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Answering Our Critics

Posted 25 September 2013

Some people don’t like what we have to say on Science-Based Medicine. Some attack specific points while others attack our whole approach. Every mention of complementary and alternative medicine (CAM) elicits protests in the Comments section from “true believer” users and practitioners of CAM. Every mention of a treatment that has been disproven or has not been properly tested elicits testimonials from people who claim to have experienced miraculous benefits from that treatment.

This article, by Harriet Hall, and posted to Science-Based Medicine, beautifully responds to the numerous criticisms leveled at CAMCheck. As she explains: “Our critics keep bringing up the same old memes, and it occurred to me that rather than try to answer them each time, it might be useful to list those criticisms and answer them here.” (This is part one. Part two continues here.)

In the event that the site goes down, as it did on 14 October 2013, the text is reproduced below.

 

Answering Our Critics, Part 1 of 2
Posted by Harriet Hall on September 24, 2013 (457 Comments)

Some people don’t like what we have to say on Science-Based Medicine. Some attack specific points while others attack our whole approach. Every mention of complementary and alternative medicine (CAM) elicits protests in the Comments section from “true believer” users and practitioners of CAM. Every mention of a treatment that has been disproven or has not been properly tested elicits testimonials from people who claim to have experienced miraculous benefits from that treatment. In previous articles I have compiled the criticisms of what I wrote about Protandim and Isagenix. It’s instructive to read through them. We welcome rational and substantive criticism, but most of these comments are neither.

Our critics keep bringing up the same old memes, and it occurred to me that rather than try to answer them each time, it might be useful to list those criticisms and answer them here. In future, when the same points are raised, we could save time and effort by linking to this page and citing the reference number. I know this list is not comprehensive, and I hope our readers will point out anything I’ve omitted. Here are some of the criticisms we keep hearing:

1. Big Pharma is paying you to promote their products and discredit CAM.

No it isn’t. We are not Pharma shills. We are not paid anything for writing this blog. We do not get money from pharmaceutical companies. We do not accept gifts from drug companies. We do not get kickbacks for prescribing certain drugs. We have no incentive to favor drugs over other treatments. Incidentally, critics who prefer natural remedies to pharmaceuticals should note that many CAM diet supplements are sold by subsidiaries of Big Pharma.

2. You’re biased.

Yes, we are, and that’s a good thing. We are biased in favor of science and reason. We are biased against claims that have been tested and disproven and that are incompatible with the rest of scientific knowledge. We are biased against health care providers telling patients things that are not true, presenting opinions as if they were facts. We are biased against using placebos because we consider it unethical. We are not biased against any CAM treatment just because it is CAM; we contend that there is only one medicine, that treatments have either been proven to work or they haven’t, and that all claims should be held to the same standard and tested by the same scientific method.

3. You’re afraid of the competition.

Not at all. The SBM bloggers aren’t affected by “competition,” since we are either salaried or retired and don’t make more money by seeing more patients. Most doctors are overworked and already have all the patients they can handle. CAM has only a very small share of the healthcare market. It’s not that we are afraid CAM will take patients away from us, it’s that we are concerned for our patients’ welfare and don’t like to see them lied to, given ineffective treatments, persuaded to reject effective treatments, and sometimes harmed.

4. Science isn’t everything: there are other ways of knowing.

When it comes to knowing whether a treatment is effective, there is only one reliable way of knowing: controlled testing using the scientific method. Intuition, tradition, revelation, “stoned thinking” à la Andrew Weil, dreams, extrapolation, speculation, and personal anecdotal experience can lead people to strong beliefs, but we can’t trust those beliefs to reflect reality. Only the scientific method can give us reliable knowledge. No matter how convincing they sound, claims must be tested before we can assume they are true.

5. It worked for me.

Maybe, maybe not. You can only know that you improved after the treatment; you can’t know for sure that you improved because of the treatment. That could be a post hoc ergo propter hoc logical fallacy. You may not be able to imagine any other possible explanation, but that doesn’t mean there isn’t one. Barry Beyerstein has explained some of the many ways people come to believe that a bogus therapy works. Also see the Quackwatch article on spontaneous remission and placebos.

6. Try it yourself.

Trying it for yourself is not a reliable way to find out if a treatment works. If the symptoms resolve, you have no way of knowing whether they resolved due to the treatment or whether they would have gone away anyway without treatment, or whether some other factor caused the improvement. That’s why science uses control groups. And what if your symptoms don’t resolve? That doesn’t rule out the possibility that the treatment works for 99% of patients and you just happened to be one of the other 1%. If you try a remedy and get better, it’s reasonable on a practical basis to try it the next time you have the symptoms, but it’s not acceptable to cite your experience as proof that “it works.”

7. Huge numbers of people use X, and they couldn’t all be wrong.

Yes, they could. Popularity is no indication of truth. Over the centuries, how many people have believed in astrology? For centuries, everyone believed bloodletting was effective in balancing the humors to treat disease. Only when it was properly tested did doctors discover they’d been killing patients instead of helping them.

8. It’s been used for centuries.

This is the argument from antiquity and is a logical fallacy. Dr. Novella explains why. It could be ancient wisdom, but it could just as well be ancient error carried over from a prescientific era.

9. It’s natural, therefore it’s safe.

Not necessarily. Many natural substances are poisons. Any natural remedy must be tested for efficacy and safety by the same standards we use to test “unnatural” remedies like pharmaceuticals. Dr. Novella has explained the naturalistic fallacy here. Herbs are drugs too, and anything that has an effect can have a side effect.

10. There is proof that X is correlated with Y (cites study).

Correlation does not prove causation. The rise in the number of diagnoses of autism correlates almost perfectly with the rise in the sales of organic food, but that doesn’t mean organic food causes autism. Correlation can be due to chance, error, poor data collection, and many other things. There may not really be a true correlation; and even if there is, that doesn’t tell us whether X caused Y or Y caused X or whether X and Y might both be caused by Z.

11. There are hundreds of studies that show X works.

In all-too-many cases, most of the studies supporters cite are in animals or test tubes, and others are opinion pieces, speculations, and irrelevant studies. There may be other, better quality human clinical studies that show it doesn’t work. Studies can be found to support almost any claim. Half of all published studies are wrong, for a variety of reasons that are constantly discussed on this blog. You can’t just look at positive studies: you have to look at the entire body of published evidence. That’s where systematic analyses come in. And they may not reflect reality: there may be negative studies that we don’t know about because they were never published: the file drawer effect and publication bias. And remember Carl Sagan: “Extraordinary claims require extraordinary evidence.” It would take a great deal of evidence indeed to overthrow all the established science that tells us homeopathy can’t possibly work as advertised.

12. You are just robotically supporting the official party line of mainstream medicine.

Most of the time we come to the same conclusions as the majority of mainstream doctors, because we are looking at the same evidence. When a body of experts evaluates all the published studies and makes evidence-based recommendations, we usually agree with them. Sometimes we disagree with their interpretation of the evidence (especially if they fail to consider prior probability or are including Tooth Fairy science) or with the way they have stated their conclusions. We understand that evidence-based guidelines are only guidelines, and judgment should be used in applying them to individual patients. We don’t agree just because we consider them authorities. There is a difference between the appeal to authority (he’s a professor at Harvard, so we should believe everything he says) and accepting the consensus of experts who know more about the field that we do (if 10 top mechanics all agree that your carburetor needs replacing, it is only reasonable to assume that it really needs replacing). All too often, CAM advocates are the ones who are parroting unreliable “authorities” who don’t know what they’re talking about.

13. Doctors only treat symptoms, not the underlying cause of disease.

This stupid CAM mantra is a vile, false accusation. Doctors treat the underlying cause whenever possible. If a patient has pneumonia, we don’t just treat the fever, pain, and cough; we figure out what microbe is responsible and provide the appropriate antibiotic. If a broken bone is painful, we don’t just treat the pain, we immobilize the fracture so it can heal. If a patient is in agony from pain in the right lower quadrant of the abdomen, we don’t just treat the pain, we try to figure out if the underlying cause is appendicitis, and if it is, we operate.

The people who accuse us of not treating “the underlying cause” are often the ones who think all disease is due to one bogus underlying cause (subluxations, disturbances of qi, poor diet, etc.). They also tend to use a single treatment (when all you have is a hammer, everything looks like a nail). I once googled for “the one true cause of all disease” and found 63 of them. Science-based medicine recognizes 9 whole categories of causes, with the mnemonic VINDICATE.

14. Science-based medicine can’t explain why some people get a disease and others don’t.

Neither can CAM. But doctors do have some pretty good ideas why it happens: exposure to infections, number of organisms that get into the body, genetic factors, toxins, immune deficiency, chance, and so on. CAM claims to fully understand why it happens, attributing it to some single cause that impairs optimum health (like a subluxation or a disturbance in qi, or improper diet). But they have not been able to show they understand the answer to that question any better than conventional medicine does, or that their understanding leads to better patient outcomes.

15. Conventional medicine kills patients.

I wrote about the “Death by Medicine” meme here. Critics gleefully cite statistics for drug reactions, medical errors, and iatrogenic deaths; but it is irrational to look at those numbers in isolation. Harms must be weighed against benefits. Medicine saves far more people than it kills. Many of those who develop treatment complications would have died even sooner without treatment. All effective treatments have side effects. We look at the risk/benefit ratios and reject treatments where the risk is greater than the potential benefit. The risk/benefit ratio of CAM should be compared to that of conventional medicine; if there is no proven benefit, no degree of risk can be justified.

16. Your minds are closed.

We are open to any new treatment, no matter how implausible, if only it can be shown to be safe and effective in well-designed controlled trials. Before we can ask how it works, we must ask if it works. If homeopathy had shown the same spectacular degree of success as penicillin, everyone would be using it. When Helicobacter was proposed as the cause of ulcers, it only took a few years for the evidence to accumulate and for antibiotics to become the treatment of choice. When a treatment like acupuncture has been studied for decades and even for centuries and its effectiveness is still uncertain, it is only reasonable to stop studying it and spend our research money elsewhere. We don’t need to keep an open mind about perpetual motion or a flat earth, and we don’t need to keep an open mind about homeopathy.

17. You are too prejudiced against CAM to look objectively at our evidence for it. No amount of evidence would change your minds.

We change our minds all the time based on changing evidence. We look at the best evidence for a CAM treatment before we reject it. We would accept CAM if it could present the same quality and quantity of evidence that it takes to reach a scientific consensus about any other medical treatment. What would it take for CAM advocates to change their minds? Most of them hold their beliefs so firmly that they reject any evidence to the contrary. One practitioner told me he would keep using his pet method even if it was definitely proven not to work, because “his patients liked it.”

18. Science keeps changing its mind.

Yes, and that’s a good thing. Scientific conclusions are always provisional. We follow the evidence wherever it leads, and we often have to change course as new evidence becomes available. CAM refuses to change its mind even in the face of clear evidence. Scientific medicine stops using treatments if they are proven not to work. CAM never rejects any treatment, and hardly ever tests one of its treatments against another to see which is superior.

19. Doctors are only out to make money.

I think most doctors go into medicine not because they want to get rich but because they want to help people. Medical education is long, grueling, and expensive. Most doctors incur substantial debts for their education and need years to repay them. The nice houses and cars don’t come until long after graduation. The median net worth for physician households is $700,000 and their median income is going down. The ones who really get rich are those who market bogus remedies or spread misinformation (like Dr. Oz, Andrew Weil, Burzynski, Daniel Amen, Kevin Trudeau, and all the companies that sell diet supplements and miracle weight loss aids). Boiron sold 566 million Euros worth of homeopathic remedies in 2012.

20. Alternative treatments are individualized and can’t be subjected to the same tests as pharmaceuticals.

Anything can and should be tested by scientific methods. For instance, homeopaths could prescribe individually in whatever way they chose, then the remedies they prescribe could be randomized with placebo controls and dispensed by someone else with double-blinding. Or the objective outcomes of treatment by conventional vs. CAM providers could be compared.

21. Doctors don’t do prevention.

They most certainly do! Who do you think invented vaccinations and preventive screening tests? Don’t you know about the US Preventive Services Task Force? MDs routinely talk to patients about weight control, diet, seatbelts and other safety topics, alcohol, drugs, domestic violence, exercise, etc. Studies on these topics are constantly appearing in the major medical journals. And there’s no evidence that the preventive efforts of CAM providers result in any better health outcomes than those of MDs.

22. Doctors don’t know anything about nutrition.

They understand the science of nutrition and advise their patients based on the available scientific evidence. Even if they haven’t taken a specific course titled “nutrition,” they learn how vitamins, minerals, and other nutrients are utilized biochemically throughout the body. CAM providers claim to know more about nutrition, but they often give pseudoscientific or unfounded diet advice.

23. CAM is better because it’s holistic.

CAM appropriated the holistic principle from mainstream medicine. Doctors are taught holistic principles in medical school. We are taught that the secret of the care of the patient is caring for the patient, not just treating the disease. Part of the standard medical history is a “social history.” Good clinicians consider the patient’s family, lifestyle, job, stresses, education, diet, socioeconomic status, beliefs, and everything about the individual that might have an impact on medical care.

24. We don’t need studies; we have plenty of testimonials.

10 anecdotes are no better than one; 100 are no better than 10. Anecdotal evidence is unreliable, no matter how many anecdotes you have accumulated. This lesson has had to be relearned over and over again throughout the history of medicine. Just think of how many testimonials there were for bloodletting in the Middle Ages. Anecdotes are useful, but only as a guide to what to investigate with scientific studies.

25. Why won’t you believe us?

We do. We believe you believe what you are telling us. We believe you had the experience you related. But that doesn’t mean your interpretation of your experience is true.

26. If you think X doesn’t work, why don’t you do a study to prove it?

It’s not that we think X doesn’t work, it’s that there is no evidence to make us think it does work. It is not up to us to prove a negative. It is up to the person making the claim to provide the supporting evidence. If I told you that putting a poker chip in your gas tank would give you better mileage, you should ask me to prove it. You shouldn’t feel obligated to either put a poker chip in your tank or do a study to prove it didn’t work.

27. Natural remedies don’t get tested because they can’t be patented and there’s no profit in it.

Nonsense. Many prescription drugs were developed from plants. The plant itself can’t be patented, but the drug company can isolate the active ingredient and patent that, or even improve on it with a synthetic version that is more effective and has fewer side effects. They can patent a unique method of converting a plant into a pill. There’s plenty of money to be made in herbal medicines, diet supplements, and even plain old vitamins: they generate billions of dollars’ worth of profits every year.

28. The medical establishment would drum out any doctor who tried to publish studies going against the party line, showing that X worked or that condition Y was real.

Quite the contrary. Peer review would critique the study. If it was a good study, others would investigate. A doctor who discovered a new disease or treatment would be honored. The treatment of ulcers with antibiotics is a case in point: Drs. Marshall and Warren won a Nobel Prize for their discovery. Montagnier was awarded a Nobel Prize for discovering the virus that causes AIDS only two years after the first reports of “gay-related immune deficiency syndrome.” Real diseases and new treatments are quickly recognized by the medical community.

29. You can’t know about it if you haven’t experienced it.

You don’t have to have been bitten by a snake to know how to treat snakebite. Male obstetricians are proof that you can deliver babies without having been pregnant yourself. We can know that antibiotics work for pneumonia without having had pneumonia ourselves. You don’t have to have used Perkins tractors to know that they don’t work. In fact, personal experience is a handicap: it tends to interfere with the ability to objectively assess the evidence.

30. If CAM makes people feel better, why deny them that? Even if it’s just a placebo, isn’t that a good thing?

That merits its own post, which will appear as Part 2 next week.

Note: If readers can think of other recurring memes that I’ve omitted, I can add them to next week’s post if you let me know in time.

31. X is officially approved by…so it must work.
They cite some organization or authority. It may be Medicare, insurance companies, state licensing boards for acupuncture/chiropractic/naturopathy, the WHO, the courts, specific hospitals/clinics, individual doctors or experts. Also: the NCCAM is studying it, so there must be something to it.

This is similar to #7, the argument from popularity. It is a logical fallacy called the argument from authority. These organizations are not authorities when it comes to scientific truth; often they are not even experts in science. They are influenced by factors like politics, expediency, customer demand, economics, lobbyists, legal maneuvering, etc. No matter how many authorities approve of a treatment, it must still be properly tested to determine safety and efficacy.

32. I can’t afford conventional medicine; CAM costs less.
If it costs less but doesn’t work, that’s false economy.

33. Studies show it doesn’t work, but what if it only works for me and a small minority of people like me?
That’s possible, but not very probable. If it worked for a significant minority of people, that would have shown up in the data, would have affected the statistics, and would have changed the outcome of the study. If the minority was too small to affect the study outcome, what’s the likelihood that you would be one of the special few that it actually worked for? The odds are against it, and there is no rational way to choose the one that might work for you out of all the various treatments that have been tested and shown to be ineffective.

34. My doctor said nothing was wrong with me, but my CAM provider did a test conventional medicine doesn’t do, and found a condition that needed to be treated.
How do you know it’s not one of the many bogus tests and bogus diagnoses that abound in the world of CAM?

35. Conventional medicine doesn’t have an effective treatment for my disease.
CAM doesn’t either. They may tell you they do, but they will only offer false hope and waste your time and money. Maybe it’s time to accept that there is no effective treatment and concentrate on finding ways to cope and improve your quality of life.

36. Why do you concentrate so obsessively on CAM instead of attacking the abuses of conventional medicine and Big Pharma?
This is sometimes phrased as “why don’t you put your own house in order before you criticize others?” We do frequently write about Big Pharma and about conventional medical practices. We don’t emphasize that, because conventional medicine is constantly criticizing and policing itself. Current practices are continually being re-evaluated and discarded if they are found ineffective. We concentrate on CAM because there is no such tradition of self-criticism in CAM, because they never reject any treatment when the evidence shows it doesn’t work, and because hardly anyone is writing critically about CAM.

This criticism amounts to saying “Why don’t you blog about what I consider to be important?” And the easy answer is: it’s not your blog, it’s ours. We get to decide.

 

 

Answering Our Critics, Part 2 of 2: What’s the Harm?
Posted by Harriet Hall on October 1, 2013 (95 Comments)

Last week I posted a list of 30 rebuttals to many of the recurrent criticisms that are made by people who don’t like what we say on SBM. I thought #30 deserved its own post; this is it. At the end, I’ve added a few items to the original list.

What’s the harm in people trying CAM? Science-based medicine has been criticized for being too rigid and intolerant. Why do we insist on randomized placebo-controlled trials to prove that a treatment is safe and effective? Isn’t it enough that patients tell us they feel better? Isn’t that what we all want, for our patients to feel better? Even if the treatment only works as a placebo, isn’t that a good thing? What’s the harm in that?
The albuterol/placebo study

I would argue that we don’t just want our patients to think they are better, we want them to actually be better. A study that illustrates that principle has been discussed on this blog before, here and here.

A group of patients using an effective albuterol asthma inhaler was compared to 2 placebo groups (a placebo inhaler group and a sham acupuncture group), and to a group that got no treatment at all. Patients reported the same relief of symptoms with each of the two placebo controls as with the albuterol inhaler; all three groups reported feeling significantly better than the no-treatment group. It could be argued that placebos are an effective treatment for the subjective symptoms of asthma.

But when they used an objective measure, improvement in lung function, airflow only increased in the albuterol group. The placebo groups were indistinguishable from the no-treatment group. So here you have patients who feel better and think they are better but who aren’t actually better, who might not recognize the severity of an asthma attack in time to get to the ER and avoid a fatal outcome. As Peter Lipson said, we have effective, lifesaving treatments for asthma, and treating an asthma attack with a placebo is folly.

An accompanying editorial was very misguided. It said:

What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place… For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.
Should the patient run the show?

Some of those conditions are not just defined by symptoms: they also have physical findings and laboratory abnormalities. Admittedly, only the patient can tell us whether he is experiencing pain, depression, etc. and we should always listen and believe him. But things like changes in behavior, medication use, and Parkinsonian tremor can be observed by others, and autoimmune disorders can be followed with blood tests.

Should patient-preferred outcomes be our goal? Do we really want to offer any treatment that makes the patient feel better? Penn Jillette famously said, “If all you want is to feel better, take heroin.” What if you carry the patient-centered concept to its extreme? What if a patient prefers high doses of heroin for headaches, or antibiotics for a cold, or demands unnecessary surgery? Apotemnophiliacs will be happy with the outcome if a normal, healthy limb is amputated. Heroin makes people feel euphoric, patients who get a prescription for antibiotics feel better than if they become angry because their wishes are thwarted, and a patient might feel reassured if an unnecessary exploratory laparotomy finds nothing wrong. Should that trump the judgment of the physician? I think not!

Doctors are consulted because they have expert knowledge. They have a responsibility to educate and advise patients and to work with them, taking their personal preferences into account, to do what’s in their best interest, not just what they think they want. Medicine is not like a retail store where the customer is always right. Placebos are unethical, and deception tends to undermine the doctor/patient relationship.
Just how powerful is the placebo?

The placebo has been highly over-rated. One writer even said it was proof that God exists. It has been claimed that one-third of all illnesses can be cured with placebo, but that’s not true. It’s a misunderstanding of a 1955 study by Henry Beecher. He looked at studies with a placebo arm and found that on average, one-third of subjects in the placebo arm reported improvement. But those subjects were not all experiencing placebo effects; some of them would have reported improvement with no treatment, due to the natural course of the disease or other factors.

Two later studies by Hrobjartsson and Gotzsche in 2001 and 2010 looked at studies that included both a placebo arm and a no treatment arm and concluded that:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

In their opinion, there is no place for the use of placebos outside of clinical research studies. Placebos may relieve headaches, but they can’t cure cancer or pneumonia. Antibiotics work just as well if the patient is asleep or in a coma; placebos only work if the patient is awake and knows he has been given something.

There’s not just one placebo effect, but a number of different placebo responses that work by different mechanisms including anxiety reduction, expectation, activation of the brain’s reward centers, conditioning, and learning. Fabrizio Benedetti has been doing exciting research on placebos, studying the physiological changes that occur when someone responds to a placebo. He also believes there is no place for placebos in clinical practice.
The stages in CAM reasoning

CAM advocates tend to pass through these stages:
They accept testimonial evidence and see no need for scientific testing.
They recognize that the scientific community will not accept their claims without scientific testing.
They do some studies.
When flaws in the studies are pointed out, they try to do better studies.
A systematic analysis of all studies fails to support their claims.
They are forced to admit that there is no convincing scientific evidence that their treatment works better than placebo.
They argue that even if the treatment is only a placebo, it should be used for its placebo benefit.
They argue that placebos are “effective” and that it is acceptable to lie to patients.
What’s the harm?

Val Jones coined the word “shruggie” to denote doctors who think alternative medicine is harmless and is not worth fighting. We think the “shruggies” are wrong.

Is there any harm in telling a patient that an ineffective treatment has real objective benefits? I would argue that this constitutes lying, is unethical, and undermines the doctor/patient relationship. If a patient finds out that the doctor has fooled him with a sugar pill, he won’t be able to trust the doctor again.

What if the patient is already using an ineffective treatment and believes it is helping him? We should ask if it is exposing the patient to a significant likelihood of harm. We should ask if the patient is using it instead of other treatments that have been proven to work or that might be lifesaving. If the answers to both questions are “no,” it is kinder and more humane not to challenge the patient’s belief.

We should have firm rules about evidence-based medicine and ethical principles, but there are times when the rules should be broken in the name of common sense and empathy. What if an 80-year-old woman has been getting monthly B12 shots for 40 years and is convinced she needs them, even though science tells us there is absolutely no legitimate medical indication for her to get them? It’s very unlikely that we could say anything that would change her belief. Challenging her belief will only cause her distress. If we deny her request, she will get the shots elsewhere. It’s not likely that the shots will harm her, and getting the shots is comforting to her and makes her feel better. In that case, I would break the rules and let her have the shots. I would feel a small twinge of guilt for breaking the rules, and we should feel that guilt whenever we break the rules, to minimize the chances of getting on a slippery slope and breaking them when we shouldn’t. We should break them only with very good reasons with which other reasonable people would likely agree.

So in individual, select cases, belief in ineffective treatments is relatively harmless and need not be confronted. But in general, false beliefs can do a lot of harm. There is a whole website, What’s the Harm, devoted to the harm that false beliefs can do. So far, it has compiled reports of 368,379 people killed, 306,096 injured and over $2,815,931,000 in economic damages. Please go there and look at some of the accounts of patients who have died or suffered serious consequences because of false medical beliefs about everything from acupuncture to vitamin megadoses.
The concept of comfort measures

What does “effective” mean? It’s important to understand the difference between objective outcomes and patient perceptions. We can conclude from the evidence that acupuncture is merely a theatrical placebo. We can conclude that it would be unethical for us to recommend it. But if a patient is already using acupuncture and feels it is effective in relieving his symptoms, that falls into the category of comfort measures, where the patient is deriving a degree of comfort from a procedure with no objective effects. Things like backrubs, fluffing pillows, and spending time listening to patients don’t cure disease, but they do provide comfort. No one wants to deny patients that kind of comfort. If the patient asks us about acupuncture or another objectively ineffective treatment, we can answer honestly with the negative scientific evidence while also acknowledging that some patients think they derive subjective comfort from it and that there is little chance of harm.
Conclusions
Placebos don’t really do much.
Placebos have no place in clinical practice. They are unethical.
Accepting false beliefs can harm and even kill. Using ineffective treatments can delay or interfere with effective conventional treatment.
Science-based medicine is the only reliable basis of establishing the safety and effectiveness of a treatment and developing rules for clinical practice, but we can sometimes justify bending those rules in the interests of patient comfort. Rigorous science can be tempered by common sense, benevolence, and empathy.
We can offer the patient comfort measures that will not change the course of the illness, as long as they are clearly identified as comfort measures with no false promises of therapeutic benefit.
We shouldn’t offer placebos, but we can sometimes condone them.
There is a fine line to walk between doing what patients think they want and what is in their best interests in the long run.

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