A Culture of Standards Matters

We are often asked “What’s the harm?” when it comes to apparently benign placebo interventions for subjective symptoms. “If people feel better, who cares if it’s pseudoscience?” We have had to point out, endlessly, that there is a great deal of potential harm – delay or even avoidance of effective treatment, opportunity costs, financial harm, psychological harm, and overall promotion of unscientific medicine.

Perhaps the most insidious form of harm, however, comes from the erosion of standards within the medical profession. Medicine is only science-based and ethical if its practitioners are science-based and ethical. There is a standard of care within medicine to maintain a minimum of both quality and ethics.

The erosion of standards takes two basic forms – weakening of the system that maintains standards, and a softening of the culture of dedication to patients, science, and ethics among practitioners. I have discussed before how proponents of alternative medicine have been (successfully) seeking to weaken the regulations that maintain the standard of care, to remove protections for consumers, to change the rules of science to favor their preferred treatments, and to introduce magical thinking into medicine. They are literally changing the laws and regulations to lower the guardrails.

But perhaps an even more damaging effect of the alternative medicine movement is the slow change in the culture. You can post whatever speed limits you want, but if the culture is such that drivers routinely ignore the speed limits, and police routinely look the other way (or simply don’t have the resources or authority to do much about it), the posted limits become meaningless.

Regardless of your political leanings or whether you think the current administration is a good or bad thing for our country, it has clearly demonstrated that our elaborate system of checks and balances mean nothing if individual politicians are not motivated to adhere to them. No system and no institution is robust enough to withstand a culture of disregard for established standards.

This is exactly what I am seeing among a disturbing number of my medical colleagues. Alternative medicine propaganda has been slowly leaching into the medical culture, it has infiltrated medical education and is therefore changing with the generations, and it has weakened our collective dedication to a rigorous science-based standard of care.

I now see many more instances of otherwise reasonable science-based practitioners routinely referring to chiropractors, naturopaths, or acupuncturists without really knowing the kind of care their patients will be receiving, for example.

Perhaps the most common example is medical practitioners actually recommending pseudoscientific interventions, mostly for symptomatic treatment. They have bought into the “What’s the harm?” argument, or the placebo medicine argument of “Who cares if it really works if the patient subjectively feels better?”

This has always been a tempting practice. Everyone will accumulate patients who are difficult to treat, or have symptoms that are refractory to standard interventions. It is tempting to essentially punt, give them some placebo intervention to distract them (for a while, at least) so at least they will call your office less often. It is easy to convince yourself that this is OK – it’s OK to recommend pseudoscience to your patients, as long as its “harmless” pseudoscience.

The harder road, but the one that is better for your patients, is to carefully vet any practitioner or any treatment that you recommend, to make sure they are above the waterline in terms of scientific legitimacy and ethical standards. At the very least, the ethical standard of informed consent demands that you give your patients adequate information.

When patients ask me about an unscientific intervention, I tell them, “I don’t recommend that because I have reviewed the evidence and it is: not convincing, not plausible, too preliminary, or may even demonstrate lack of efficacy.” If they still decide to pursue it, at least you gave them your honest, professional, and informed opinion, and you did your due diligence.

Even worse is the increase in the number of practitioners and institutions who are increasing their income by directly selling pseudoscience. I know many local practitioners who are regular doctors, but they also have a cryotherapy chamber in their office, or sell aromatherapy supplements. Hospitals now routinely offer alternative treatments as add-ons for “quality of life”. Sure, we’ll have someone wave their hands over you for a fee. It’s almost free money.

The only thing that is really keeping doctors and hospitals from practicing rank but lucrative quackery is a culture of dedication to scientific standards in medicine. As that culture erodes, quackery increases.

And that is what the alternative medicine movement has always been about – it is about promoting profitable snake oil. Pesky laws, regulations, and the standard of care have been an obstacle to selling snake oil, and so the purveyors of all sorts of dubious treatments have campaigned to weaken the laws and regulations, and to abolish the standard of care.

They have largely succeeded. I don’t mean that there isn’t dedication to science within medicine, or many practitioners who do maintain high standards. Rather, I mean that the system now happily accommodates anyone who wants to sell snake oil alongside legitimate medicine. It’s all good.

I don’t know if it’s too late to turn this ship around. I’m hoping it isn’t. It will take scientists, academics, and serious politicians to wake up and see what is happening. There are signs of progress here and there, like the retreat of homeopathy over the last decade. It is still possible to make an argument that magic water doesn’t work and should not be accepted as a legitimate part of medicine.

But it will take those of us who clearly see the need for standards and the harm of pseudoscience in medicine to continue to forcefully make our case. Science matters. Standards matter. And while institutions and regulations matter also – the most important thing is a culture of respect for science and standards.