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Misleading the Patient for Fun and Profit

by Lewis Vaughn

The following article is from Free Inquiry magazine, Volume 18, Number 3.

Romance is in the air. The media, the public, the gurus, and the hucksters have gazed upon acupuncture, homeopathy, chelation therapy, herbal concoctions, magnetic therapy, and any other treatments called "alternative medicine" ... and have fallen in love. So, as in any romance, current talk about a beloved "alternative" therapy is usually marked by uncritical acceptance, blind commitment, feverish thinking, and occasional cooing.

In this atmosphere, there are two politically incorrect questions that you must never utter: (1) Is this true? (Are there good grounds for believing this claim?) and (2) Is this right? (Is it morally permissible to use or promote this treatment?) We are told that to ask question 1 (and the relevant accompanying questions about evidence and reasons for believing) is to reveal an annoying and pernicious bias in favor of Western science and rational ways of knowing. It is to show a callous disregard for the kind of validation that can come from people's subjective experiences. It is - worst of all - to give offense to those who have strong beliefs about the effectiveness of a treatment.

Fortunately, scientists - being the pigheaded realists that they are - have persisted in asking question 1 and have thus discovered, among other things, that acupuncture is no better than placebo, homeopathy doesn't work, and chelation therapy can kill you.

Question 2, however, is almost never asked. One version of it is particularly rare: Is it ethical to recommend or promote an unproven treatment - one that has little or no scientific evidence supporting its efficacy?

The issue is important because companies, advertisers, special interest groups, magazines, newspapers, television talk-shows, health practitioners, and others often do promote remedies and health practices that are unproven. This practice - for better or worse - can have enormous consequences for all of us.

Most medical scientists and health officials oppose the practice, sometimes warning that there isn't yet enough evidence to recommend a certain treatment to the public. Promoters of unproven treatments strongly disagree and sometimes ridicule officials for being "overly cautious" or "too conservative." Their most plausible arguments usually involve an appeal to the relative costs and benefits of a treatment. "What's the harm?" they may ask. "If the treatment itself is harmless, why shouldn't suffering people be given a chance to try it? There may be no strong evidence that it works, but if it does, the benefits to many people would be substantial. The costs to people - in terms of potential physical harm - are low. So on balance, it's best to urge people to try it; the possible benefits outweigh the possible costs." Promoters may believe that this argument is especially strong if the treatment has some preliminary evidence in its favor or if the monetary outlay for the treatment is low.

But is this really a good argument? Many on both sides in the debate would probably agree that weighing costs and benefits is a valid way to judge the issue. (This approach is based on the fundamental ethical insight that we ought to do what's likely to benefit people and avoid doing what's likely to harm them.) So the question reduces to whether promoting unproven treatments is likely to result in a net benefit to people. Does the promoter's argument show that his promoting leads to such benefit?

Actually, his argument fails. It fails because it's too simplistic, neglecting to take into account important factors in the cost-benefit equation.

One such factor is probability. Few people would judge a treatment solely on the magnitude of its proposed benefit or harm. Most would want to take into account the probability that the proposed effects would happen. Someone may claim that rubbing a stone on your belly will cure cancer. The alleged benefit is enormous - but the likelihood of receiving this benefit is almost nil. If someone wanted to sell you such a "cancer-curing" stone for ten dollars, would you buy it? Probably not. The proposed benefit is great but not likely to happen. The cost, though, is a sure thing: if you want the stone, you'll have to pay the price. So on balance, the likely cost, though small, outweighs the unlikely benefits, though great.

But what's the probability that any unproven remedy will be effective? The evidence relating to the remedy can't tell us; by definition, it's too weak to help us figure probabilities. We can, however, make a reasonable assumption. Scientists know that the chances of new hypotheses being correct are very low simply because it's far easier to be wrong than to be right. For the same reason, the likelihood of new health claims turning out to be true is also low. Historically, most health hypotheses, when adequately tested, have been found to be false. In drug testing, for example, scientists may begin with thousands of substances proposed as medicines, some with preliminary evidence in their favor. In the end, after assessing them all, only a meager handful are proven effective in humans. Some promoters misjudge the cost-benefit of recommending a treatment because they either overestimate the probability of its effectiveness or don't consider the factor at all. They seem to assume that the odds of any proposed remedy being effective are close to 50-50, especially if there's some preliminary evidence in its favor. This assumption is false.

When we plug realistic probabilities into our moral equation, the wisdom of promoting unproven treatments becomes suspect. Even if an unproven treatment has considerable possible benefits, is harmless, and costs little, it may be no bargain. In general, given the realistic probabilities, the most likely prospect is that the treatment will be ineffective. So, in fact, the odds are excellent that people who buy the treatment will waste their time and money. The likely cost outweighs the unlikely benefits. Promoting the treatment is not likely to result in a net benefit for people, but net harm. The possible benefit of a ten-dollar "cancer-fighting" rock may be great, but the low probability of its working makes buying it a bad deal. Promoting it would be unethical.

Clearly, the higher the cost of an unproven treatment, the less likely that promoting it will result in a net benefit. But there's more to the cost of an unproven treatment than many promoters realize. The monetary cost can vary tremendously and may not be low at all. (Many unconventional treatments cost hundreds or even thousands of dollars.) Other costs include the direct physical harm that a treatment can cause (nearly all treatments - drugs, surgery, herbs, vitamins, and others - cause some side effects). There's also an indirect cost: A few people (maybe many people) may take the promoter seriously and stop, postpone, or refuse a proven therapy to try the unproven one - a gamble that sometimes has tragic consequences. Then there's the very real emotional pain that false hope can often bring. In these ways, even a harmless therapy can cause harm. All these costs must be factored into the cost-benefit equation. Usually, they just make the promoter's argument weaker.

But, some will say, what about the placebo effect, the well-documented phenomenon of people tending to feel better after being given a bogus or inactive treatment? If someone who tries an unproven treatment experiences the placebo effect and therefore feels better, doesn't this mean that there is benefit to trying an unproven treatment after all? Doesn't the placebo effect thus change our moral equation?

The placebo effect (which happens in 30% or more of cases) would change the equation if it were unequivocally beneficial. But it is not. First, the placebo effect does not happen in every case. In fact, it is probable that in most cases it does not happen. Even when it does, it is often of short duration. So there is no guarantee that anyone will benefit from a placebo in any particular case. Second, placebos can cause adverse side effects (when they do, they're called nocebos). So they're not uniformly helpful. Third, placebo effects can encourage people to continue to use an ineffective treatment when more effective treatments are available. Placebo effects, after all, are not cures, but temporary feel-good phenomena. Fourth, placebo effects often inspire people to promote a remedy to friends and relatives - even though the remedy may be ineffective or harmful. This simply multiplies the problems that accrue to use of placebos. So in the promotion of unproven treatments, the placebo effect is usually not a point in the promoter's favor. Our moral equation still stands - generally against the promotion of meritless remedies.

Now, it's possible that a person could apply the cost-benefit approach in her own life and rightly conclude that she should try an unproven remedy. She could calculate that any possible benefit, though very unlikely, is well worth the cost because no other treatment is possible or because she considers the cost inconsequential. Promoters, however, aren't privy to such personal information about those who try unproven remedies. Promoters can only weigh the probable impact of their actions on other people. If they do so honestly, they'll have to conclude that, generally, promoting unproven treatments does more harm than good.

Lewis Vaughn is the Editor of Free Inquiry and The Scientific Review of Alternative Medicine.

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