Auto repairs, alternative medicine and fiduciary duty

I went and got my car winterized the other day, just in time for the impending meteorological catastrophe. They told me I needed, among other things, a radiator flush. They took me through the steps in making the “diagnosis”, dutifully showing me their findings, but it didn’t really matter. Mechanically disinclined not-so-smart consumer that I am I ultimately had to take their word for it. It was one of those reputable quick-lube chains, trusted by housewives and little old ladies, with mechanics who were certified. I didn’t know exactly what that meant, but I figured it was something significant. It probably meant they had a certain level of expertise and could reasonably be expected to apply that expertise honestly to my service needs. In other words I had reason to trust them. I was entitled to certain assumptions about the service I would get, assumptions I couldn’t make if I had taken my car to, for example, the Griner Brothers’ Garage, where it’s strictly caveat emptor.

And so it is with medicine. I know it’s dangerous to compare medicine with auto repair, but there may be a useful analogy here concerning the responsibility of a person in a position of trust (and we’ll restrict the comparison to just that). In medicine we sometimes call it fiduciary duty. Our particular fiduciary duty to patients is to be and do what all those certifications and accreditations lead them to expect. They expect expertise, and for that expertise to be applied honestly. Moreover, the general public perception of that expertise, at least for us in mainstream medicine, is that it’s based on science. Most patients, when offered a particular treatment, believe that. Lacking any desire or ability to verify it independently they simply trust that it’s so. This presents an ethical problem when unscientific treatment methods are offered to patients (call it alternative medicine, call it what you will; I think Orac’s term “woo” should serve our purpose here as well as any other).

Now, in order to really parse the ethics of woo I would propose two broad contextual categories: stand-alone woo and integrated woo. Here are my definitions. Stand alone woo: woo which is offered by a clinic or institution as its major method of treatment. Integrated woo: woo which is promoted by “mainstream medicine”, accounts for a relatively small fraction of total treatment offerings and is more likely to be disguised as science.

This definition is somewhat imprecise and there are fuzzy areas. Some stand-alone woo providers, for example, have “MD” after their names and purport to “integrate” the best of woo with the best of conventional medicine. Nevertheless I place such institutions in the category of stand-alone woo because they major in woo, and that fact is usually patently clear to patient-shoppers. The average consumers know it when they see it.

Integrated woo presents the more serious ethical problem because the mainstream institutions (like, I’m embarrassed to say, my beloved medical alma mater Vanderbilt) are putting their good names, their certifications and accreditations, behind the woo they promote. Patients come, most of them anyway, expecting scientifically based treatment, and may be none the wiser when offered woo. After all, mainstream science-based providers wouldn’t promote something unscientific, would they? Why should patients expect them to? When they receive treatment based on an eclectic, mystical world view it's disguised, implicitly or explicitly, as science. The woo is more insidious, more subtle, which is why it’s all the more egregious. Patients are flat out being deceived unless, as recently suggested by anti-pseudoscience warrior Wallace Sampson, they receive explicit informed consent about the nature of the method being offered.

I have less of an ethical problem with the stand-alone woo providers. For one thing, maybe they don’t know any better. I’m convinced that they (many of them anyway) truly believe in what they do, are trying to make an honest living and have a heart for helping patients. (This is in contrast to the mainstream hospitals and medical schools which know better, or should know better). Secondly, the stand-alones, many of whom are openly dismissive about western science, aren’t nearly as pretentious about any scientific underpinnings as are the mainstream folks. As a consumer you know what you’re getting with the stand-alones. It’s caveat emptor, like going to the Griner brothers’ garage.

So, I say let the stand-alones compete in the open market place of ideas. To those in the mainstream for whom this shoe of integrated woo fits, clean it up. To medical school faculty who remain silent while the largest and most influential activist group of medical students on your campus promotes chelation for everything under the sun that ails a person, wake up. To physicians who care about evidence based medicine, if you see woo creeping into your hospital or clinic, speak out. To those in the mainstream who lend your good name to the promotion of quackery in your institutions, STOP IT! It’s unethical. It’s a violation of fiduciary duty.