation therapy,” said Martel, “it’s a significant risk.”

For More Information Contact:

 Michael Kruse, Co-Chair and Spokesperson

Committee for the Advancement of Scientific Skepticism

.(JavaScript must be enabled to view this email address) 

 

CPSO’s draft policy can be found here: http://www.cpso.on.ca/uploadedFiles/policies/consultations/non-allopathic-consultation-draft.pdf

 

Please Comment on the Policy here:  http://www.cpso.on.ca/policies/consultations/default.aspx?id=4310

 

 

CASS’s full response to CPSO’s draft policy can be found below (updated August 15 2011):

 

Comments on “Non-Allopathic (Non-Conventional) Therapies in Medical Practice”

 

About the Committee for the Advancement of Scientific Skepticism (“CASS”)

The Committee for the Advancement of Scientific Skepticism (CASS) is a national body of the Centre for Inquiry (CFI).  The mandate of CASS is to critically examine scientific, technological and medical claims in public discourse. Working with our expert advisers, we address factual inaccuracies and misinformation in public debates by promoting evidence-based science. To achieve these ends, CASS works within the infrastructure of CFI to co-ordinate campaigns with them and other interested parties.

General response

CASS has reviewed the CPSO draft policy, “Non-Allopathic (Non-Conventional) Therapies in Medical Practice”, and has a number of serious concerns about the policy. We understand that the aim of the new policy is to balance respect for patient autonomy with the need to protect the public from harm. Unfortunately, the draft policy leans far too heavily in the direction of the former, and is not sufficiently focused on the latter. In doing so, the new policy is unduly slanted in favour of non-conventional therapies. The loaded terminology used, and the painstakingly neutral language employed in comparing conventional and non-conventional therapies, suggests a false equivalence between the two. Given the woefully unscientific nature of most non-conventional therapies, we find such neutrality completely unwarranted.

 

In a message in CPSO’s Dialogue, Dr. Lynne Thurling states, “The bottom line is that we believe that the tenets of good medical practice apply to allopathic and non-allopathic care equally.” Unfortunately, this sensible principle is too frequently ignored in the text of the draft policy, where loose standards of evidence would allow the recommendation of non-conventional treatments that would never make it through the rigorous approval processes of conventional medicine. Indeed, the notion that non-conventional therapies that have been shown to be safe and effective exist is almost an oxymoron; such therapies would simply be added to the roster of conventional medicine.

 

Patient autonomy is an important principle, but it must not be confused with the adage that “the customer is always right.” When it comes to healthcare, patient choice has little meaning if it is not informed by expert medical advice, based on sound scientific research. We believe that physicians have a duty to inform patients who may be considering non-conventional therapies that the vast majority of such therapies have either never been properly tested for safety or efficacy, or else have been tested and have failed. Neutrality here is not an appropriate stance.

 

We have detailed below the main concerns we have with the draft policy. Rather than suggesting revisions to the existing document, we direct your attention to the guidelines produced by the College of Physicians and Surgeons of British Columbia, available online at https://www.cpsbc.ca/files/u6/Complementary-and-Alternative-Therapies.pdf (and attached to this submission). These guidelines capture far more accurately, we believe, the appropriate stance to take toward these therapies. In particular, the BC guidelines clearly capture the essential point that non-conventional therapies are generally unproven, and that in such circumstances it is unethical for a physician to recommend or endorse such treatments.

 

 

 

Detailed response

1.       Title and Terminology

The first objection we have to the draft policy lies in its title. This title introduces the terminology, to be carried throughout the document, of “allopathic” and “non-allopathic” therapies. This terminology, while commonplace in certain parts of the alternative medicine community, is rarely used within the medical community – with good reason[1]. As the history of the term “allopathy” shows, the term sets up a false dichotomy of medical paradigms, incorrectly suggesting a genuine competition between theories. Its use has historically been derogatory, invoking a spurious criticism of conventional medicine. Furthermore, it distracts attention from the real distinction between conventional and non-conventional medicine: that conventional medicine is based on substantial clinical and scientific research, while non-conventional medicine is based largely on tradition and scientifically-flawed principles.

 

The term “allopathy” was coined in 1810 by Samuel Hahnemann, inventor of homeopathy. Hahnemann intended the term as a contrary to “homeopathy”. Homeopathy is defined as the treatment of like with like, i.e. a disease is to be treated with a remedy which causes the same symptoms as the disease itself.    This is seen in the etymology of the term, derived from the Greek “homeo” = same and “pathos” = suffering. Allopathy, by similar formulation (“allos” = “different”), refers to the treatment of disease by a remedy that causes the “opposite” symptoms. In Hahnemann’s time, allopathy thus referred to the medieval medical practice of attempting to balance the four “humours”. Modern medicine, of course, follows no such principle, which would rule such mainstream practices as vaccination and radiation therapy non-allopathic, by definition.

 

Although Hahnemann’s term has always been rejected by mainstream medicine, it has frequently been adopted by chiropractors, naturopaths, and other opponents of conventional medicine, as a pejorative term. In this usage, allopathic medicine is solely concerned with the suppression of symptoms, whereas non-allopathic medicine treats the underlying cause. The term is thus a rhetorical weapon, used to advance an ideological claim. Moreover, the claim bound up in the term is fundamentally wrong; indeed, it exactly reverses the real situation. Whereas conventional medicine is frequently directed at discovering and treating underlying causes of illness – such as antibiotics to eliminate the microbial causes of infectious diseases – few non-conventional practices even address the real causes of illness. Homeopathy itself is purely concerned with symptoms, as shown by the homeopathic method of “provings”. And many naturopaths and traditional chiropractors are driven to reject modern theories of disease, in order to adhere to their vitalistic ideologies.

 

Finally, the terms “allopathic” and “non-allopathic”, by falsely suggesting an ideological opposition between competing medical paradigms, disguise the real distinction between mainstream medicine and the scientifically-unproven “traditional” remedies that fall under the label “Alternative and Complementary Medicine.” This is the distinction, buried in the draft policy, between therapies that have been rigorously tested and shown to be effective, and therapies which have either not been properly tested, or which have been tested and shown to be ineffective. The draft policy does note, “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.” What this formulation leaves unmentioned is the key corollary: that existing “non-allopathic” therapies are those for which such clinical evidence does not exist, and for which such evidence, in the vast majority of cases, is never likely to exist. It is this distinction that should be front and centre, and driving the entire policy.

 

Setting aside the problematic terminology, CASS also found problems in the definitions offered in the draft policy. Whereas, conventional (“allopathic”) medicine is defined as:

“the type of treatment, diagnostic analysis and conceptualization of disease or ailment that is the primary focus of medical school curricula and which is generally provided in hospitals and specialty or primary care practice,”

non-conventional therapies simply “differ” from conventional medicine in

“diagnostic techniques, theories of illness and disease, and treatment paradigms.”

This doggedly neutral language suggests a determination on the authors’ part to reinforce the notion that these are equivalent, competing paradigms. However, it has already been seen that the real difference is between evidence-based and non-evidence-based approaches. Such neutrality is entirely unwarranted and it is dangerously misleading for the College to suggest otherwise.

 

Let us be clear what is being implied here: the definitions in the policy suggest that the difference between the theory that diseases such as measles, cholera, and smallpox are caused by germs, and the theory, still held by some chiropractors, that such diseases are caused by “subluxations” in the spine lies merely in the fact that the former theory is the one taught in medical schools. No mention is made of the fact that the reason why such “conceptualizations” of disease are taught in medical schools is that they have been validated beyond any reasonable scientific doubt by centuries of basic and applied scientific research. No mention, either, that the conceptualizations of disease found in many non-conventional therapies – especially those based on vitalistic notions – are based on archaic medical models that have been thoroughly refuted by modern science. It is highly irresponsible for a professional organization to pander to such pseudo-scientific views via the spurious equivalence implicit in these definitions.

2.       Standards of Evidence

Although the draft policy includes, commendably, language requiring objective justification for all diagnoses and treatments, this language is frequently couched in terms that provide far too much latitude; potentially leading to the recommendation of treatments that are, in all likelihood, ineffective. The policy should make clear that the vast majority of non-conventional treatments have not been adequately tested, and that very few of them would survive such testing. In light of the poor track record of such treatments, the default position should be that they are not to be recommended. Instead, the policy allows, in many cases, for a diagnosis or treatment to be offered on the basis of very slim evidence. For example:

a.       Diagnosis

On diagnosis, the draft policy states that:

“If physicians also form a non-allopathic diagnosis, such diagnosis must be objectively justifiable, based on the clinical assessment conducted and other relevant information available to the physician.”

The problem with this requirement is that, as we saw earlier, many, if not most, non-conventional therapies (and diagnoses) are based on medical theories that are not merely unproven, but patently false. A diagnosis that the flow of one’s qi is blocked presupposes that qi exists, that it can be blocked, and that this can cause the symptoms observed; all of which is scientifically preposterous. Yet a physician may well claim objective justification for such a diagnosis, if such is the diagnosis suggested by an “authoritative” reference on acupuncture. Physicians should never suggest diagnoses that are based on scientifically implausible medical theories, and the Policy should make this clear.

b.       Therapeutic Options

In the section on therapeutic options, the draft policy does require that there be a reasonable expectation of efficacy, and that this expectation “must be supported by sound evidence.” However, the draft policy goes on to suggest that this evidence can be very weak in many cases:

“The type of evidence required will depend on the nature of the therapeutic option in question, including, the risks posed to patients, and the cost of the therapy. Those options that pose greater risks than a comparable allopathic treatment or that will impose a financial burden, based on the patient’s socio-economic status, must be supported by evidence obtained through a randomized clinical trial that has been peer-reviewed.”

This suggests that the evidential standard is lower for therapies that are low-risk, even if they are probably less effective than a conventional, more rigorously tested therapy. Moreover, the standard even for risky or expensive non-conventional options is far lower than it might appear: a single clinical trial, even of high quality, is of limited evidential value in the absence of replication or other evidential sources. The proposed standard would allow for the cherry-picking of one favourable trial, perhaps in a sea of contrary evidence, to be counted as “sound evidence”.

 

The bottom line is that, in determining therapeutic options, the standards applied to non-conventional treatments should be every bit as high as those applied to conventional treatments. Those standards are far higher than suggested in the draft policy.

c.        Ineffective and Unproven Therapeutic Options

Two further points are in order regarding the draft policy’s discussion of ineffective treatments and of treatments for which the effectiveness or risks are unknown. Regarding the former, an appropriate mandate to never propose ineffective therapeutic options is hollowed out by narrowing the mandate to options that have been “proven” to be ineffective. In science, we are told, it is impossible to prove a negative, thus rendering this rule effectively empty. A more appropriate mandate would be that treatments which are probably ineffective should not be proposed.

 

Regarding the far broader category of treatments for which effectiveness and risk are unknown, the draft policy veers toward incoherence. Given that the vast majority of non-conventional treatments fall into this category (or the probably ineffective category), the expectation of caution and suggestion of clinical trials appears incongruous with the generally more permissive policy in the earlier paragraphs. Perhaps the caution suggested here is more appropriate: where risk and efficacy are unknown, the cautious and ethical approach must be to refrain from proposing such treatment.

3.       Additional Concerns

a.       Line 97-100, line 223-226:

“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.”

“Clinical concerns must always be highlighted, however physicians must refrain from expressing personal non-clinical judgements or comments about the therapeutic options, or the patient’s health care goals or preferences unless that input is specifically requested by the patient.”

In these passages, it is unclear which “non-clinical judgements” are being excluded. We are concerned that they may be interpreted as imposing tight limits on physicians’ ability to state their honest, scientifically- sound, objections to pseudo-scientific medical theories and ideas. While physicians should refrain from expressing personal judgements about their patients holding such views, it would be morally and intellectually dishonest for a physician to withhold a view as to the merits of such bankrupt theories as homeopathy, even when the expression of such a view goes beyond the strictly clinical realm.

 

The apparent attempt to prevent physicians from expressing legitimate scientific skepticism about non-conventional medical practices and theories is particularly troubling, given that their non-conventional counterparts feel no such compunction in spreading misinformation about legitimate medical practices such as vaccination, as well as in misrepresenting the scientific standing of dubious non-conventional practices. Any policy that stands in the way of correcting this torrent of misinformation does a great disservice to the important goal of public medical literacy and may facilitate harm to patients.

b.       Line 176-177:

“…have a demonstrable and reasonable connection, supported by sound clinical judgement, to the diagnosis reached;”

“diagnosis” here is ambiguous: since the draft policy allows for the formation of a “non-allopathic diagnosis”, this clause might be thought to refer to such diagnoses. This would be problematic: since a non-conventional diagnosis may well have little bearing on reality, having a treatment option that is demonstrably and reasonably connected to it is hardly comforting. “Diagnosis” should read “conventional medical diagnosis”.

c.        Line 247-249:

“Where physicians are unfamiliar with the non-allopathic therapy in question, they must indicate as much to the patient, and explain that they are consequently unable to comment on the matter.”

This requirement, while seemingly innocuous, would prohibit a physician from advising a patient that, since the vast majority of non-conventional therapies are without merit, it is highly likely that the unknown new therapy is similarly without merit. Moreover, where an unproven therapy obviously conflicts with established medical knowledge, even a physician unfamiliar with the therapy is in a position to offer dissuading advice. (The requirement to indicate the limits of the physician’s knowledge is, however, clearly appropriate.)

d.       Footnote 13:

“This may include directing patients to journal articles, scientific studies and/or websites or providing them with more general resources, such as the contact information of regulatory colleges which govern practitioners of the desired therapy.”

The regulatory colleges for non-conventional medical practices (as well as related websites) are, regrettably, very poor sources of reliable information, and would be a poor recommendation.

e.        Line 278-279:

“there is a reasonable expectation that the care provided will be clinically effective.”

The standard of “reasonable expectation” is clearly lower than the standard of “on the basis of evidence, and sound clinical judgement” from the prior clause. Since one of the primary dangers from the use of non-conventional medicine is the harm that may result from the use of ineffective therapies in place of effective conventional therapies, the standard of evidence required should be no lower for efficacy than it is for risk. Furthermore, the required evidence must indicate that the efficacy is at least that of conventional alternatives.

4.       Conclusion

 

Despite the advancement of science and the ability to verify the efficacy of clinical interventions, there remain a number of hold-outs from our pre-scientific ancestors that either have not been shown to work or have been shown not to work.  Homeopathy is an example of such a therapy that has not been sufficiently studied and, where sufficient studies exist, has been shown not to be effective[2].  Despite this lack of evidence for efficacy, the general public makes extensive use of “complementary and alternative therapies” either alongside or, more worryingly, in place of conventional, evidence-based treatments.  In 2006, a survey found that 76% of Canadians had used at least one alternative therapy in their lives and it was estimated that Canadians spent around $7.84 billion between the latter half of 2005 and first half of 2006 on alternative therapies ($174 per user)[3].

            Physicians in Ontario have an opportunity to promote the principle of evidence-based medicine and start to reverse this potentially dangerous trend.  This principle is espoused in many policies at the College. We ask that you re-focus on this principle and reconsider the slide toward an ad populi capitulation in your draft policy on non-conventional medicine.

 

 

   

 

Comments:

Comment

Name:
Email:
Location:

Remember my personal information

Notify me of follow-up comments?

CFI Canada

Posts by CFI Canada Show Entries by all Voices of Reason Contributors

• Letter to Simon Fraser University concerning “Vaccine Summit: Vancouver 2013” at SFU Harbour Centre.

  4

  CFI Canada Mar 05, 2013

• Concerns over the Office of Religious Freedom and 3 Easy Ways YOU Can Help!

  CFI Canada Feb 21, 2013

• Media Advisory: BC Premier needs to clarify how her faith influences her politics

  2

  CFI Canada Jan 22, 2013

• Theology Pub, Topic: Free speech

  CFI Canada Jan 08, 2013

• Debate: Be it Resolved Government Funding for Ontario Roman Catholic Schools be Abolished

  2

  CFI Canada Jan 08, 2013

• Debate: Can We Be Good Without God and Where Does Our Morality Come From?

  1

  CFI Canada Jan 08, 2013

• Media Advisory: Protest Called Against Ugandan “Kill the Gays Bill” at Ugandan High Commission

  1

  CFI Canada Nov 30, 2012

• Media Advisory: Science Should Decide Harm Reduction Drug Policy, Not Politics

  CFI Canada Nov 27, 2012

• Eschaton 2012: A Conference Celebrating Reason at the End of the World (Ottawa Nov 30 - Dec 2)

  CFI Canada Oct 18, 2012

• Media Advisory: Atheists and Skeptics Host Major Ottawa Conference, First in Eastern Canada

  CFI Canada Sep 19, 2012

• X-Files “Smoking Man” Actor William Davis Discusses Skepticism and the Paranormal in Toronto

  CFI Canada Aug 20, 2012

• Media Advisory: Atheist Son of Homophobic Westboro Patriarch Fred Phelps Participates in Pride

  1

  CFI Canada Aug 17, 2012

• CFI Speaks in defense of Pussy Riot at Toronto Protest

  CFI Canada Aug 17, 2012

• Media Advisory - BC Premier Has Made Religion Fair Game For Critique: National Secular Organization

  1

  CFI Canada Aug 03, 2012

• Today: CFI Spokesperson Justin Trottier on Sun TV, CHCH News, 1010 Newstalk

  1

  CFI Canada Aug 02, 2012

CFI Canada's Index

Posts by All Free Thinking Contributors Show Entries by CFI Canada

• Letter to Simon Fraser University concerning “Vaccine Summit: Vancouver 2013” at SFU Harbour Centre.

  4

  CFI Canada Mar 05, 2013

• Concerns over the Office of Religious Freedom and 3 Easy Ways YOU Can Help!

  CFI Canada Feb 21, 2013

• Media Advisory: BC Premier needs to clarify how her faith influences her politics

  2

  CFI Canada Jan 22, 2013

• Theology Pub, Topic: Free speech

  CFI Canada Jan 08, 2013

• Debate: Be it Resolved Government Funding for Ontario Roman Catholic Schools be Abolished

  2

  CFI Canada Jan 08, 2013

• Debate: Can We Be Good Without God and Where Does Our Morality Come From?

  1

  CFI Canada Jan 08, 2013

• Media Advisory: Protest Called Against Ugandan “Kill the Gays Bill” at Ugandan High Commission

  1

  CFI Canada Nov 30, 2012

• Media Advisory: Science Should Decide Harm Reduction Drug Policy, Not Politics

  CFI Canada Nov 27, 2012

• Eschaton 2012: A Conference Celebrating Reason at the End of the World (Ottawa Nov 30 - Dec 2)

  CFI Canada Oct 18, 2012

• Media Advisory: Atheists and Skeptics Host Major Ottawa Conference, First in Eastern Canada

  CFI Canada Sep 19, 2012

• X-Files “Smoking Man” Actor William Davis Discusses Skepticism and the Paranormal in Toronto

  CFI Canada Aug 20, 2012

• Media Advisory: Atheist Son of Homophobic Westboro Patriarch Fred Phelps Participates in Pride

  1

  CFI Canada Aug 17, 2012

• CFI Speaks in defense of Pussy Riot at Toronto Protest

  CFI Canada Aug 17, 2012

• Media Advisory - BC Premier Has Made Religion Fair Game For Critique: National Secular Organization

  1

  CFI Canada Aug 03, 2012

• Today: CFI Spokesperson Justin Trottier on Sun TV, CHCH News, 1010 Newstalk

  1

  CFI Canada Aug 02, 2012

Free Thinking Index