Which Alternative Therapies is it Ethical To Sell?
Homeopathy has been getting a bit of a rough ride in the UK lately, as the 10:23 campaign has been doing its best to shame UK pharmacy chains for selling unproven remedies.
Then just this week, a committee of the House of Commons concluded that the government should no longer pay for homeopathic treatments. Here’s a bit more detail, from The Guardian: MPs criticised homeopathy this week. What’s their evidence?
This week, the House of Commons Science and Technology Committee published a report criticising government policy on homeopathy, saying that homeopathic remedies should no longer be funded by the NHS or licensed by the drug safety watchdog.
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The committee discussed evidence from all kinds of sources, including the Department of Health, the British Homeopathic Association, the British Medical Association, Boots, doctors and scientists, NHS trusts, the UK’s drug safety watchdog, NICE, campaigning groups, and the Advertising Standards Authority.
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The committee’s report is highly critical of homeopathy. It recommends that placebos should not be routinely prescribed by the NHS, that the NHS shouldn’t fund homeopathic hospitals, and that doctors shouldn’t refer patients to homeopaths. According to the Society of Homeopaths, current NHS funding for homeopathy runs to £4 million each year….
Homeopaths and their customers, not surprisingly, have been up in arms, shocked that very idea that the government might end funding for the form of treatment the believe in so fervently. The fact that the Committee pointed to an absence of Randomized Controlled Trials (RCTs) showing that homeopathy works is taken by defenders of homeopathy as evidence of a too-narrow view of what counts as evidence.
But let’s set homeopathy aside. (Please, seriously!)
Let’s ask the question more generally: what evidence should be required in order for a government insurance scheme (or any other insurance scheme I guess) to pay for a particular treatment modality? Should RCTs be required? Or is some lesser form of evidence sufficient? How much evidence is enough? How little evidence is too little?
Or, since this is The Business Ethics Blog, let’s ask it this way: which products is it ethical for a pharmacy to sell? Should pharmacies only sell remedies supported by RCTs? Or is consumer demand the only standard that matters?
Presumably defenders of homeopathy don’t think that the government should fund literally every therapy that someone claims is useful. There have to be some standards. Likewise, surely defenders of homeopathy don’t think that pharmacies should sell literally every product claimed (by someone) to have some therapeutic value. If I were to think up a “cure for cancer” while in a drunken stupor, surely my new “discovery” shouldn’t be sold in pharmacies just because I think it’s a cool idea. So, what generalizable principle do fans of homeopathy recommend for sorting this out?
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A note about posting comments:
Sorry, but I will not approve comments that don’t at least try to answer the question above. If you love homeopathy or hate it, that’s fine, but save it for another blog entry. Sorry, skeptics, that means there’s likely little for you to contribute here. My question is aimed at the believers. Likewise, comments about how “homeopathy worked for me!” are off-topic, here.
The Business Ethics Blog 
This is a really good question you have posed regarding the standard of proof required before medical insurance (public or private) pays and/or subsidizes the cost of a particular medicine. After all, with the costs of health care ever increasing at an exponential rate, if steps aren’t taken soon to bring costs under control, we in Canada are at an ever increased risk of our Medicare program imploding.
It is a well known fact that RCT’s are both time consuming and expensive to carry out and only the very well funded pharmaceutical and science research companies are able to afford the costs associated with achieving this standard of proof.
Because Governments have so much at stake, why not a Government department be responsible for the overall carrying out and documenting RCT’s?
I’d like to pick up on your question of whether public demand should rule what gets sold. No. Never. If public demand is the new “rule” then homeopathy gets in, which to my mind is fine although I myself don’t use this technique, but Joe Public has some strange ideas about what s/he wants. Is there a generalised principle? Maybe we could persue the “does no evil” idea. Does homeopathic treatment cause harm? And who should be the judge?
JP:
I think the main reason not to make the actual testing a government responsibility is cost, and the fact that it would mean pushing private-industry costs (even for not-very-promising ideas) onto taxpayers. My phony cancer cure isn’t plausible enough for testing; so no one should want the government to spend a few hundred thousand dollars testing my crazy idea. The cost of clinical trials should work to filter out ideas where no one is willing to foot the bill.
Chris.
Hazel:
Not doing harm is a good start, but I don’t think it’s sufficient.
My phoney cure for cancer “does no harm.” (It’s just something I made in the kitchen.) Should it be allowed to be sold? We need a way to filter out useless, deceptive frauds, don’t we?
Chris.
In lieu of a lengthy comment, my thoughts about this topic resulted in the following three notions:
(i) Patients have some right to choose their method of treatment
(ii) Patients have the right to be informed of the efficacy of their various treatment options
(iii) Patients have the right to necessary health-care, even if they are unable to afford it
First, the second notion requires two things: that someone is responsible for determining the efficacy of various treatments on various diseases, and that someone interprets this data in way which is relevant to the patient’s situation. With respect to determining efficacy, I agree with Chris, the government should not be responsible for testing. Instead, the business themselves should take on responsibility for testing potential products, with appropriate strict regulation from the government. Hopefully, this would result in each treatment being identified with a collective understanding of the drugs affects, which can then be judged. In such a scenario, the druken ‘cure for cancer’ would not even merit if the inventor could not convince any of the businesses that the idea had potential. Who exactly judges these results is another question. I would argue (in line with notion (i)) that the consumer, being the one who is undergoing treatment, has a right to choose which treatment/effect they apply to their situation. Unfortunately, not many of us have medical degrees and often the decision is better given to someone who is licensed.
We run into similar problems when considering notion (iii). Who is to determine what a necessary treatment is? According to notion (i) the consumer should have the ability to choose whether they want the negligible placebo effect of the drunken cancer treatment, or if they would like something with a higher success rate. Of course some of us may opt for far more treatments than are necessary, which would put an unnecessary burden on our healthcare system (I may decide, for example, that my runny nose is best treated with daily massages). The converse problem arises if we allow doctors or the government to decide what is necessary. Since neither doctors nor government agents have as much concern as us when it comes to our individual well being, they may opt to treat us only insofar as we are considered objectively well-off, rather than living up to our subjective standard (consider something not everyone may find necessary, such as psychological counseling to deal with a grave injury).
The upshot of all this, in my opinion, is that the decision cannot rest entirely on one of these agents (the government, the consumer, trained professionals, or the producer). Instead, we must rely on a compromise which allows each agent to influence the decision in the appropriate way. Whether or not such a compromise is possible, I am still unsure.
Oddly enough I’ve just done some research into EU law in this area. The opinions below are not my own but are based on the opinions of leading manufacturers & small scale therapists in the CAM sector.
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In brief (and in broad strokes), very soon any product / substance which wishes to make a health or nutritional claim has to be able to provide RCTs in order to make that claim (NB. can still be sold, bu the claim cannot be made).
So prunes, the well known bowel loosening aid of the elderly, have just been judged as unable to make the claim that they loosen bowels because the scientific evidence isn’t there … no one’s ever done an RCT on them, because they work!
Add to this that most Gvt sponsored health claims (such as reducing salt and fat in your diet, or eating lots of fresh fruit and veg in your diet) are based on observational trials, not RCTs.
*That*, ethically speaking, has infuriated alot of people. Why should the CAM sector have to meet a higher standard of proof that government advice??
But it should not be forgotten that some traditional forms of herbal medicine are either poisonous of contain illegally high levels of heavy metals. Charlatans have cut other herbal substances with high levels of prescription medicines to make them appear effective.
So obviously some form of control is needed. The suggestion is that if a medicine of therapy is non toxic, then providing it may be effective (observational not RCTS) then it should be allowed to be sold.
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I never asked any of my interviewees about Gvt sponsorship of tests but I guess most would baulk at it. The argument is not for a bigger state, but for the CAM sector to be allowed to sell non toxic therapies which live or die by their popularity in the marketplace.
By what principle do we reject the ‘anything goes unless harmful’ system? To my mind it must be some of the following:
1) We should permit treatments which work and not permit those which do not work. (effective/ineffective distinction)
2) People ought not have false beliefs regarding the efficacy of legally sanctioned treatments. Either believing an effective drug to be useless, or an ineffective drug to work.
3) We should not permit treatments which do more harm than good.
I expect that homeopaths would agree with these points which, ultimately rest on the premises that there is an objective distinction between effective and ineffective (so I’m ignoring placebos). And that the medical profession and the laws surrounding it have a moral obligation to provide the patient with the most effective treatment. It is more likely homeopaths would reject the first of these premises, although puzzlingly they maintain their treatments are not placebos.
Can these principles be satisfied by anything which is not an RCT?
A popular defence, and one used by an executive of Boots, a British pharmacists chain which sells homeopathic remedies, is that a large number of people believe homeopathic remedies are effective and that these remedies have a history of being used to treat condition X. This clearly doesn’t satisfy the three conditions; historically wildly popular treatments have turned out to be ineffective or harmful.
Rather than looking at evidence for, we should look for evidence against. I think a more pointed question to put to a homeopath, or any alternative medicine practitioner, is this: What evidence would demonstrate the ineffectiveness of a given treatment? Impossibly high standards, or a reluctance to answer would indicate an indifference to the truth of the matter, and by implication the effective/ineffective distinction, disqualifying the answer by the points above.
On a more business ethics tack:
Q:What do Pharmacists sell?
A: Two things, medical treatments and expertise. We trust pharmacists, most people would rather buy their treatments from a pharmacist than a gas station. Merely appearing on a pharmacist’s shelf gives a product respectability.
Q: If the rule by which a pharmacist decides to sell an item is anything other than RCT evidence are they in violation of the bond of trust between themselves and their customers?
A: Probably. We want treatments we buy to be effective, but stocking a treatment merely because of its popularity is no guarantee of effectiveness. In adopting this rule a pharmacist becomes no different from the gas station, the customer pays for an expert’s opinion, but receives an opinion available to anyone capable of looking up sales numbers. A pharmacist operating under this rule is effectively committing fraud; the customer pays for expertise and a treatment but receives only a treatment. The price remains the same.
I would bet that the sort of expertise most people are looking for in a pharmacist is not the ability to assess what products sell well, but rather the ability to spot effective treatments. People almost certainly assume that one rule is applied to all products: Ibuprofen is sold to treat headaches for the same reason arnica, a homeopathic remedy, is sold to treat bruising. This assumption is false.
James:
Thanks for your comments. Excellent points.
I especially like your point about asking “What evidence would demonstrate the ineffectiveness of a given treatment?” You’re right: there absolutely has to be an answer to that. In fact, even (or especially?) for a product one endorses, one ought to be able to answer that question. If one’s answer is “nothing,” that implies that one is for some reason or another immune to evidence, and that one’s commitment to that product is a matter of blind faith, rather than reason.
Regards,
Chris.
Conventional wisdom says that homeopathic treatments don’t work. People who have had success with the treatments say that they do. They’re both right, of course, because they are each coming from a different background and frame of reference. Did you know that the U.S. government has a website about this? http://nccam.nih.gov/health/homeopathy/
The discussion really needs to be about whether or not we are focusing on total heath and well-being or treating symptoms. I would argue that we need to be focusing on the health of the total person. If you agree with that, then homeopathy appears to be a more reasonable option.
If mainstream medicine were to select the “whole person health” approach as its core operating system, then many alternatives that are not now always considered before prescribing medications (prescribing a better diet to treat digestive problems, for example)would be extremely useful in reducing the need for expensive prescriptions. In the future, this whole health approach (including homeopathy)might play a key role in reducing health care costs.
Linda:
It’s not so much “conventional wisdom” that says that homeopathy doesn’t work, as science.
And unfortunately personal experience isn’t something pharmacists can reasonably rely on for guidance in figuring out what to sell. Anecdotes are really hard to aggregate into something like data. Personal experience might say that carrying a rabbit’s foot brings good luck, but that doesn’t make it so. We need methods for *filtering* personal experience to compensate for the kinds of factors that too often bias first-hand accounts of personal experience.
Chris.
Choosing filters is extremely difficult because our scientific understanding is evolving. “There are challenges in studying homeopathy and controversies regarding the field, largely because a number of its key concepts are not consistent with the current understanding of science, particularly chemistry and physics.” http://nccam.nih.gov/health/homeopathy/
“Science” is not always on the leading edge. Most people’s grandmothers knew that getting chilled made you more likely to get sick, but it took science many more years to prove that in studies. If, by our current understanding of “science,” homeopathy does not work, but when using a different definition of “science” it does work, then we should question our scientific assumptions. Given the tension around this issue, in five or ten years the definition of “science” will probably change to incorporate different assumptions than it now is able to accept. Homeopathy may or may not end up being considered effective medicine. In the meantime, what if we are actually doing harm by using more potent medications than we need to, leading to other health problems that require medication…? What if permitting the use of homeopathic medicine before using other medicines would be less systemically harmful to people, in the short-term and long-term? Ethically, we should at least consider this question.
This blog posting wasn’t really about homeopathy, but I need to clarify based on what you’ve claimed in your comment:
While it’s true that scientific knowledge is always growing and changing, the idea that “our scientific understanding is evolving” is generally false with regard to homeopathy. The basic principles of homeopathy have been at odds with basic physics and biochemistry for decades, and that hasn’t changed a bit.
As for your question bout whether homeopathy might some day be vindicated: well, it’s possible, though highly doubtful. But the same could be true for the “cure for cancer” that I dream up in a drunken haze. It *could* turn out to be a cure for cancer. But should I really be allowed to *sell* it, just in *case* it works?
Yes, science is very slow to change its core assumptions… PIcking up on what others have commented, the “harm” issue is a major one to resolve in building a filter. I like to use the Precautionary Principle, which would lead us to err on the side of minimizing harm. Using that principle, if any treatment “works” and is not causing any physical harm, that could hypothetically make it a better solution than one that “works” with serious health side effects. In agreeing on a “filter” some people will err on the side of minimum harm, and others will err on the side of maximum effectiveness, or minimizing costs, etc. In the absence of agreement on the principles that should drive the choices, wouldn’t any widely accepted filter need to take all of those perspectives into account?
Linda:
Yes, but shouldn’t the public be able to rely on people selling them stuff to make sure that their products meet at least some *minimal* level of effectiveness, too, beyond just not being harmful?
I mean, we *do* want to avoid products that are outright fraudulent, right? Or should people literally be allowed to sell any product, and make literally any claim on its behalf?
Chris.
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