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Statement to the White House Commission on
Complementary and Alternative Medicine Policy

William M. London, Ed.D., M.P.H.

May 15, 2001

Executive Order 13147 calls for the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) make recommendations addressing:

1. The education and training of health care practitioners in complementary and alternative medicine
2. Coordinated research to increase knowledge about complementary and alternative medicine practices and products
3. The provision to health care professionals of reliable and useful information about complementary and alternative medicine that can be made readily accessible and understandable to the general public
4. Guidance for appropriate access to and delivery of complementary and alternative medicine

In making these recommendations, the Committee should acknowledge that the term "complementary and alternative medicine" implies much more than the definition used by the National Center for Complementary and Alternative Medicine (NCCAM):

Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies.

The NCCAM definition is similar to the definition of "unconventional medicine" in a paper by Eisenberg and others [1] who reported on a national telephone survey of adult use of methods such as relaxation techniques, massage, exercise, prayer, self-help groups such as Alcoholics Anonymous, imagery, biofeedback, and hypnosis. This study is often misrepresented as evidence that Americans are so interested in "complementary and alternative medicine" that NIH funding of CAM research is needed. (The terms "complementary" and "alternative" have far more promotional value than "unconventional.") Many of the methods included in the Eisenberg survey are either self-care or medically establshed methods that don't fit the study's definition of "unconventional medicine." [2] The study actually showed that few survey respondents used commercially promoted methods such as acupuncture, homeopathy, energy healing, megavitamin therapy, and herbal medicine. Strangely, 30% of respondents who reported use of chiropractic didn't actually see a provider of chiropractic services.

The NCCAM definition has little to do with the meaning of "complementary" and "alternative" in everyday language. These words imply that such methods actually complement or serve as sensible alternatives to other methods. The "CAM" marketplace is dominated by products, services, and regimens that do not.

The American Heritage Dictionary defines complementary as: "1. Forming or serving as a complement; completing. 2. Supplying mutual needs or offsetting mutual lacks." [3] Thus, referring to something as "complementary medicine" implies that it completes what some other medicine does not do on its own. However, just because someone refers to a method as complementary does not mean it actually complements anything else. If a method doesn't add to the outcome, it isn't complementary; it just adds to the cost.

The American Heritage Dictionary defines alternative, when used as an adjective, as: "

1. Allowing or necessitating a choice between two or more things. 2.a Existing outside traditional or established institutions or systems: an alternative lifestyle. b. Espousing or reflecting values that are different from those of the establishment." [3]

The NCCAM definition suggests that "alternative" medicine is "alternative" in the sense of dictionary definition 2a. To some extent this is a fair characterization. However, "alternative" medicine is largely "traditional" itself and it has become its own "establishment." Promoters of "alternative" medicine often promote traditional systems for alleged healing. Strong reliance on tradition is one of "alternative" medicine's biggest problems. Tradition-bound systems resist change. Their proponents selectively seek affirming evidence while rejecting disconfirming evidence and criticism. Proponents adhere to orthodoxy.

On the other hand, science/evidence-based medicine is iconoclastic. Medical practice changes over time because scientifically-based practitioners learn to discard unsafe and ineffective methods. Traditionalists and true-believers cling to unsafe and ineffective methods as a matter of faith.

I am unaware of any efforts by the National Institutes of Health Office of Alternative Medicine and later by the NCCAM to identify methods promoted as "complementary" or "alternative" that should be discarded. In order to provide reliable and useful information about complementary and alternative medicine, it is necessary to identify methods that should be discarded. I ask that the WHCCAMP make recommendations to accomplish this based on principles of consumer protection and science and recognition that health fraud and quackery constitute a public health scandal [4].

Much has been written about the "medical establishment" and its institutions and systems of delivering medical care. I think it is fair to note the existence of the "'alternative' medical establishment" which includes promoters, practitioners, organizations, foundations, retail businesses, wholesale businesses, politicians, the NCCAM, the WHCCAMP, and other institutions. The "alternative" medical establishment has even extended its reach into medical schools, other professional schools, colleges and universities, hospitals, and insurance plans. In so doing, alternativists have increased their power and, in effect, invalidated the NCCAM definition of complementary and alternative medicine.

"Alternative" medicine is alternative in the sense of espousing or reflecting different from those of the establishment. The science-based medical establishment insists that health products and services be proved safe and effective -- with proponents bearing the burden of proof -- before promoting them. Alternativists often value hunches, clinical impressions, subjectivity, anecdotes, reports of best cases, legends, and so-called "other ways of knowing," as sufficient "proof" to justify their promotional efforts. They tend not to value efforts to identify sources of clinical illusions and to reduce the problems of systematic and nonsystematic errors leading to faulty conclusions.

Alternativists also value different credentials and standards of practice than most consumers expect. Many "alternative" credentials and standards of practice do not require professional accountability. I believe the WHCCAMP should note that this poses a problem for consumers.

Drs. Marcia Angell and Jerome P. Kassirer, former editors of The New England Journal of Medicine, have pointed out:

There cannot be two kinds of medicine-conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work [5].

Medical alternatives can be classified into three categories: genuine, experimental, and questionable [6,7].

1. Genuine alternatives are backed by sufficient scientific evidence showing that the potential for benefit exceeds the potential for harm to specific populations for specific intended purposes. Genuine alternatives or genuinely complementary methods tend not to require the justification of labels like "alternative" or "complementary" in marketing.
   
2. Experimental methods are unproven, but are studied responsibly with extra care given to the rights of study participants and protecting participants from exploitation. It is reasonable for taxpayers to expect that their financial support will be used to study promising rather than implausible methods. But many taxpayers don't realize that alternativists do not espouse such values. Alternativists have no problem with taxpayers supporting the study of implausible methods. Remarkably, NCCAM is currently funding a study of an "alternative" protocol involving enzyme supplements and coffee enemas in the treatment of people with pancreatic cancer. The protocol is implausible [8]. It had been used on a Hodgkin's lymphoma patient who died. Last year a jury found that the patient was 51% responsible for her harm. The jury said that the patient was "negligent" in letting the physician treat her and for foregoing the standard care her original doctors had recommended [9].
   
3. Questionable methods are those fthat are unproven but lack a scientifically plausible rationale. Some of these are still promoted even after repeated failures in scientific testing. Such methods aren't just unproven; they are -- for practical purposes -- disproved. The most implausible questionable methods are legitimately described as dubious or quack.

According to a usage dictionary, "alternative" may suggest adequacy for some purpose and/or "compulsion to choose." [10] Questionable and dubious methods are not adequate for their intended purpose, and consumers should not feel compelled to choose them.

It is unavoidable for responsible healthcare professionals to use unproven methods in caring for patients. We will never have all the answers to address the complexities of human health problems. Clinical judgment and innovation will always be an essential part of the art of delivering healthcare. However, responsible healthcare professionals do not promote the use of unproven methods. The promotion of unproven methods through such methods as advertising and publicity is objectionable because it is deceptive. It violates the ethical principles of veracity and nonmaleficence (the general duty of "first do no harm").

Consumers want alternatives, but they want genuine alternatives. Many promoters of "alternative" medicine exploit this by calling for "freedom of choice" for consumers. What these promoters really want is freedom from accountability to consumers. They support the concept of caveat emptor ("let the buyer beware") and oppose the concept of caveat vendor ("let the seller beware"). Caveat vendor provides a rationale for consumer protection laws to compensate for the disadvantageous bargaining position consumers have in the health marketplace. It is difficult to evaluate claims for health products and services. People are especially vulnerable to mistaken perception and deception when they feel threats to their well-being and are desperate for answers. It is important to protect consumers from both intentional and unintentional deception. And it is also important to preserve true freedom of choice. Thus, the motto of The National Council Against Health Fraud is: "Enhancing freedom of choice through reliable information."

Recommendations

NCAHF urges the Commission to enhance freedom of choice by recognizing the need to identify health fraud and quackery masquerading as "complementary" and "alternative" medicine. In line with the four topics you are charged to address:

1. The education and training of health care practitioners must address principles of consumer protection and science. Health care practitioners must learn to recognize quackery/health fraud associated with "complementary" and "alternative" medicine.
2. WHCCAMP should promote opportunities for research to increase knowledge about quackery/health fraud as a public-health problem associated with the "complementary" and "alternative" medicine marketplace [4].
3. WHCCAMP should declare that it is misleading to use the terms "complementary" and "alternative" to refer to questionable, unproven, and disproved methods. Reliable and useful information must be grounded in principles of consumer protection and science.
4. WHCCAMP should recommend that appropriate access and delivery of healthcare be based on principles of consumer protection and science.

References

1. Eisenberg DM et al. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. New England Journal of Medicine. 328:246-252, 1993.
2. Gorski T. Do the Eisenberg data hold up? Scientific Review of Alternative Medicine 3(2):62-69, 1999.
3. American Heritage Dictionary of the English Language, Third Edition. Boston: Houghton-Mifflin, 1992.
4. Jarvis WT. Quackery: The National Council Against Health Fraud Perspective. Rheumatic Disease Clinics of North America 25:805-814, 1999.
5. Angell M, Kassirer J. Alternative Medicine -- The Risks of Untested and Unregulated Remedies. New England Journal of Medicine 339:839-841, 1998.
6. London W. Alternative health (letter). The Plain Dealer Magazine. November 19, 1989, pp. 14, 32.
7. Barrett S. Be wary of "alternative" methods. Quackwatch Web site, revised May 17, 2001.
8. Green S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA 268:3224-3227, 1992.
9. Jury calls the 'hair test' a scam. PROBE 8(10 & 11):9, 2000.
10. Garner BA. A Dictionary of Modern American Usage. New York: Oxford University Press, 1998.

____________________

Dr. London is president of the National Council Against Health Fraud, associate professor of health care management and director of the Graduate Program in Health Care Management at the College of Saint Elizabeth (Morristown, NJ), and a faculty mentor in the Master of Science in Public Health Program of Walden University (Minneapolis, MN).