Complementary Medicine: An Introduction to the Debate
By Elizabeth M. Whelan, Sc.D, M.P.H.
The January l9th New York Times obituary for Dr. William R. Fair, a renowned prostate cancer surgeon associated with Memorial Sloan-Kettering Cancer Center in New York, raises questions about so-called "alternative" and "complementary" medicine.
Dr. Fair was diagnosed with colon cancer in 1995 and underwent traditional therapy, including surgery and chemotherapy. These treatment approaches to colon cancer, while not guaranteeing a cure, have a strong record of efficacy in containing the disease and prolonging life.
But Dr. Fair chose to do more. He sought "complementary" therapy as well, including diet modification and herbal treatments approaches which have no known efficacy. The obituary writer, Denise Grady, was careful to point out that complementary medicine differs from alternative medicine in an important way: As the names suggest, complementary medicine is used in addition to proven therapies, while alternative medicine is used in place of proven therapies.
Should mainstream physicians and scientists recommend unproven methods to patients? Should physicians at least accept such methods when patients want to pursue them? Or should physicians dissuade patients? We asked two experts, Ross and Green, to comment:
Dr. Fair and Complementary Medicine
By Gilbert L. Ross, M.D.
I have been a strong advocate of orthodox biomedicine since my medical school days. This position has only been strengthened during my years as a public health advocate. One of my favorite sayings is: There is no such thing as "alternative medicine." There is no alternative to science; medicine is either scientific, i.e., supported by evidence of efficacy, or it's some mixture of superstition, hope, and magic.
That being said, the case of the late Dr. William Fair is the subject of some discussion and debate in medical circles, as it is with those who believe in the concept of "complementary-alternative medicine," or CAM. Dr. Fair, a renowned prostate cancer surgeon at MSKCC, developed colon cancer in 1995, at age sixty. He had first-rate care, obviously, including surgery and chemotherapy, but unfortunately a recurrence was discovered two years later. Further surgery yielded only temporary improvement, and his hope for a cure became effectively zero.
At this point, in an attempt to slow the progression of his disease without undergoing further debilitating treatments, he turned to unproven remedies, including yoga, exercise, prayer/meditation, diet, and herbal supplements. He also tried to assist researchers in developing a vaccine with specific potency against his own tumor tissue, without success. He is said to have noted an improvement in his sense of well-being, and his tumors were noted to have shrunk, to some degree. One of his colleagues noted that "whatever he was doing didn't do any harm."
What should physicians caring for patients in Dr. Fair's situation do when confronted with requests from patients for guidance on using CAM? For me, the decisive question would be, is the patient cooperating with recommendations for accepted treatments given by consultants expert in his/her condition? If so, and absent any specific known adverse interactions between a "complementary" program and the regime being prescribed by the oncologist in charge, I (as the patient's primary physician) would not object. Some would even define "complementary" medicine as being an addition to proven treatments, as opposed to "alternative" therapies which are given instead of proven therapies.
Why stand in the way of an informed, adult patient's desire to utilize such admittedly non-traditional medical approaches, as long as regular treatment is co-administered? I believe such pro-forma interference would be merely paternalistic. I would share my doubts with the patient as to the likely efficacy of CAM, but I would not try to stand in his or her way in the matter. To do so would show a stubborn adherence to dogma in the service of biomedicine. As long as the first principle of doing no harm is fulfilled, I will have done my duty towards my patient while helping to fulfill a goal that while almost certainly fruitless is nonetheless harmless.
Gilbert L. Ross, M.D.
Medical/Executive Director of ACSH
From an interview with Saul Green, Ph.D.
The use of words that are understood one way by the public and another way by the professional is dangerous. If you ask a doctor what the word "healing" means, he will describe a process that takes place in the body, identified step by step, such as the healing of a wound or the repair of a bone. When alternative medicine defenders use the word "healing," the medical consumer assumes the word still means "curing" in the physical sense. It does not. I've asked alternative medicine proponent Dr. Andrew Weil and others to define "healing" as opposed to "curing," and they all emphasize the fact that curing is merely a return to the state of health that you were in before you got sick, whereas healing, as they use the word, is essentially a spiritual or mystical process that enables "your body to heal itself," in ways that are not even be perceived by doctors or tests.
As alternative treatments have failed lab tests and trials, defenders of the techniques have moved to the term "complementary," to make these methods sound like harmless bonus items. Increasingly, testable physical claims are avoided and emphasis is put on the claim that for the methods to be useful, the patient must believe that they are going to work. Of course, if the patient is filled with hope and believes it's going to work, the patient in some sense "feels better" without actually getting better in any way we can measure. If the doctor sticks acupuncture pins in your ears and tells you it'll stop your arthritic pain, and you feel a little happier just because the doctor's paying attention to you, you may well say, "I feel better" for a moment. In fact, it seems the only way in which one can ever demonstrate any effect from these treatments is by asking the patient his mood. The catch phrase that is used by almost all practitioners of complementary medicine to gloss over the highly subjective and illusory nature of these results is to say merely that CAM is "intended to improve the quality of life of the patient" without directly addressing physical symptoms.
Now, there's nothing wrong with improving the patient's state of mind. I spent twenty years at MSKCC and there was a staff of priests, ministers, rabbis, social workers, volunteers who were art or music majors, psychologists, etc., all of whom provided services for free. But now, we have the department of Integrated Medicine at MSKCC and similar departments at hospitals elsewhere at which they give essentially the same treatments but talk as if they constituted a bold new area of medicine worth spending money on. (Thank goodness MSKCC at least makes these treatments complementary and not alternative.)
There is nothing wrong with providing a patient with comfort with music, art, nice smells, massages, meditation, and supportive company but when patients go into CAM clinics, they are not told clearly: What you are going to get may change your mood but isn't going to affect your disease or your treatment. The patients naturally believe that because they "feel better," they are getting better. It's a lie, and the people who practice this stuff know it.
Dr. William Fair gave up standard care only when it became clear it could no longer help him. Getting in the habit of arousing false hopes for unproven methods can all too easily lead to worse decisions, though, such as those made by another doctor, Ernst Wynder. He had treatable thyroid cancer but abandoned conventional treatment at the suggestion of his wife, a firm believer in the medical benefits of diet treatments, organic water, prayer, and other quackery such as the regimen of Dr. Nicholas Gonzalez, who fights cancer with coffee enemas. Wynder, who had once been a good scientist, died about two years later of metastatic thyroid disease. Standard treatment might have kept him alive another twenty years.
Ultimately, a doctor has to show respect for the patient's wishes, as Dr. Ross suggests in his article, but is it disrespectful toward the patient for the doctor to say some methods are quackery, some methods hold out false hope, some methods are just plain bad and won't help you? You tell patients the truth if you know it. Lies do moral harm, even if there's no immediate physical damage. Lies harm both the patient and the medical profession. Don't give the patient the impression even by tacit consent that an unproven method is going to help him. Doctors can offer options for counseling and psychological aid, but false hope is not responsible medicine.
Dr. Saul Green, biochemist retired, Memorial Sloan-Kettering Cancer Center; science editor of the Scientific Review of Alternative Medicine; president ZOL Consultants, New York City.
An article by Dr. Green on the grants given out by the government's National Center for Complementary and Alternative Medicine will appear in the Fall 2001 (Vol. 5, #4, out in early 2002) issue of The Scientific Review of Alternative Medicine.
February 6, 2002
To the Editor:
As a consumer health advocate concerned about complementary medicine misinformation, I was quite disturbed by the position taken by ACSH Medical Director Gilbert Ross in his commentary on CAM and the death of Dr. William Fair. Given his high position at ASCH, I am especially concerned that his remarks may represent a softening in ACSH's hitherto strong opposition to CAM irrationalism.
Commentator Saul Green correctly identifies Ross's attitude of "benign neglect" toward CAM to be what it really is an appeal to withhold the truth about CAM treatments (or "benign lying") from patients who are using such treatments. Ross, like so many other CAM-neutral docs, goes along with patients' CAM practices as long as standard treatments are also being practiced. Ross seems unconcerned that his patients' involvement with unproven CAM treatments may lead them away from scientific medicine, if not while he is treating them, perhaps during some future health crisis. The truth is that a doctor's knowing tolerance of irrational health beliefs and practices does neither his patient nor the greater society any good whatsoever.
A superb example of this is Dr. William Fair, the oncologist turned CAM devotee, whose death provided the occasion for the Ross-Green debate. While Ross comments that Fair was in search of a cancer vaccine, a presumably respectable endeavor, Ross does not tell the whole story. Indeed, he seems to be apologizing for Dr. Fair. Does he not know that Fair, in his desperation, was ideologically converted by medical mystic Dean Ornish, a believer in "distant healing" and psychic diagnostics, among other things? Fair not only practiced Ornish's dietary and meditational regimens, he also embraced wholeheartedly the entire mystical CAM movement. Fair, then, became useful to Ornish and friends as a "poster doc" for virtually all CAM treatments for cancer. Dr. Fair fell so far off the deep end that he became an editor of "distant healing" guru Dr. Larry Dossey's _Alternative Therapies in Health and Medicine_ journal. Dossey's (and Fair's) journal is notorious for boosting every paranormal healing practice in the books. "Distant healing", shamanism, "energy medicine," and Qi Gong are quite a jump from vaccine research. And, yet, this is what the befuddled Dr. Fair became involved in, up to his ever-loving earlobes.
By 2000, Fair had become such a "poster doc" that the bizarre James S. Gordon selected him (and Ornish) for his White House Commission on Complementary and Alternative Medicine. Ornish had already gotten Fair on Gordon's Mind-Body Center's Board of Directors. The Gordon commission is probably the most corrupt in U.S. history, stacked to the ceiling with mystics, ideologues and CAM lobbyists. For a complete rundown on every member of this corrupted commission I suggest you read the testimony of Dr. Timothy Gorski before the Senate Aging Committee posted last fall at http://www.quackwatch.com/01QuackeryRelatedTopics/Hearing/gorski2.html on Quackwatch. With the help of people like Dr. Fair, this commission hopes to fully integrate CAM into every aspect of U.S. medical activity. Its report is due next month.
And, to top it off, Dr. Fair and son just before Fair's death had launched their own CAM centers, exploiting Fair's Presidential Commission appointment to enhance this business project, hoping to set up centers across the nation.
How did this happen to such a prominent doctor as Dr. Fair? How was he permitted by his peers and colleagues to fall off the cliff into medical irrationalism, not only as a personal recipient but as a committed ideologue? His peers apparently thought a lot like ACSH's Dr. Gilbert Ross.
Indeed, Dr. Fair's friends practiced Dr. Gilbert Ross's policy of "benign neglect." Ross justifies his position by quoting one of Fair's friends saying, "whatever he was doing didn't do any harm." In fact, Fair's "open-minded" friends share the responsibility for the deterioration of his scientific thinking under pressure of his disease. They went along with him, not criticizing him as he got into the wrong crowd. The result: Fair's credentials and misguided passions have been used to foster the medical irrationalism now being embraced by NIH. Indeed, "whatever he was doing" may cause our nation's health care incalculable harm.
Dr. Fair's case may seem extraordinary, but he is not the only M.D. to have joined the CAM parade under similar circumstances due to personal crises. As a matter of fact, the most radical wing of the Mind-Body movement, the Transpersonal Psychology movement (with which Dean Ornish is deeply involved) specifically recruits its followers from those undergoing "spiritual crises." Others are pure opportunists, ideologues, and quacks.
While the "conversion" of Dr. Fair has had an enormous effect in giving undeserved credibility to CAM practices, even the CAM practices of more ordinary patients have a cumulative negative effect across the patient population. CAM practices are exploding. Fraudulent CAM "science" is being generated to provide "plausibility" to these practices. NIH's National Center of Complementary and Alternative Medicine runs amuck. Dr. Barrie Cassileth, who used to be considered a "skeptic," now runs Sloan-Kettering's own CAM program where the entryway has been designed to the principles of Feng Shui and the offerings include mystical Reiki treatments.
Often, the only contact patients have with persons schooled in medical science is with their own personal physician. If those physicians, as Dr. Ross recommends, ignore the patient's CAM practices, do not criticize them and explain what proper scientific medicine is, then those practices and the accompanying aberrant beliefs will continue to sweep through the population. Indeed, like Barrie Cassileth, more and more doctors will opportunistically embrace CAM practices themselves to help the bottom line and not "turn off" patients. This is a recipe for disaster.
Dr. Ross's prescription for CAM tolerance is a policy of "benign neglect" of social responsibility. ASCH needs to get its act together if it is going to stand up to its name. Ross's prescription is a prescription for failure.
E. Patrick Curry Pittsburgh, PA.
February 12, 2002
In reply to E. Patrick Curry of Pittsburgh, PA.:
I appreciate the spirit of Mr. Curry's response to my position on use of CAM along with adherence to standard biomedical therapies. However, my position, if read carefully, certainly does not represent any ACSH deviation from our science-based "opposition to CAM irrationalism."
Nothing in my short article specifically dealing with Dr. Fair and his late-in-life conversion to belief in CAM was meant to be applicable to the population at large. My general comments were aimed at primary care doctors and their often desperately-ill patients. I advocated neither "benign neglect" nor lying in terms of these patients' desire to seek complementary treatments. I said I would not object if an "informed, adult" patient wanted to use such methods "as long as regular treatment is co-administered." This clearly entails discussing the pros and cons especially the latter of such "treatments."
Mr. Curry seeks to extrapolate my concerns for refusing to withdraw all hope from end-stage patients by invoking some potential "future health crisis," at which time users of CAM would, hypothetically, be irrevocably lost to biomedicine. I believe this to be a frivolous concern. And his use of Dr. Fair's terminal conversion to CAM "poster-doc" as a reason not to be sensitive to other patients' desires and concerns is un-fair (forgive me).
As for Dr. Green, he seems to dismiss medical efforts to elevate the mood of end-stage cancer patients. I strongly believe that in the face of end-stage disease, all efforts at restoring hope and a positive outlook which don't compromise continued therapeutic goals should be pursued. Dismissing such efforts seems a needless sacrifice at the altar of orthodox medicine.
Gilbert Ross M.D.