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Alternative Medicine Paternalism PDF Print E-mail
Swift
Written by Dr. Steven Novella   

Cultural norms shift over time. Up until about half a century ago Western medicine largely practiced under the accepted ethic now called paternalism. This approach was phased out over the 1970s and 80s and was gradually replaced with the currently dominant style of informed consent.

In the paternalistic view the physician was seen as the expert who could be trusted to do what was best for their patients, whether the patients understood their treatment or not. The name derives from the fact that this approach is very analogous to that of the physician as parent and the patient as child. Parents do what is best for their children, and don’t expect especially young children to understand. Eat your vegetables. I don’t care if you don’t like them. No, you can’t have ice cream for dinner.

Under the paternalistic model it was acceptable for physicians to withhold vital information from their patients. If a patient had terminal cancer there was no point in telling them. That would just upset them. Better to tell them a comforting lie, and then give them medicine to make them feel better. It was also acceptable to deceptively give a patient a placebo, especially if you thought their illness was due primarily to stress or a certain personality type.

The modern model of medicine sees the relationship between doctor and patient more as a partnership than parent-child. We follow the ethic of informed consent and autonomy – adult patients have the right to make their own decisions about their health care. Physicians, as professionals and experts, are there to provide information, opinion, and skilled procedures based upon their training and experience. Decisions are made together, with the patient being as well-informed as possible.

The modern approach is incompatible with deception and deliberate lying. Further, I would argue, the health care professional has a duty to vet the advice and information they dispense. It’s not enough that they believe it, they have a duty to make sure their information is correct and reasonable. Further still, they have a duty to inform their patients if their opinions diverge significantly from the standard of care, or the general consensus of opinion.

All of the above is background to the main point of this article – that the complementary and alternative medicine (CAM) movement, while unfairly and ironically criticizing mainstream medicine, is often extremely paternalistic. The entire premise of the current “placebo medicine” justification for CAM modalities that are admittedly just placebos is a throwback to the mid 20th century.

I recently discussed a commentary in the medical journal BMJ in which general practitioner Des Spence directly advocates this paternalistic approach in defense of homeopathy. He writes:

“They listen, spend time, and offer some explanation for the unexplainable—and their patients like them. The effect of homeopathy is the positive effect of a therapeutic relationship that is reassuring, accepting, and supportive. Society should never underestimate the healing effect of a kind word or the value of a holistic approach.”

Spence acknowledges that homeopathic pills are placebos – that they have no physiological effect, and that they should not be used to treat real illness, like infection or cancer. But for the “worried well” the ministrations of a homeopath with nothing but placebos in their arsenal is just fine.

Homeopaths, he argues, offer an explanation for the unexplainable. Setting aside the assumption that subjective symptoms are “unexplainable,” what explanation do homeopaths offer? According to Spence’s own acknowledgements, their explanations are 200 year old made up fantasies. They have nothing to do with reality, or with how modern science understands the world.

So, according to Spence (and this attitude is common among CAM apologists), it is OK to directly lie to patients, and even to instill in them a false pseudoscientific understanding of health, disease, chemistry, biology, and physiology, as long as it’s done with a smile and makes them feel good.

This is paternalism on steroids (and not homeopathic steroids). It is a blatant violation of the principles of autonomy and informed consent. Homeopaths are not telling patients that their pills are just placebos, or that the laws of homeopathy not only have not been demonstrated scientifically, they are at odds with a couple centuries of well-established science.

Spence entirely ignores the potential harm of instilling in patients a false notion that a particular brand of fake medicine is real and effective, because their subjective symptoms improved due to a non-specific response to a positive therapeutic interaction.

Spence concludes that “homeopathy is bad science but good medicine.” You can only believe this if you think science is irrelevant to medicine, that it is ethical to lie to patients as long as it makes them feel better, and that it’s OK to offer patients a fake explanation rather than honestly say “I don’t know.”

What is ironic is that this attitude is now common in the world of CAM, while simultaneously standard CAM propaganda (which Spence also parrots) is that mainstream physicians are dismissive and paternalistic.

One of the main battle cries of CAM proponents is “health care freedom of choice.” But there is no freedom of choice with deception. Freedom of choice requires informed consent. What CAM practitioners really want, it seems, is the freedom to lie to patients and sell them fancy placebos using fake explanations - one might call this fraud, as it used to be called before newspeak changed “health fraud” into “alternative medicine.”

 

Steven Novella, M.D. is the JREF's Senior Fellow and Director of the JREF’s Science-Based Medicine project.