CAM and Children: "Unethical Prescriptions"

CAM and Children: "Unethical Prescriptions"

Survey of Complementary and Alternative Medicine (CAM) Services in Freestanding US Children's Hospitals accepts the premise that CAM use in children is ethical.The authors of this recent journal article don't explicitly state it that way, but their discussion makes it as clear as if they'd said it out loud.

"Offering CAM services reflects a hospital's desire to treat the whole person – mind, body and spirit."

Treating the "whole person" is a good thing, right? The authors seem to think so. Even though they note in the very same paragraph that

"little research is available documenting the effectiveness of these programs."

In this survey of 26 freestanding children's hospitals in the US (the number responding to a survey sent to 43 hospitals) a whopping 92.6% offer one or more CAM services. Since there is no accepted definition of what constitutes "CAM," as is typical, this survey included implausible and unproven treatments like acupuncture/acupressure (46%), homeopathy (4%), naturopathy (thankfully, no hospital reported using naturopathy), therapeutic touch (35%) and reiki (31%). Right alongside these were the more mainstream art (58%), pet (81%), massage (69%) and music (81%) therapies. As is also common in such surveys, modalities having nothing whatsoever to do with CAM -- lactation services (69%) and relaxation (46%) -- were rebranded and included. Of course, given the small number of survey participants, these percentages make it look like pediatric CAM use in hospitals is huge.

Disturbingly, the survey also found that only 60% of hospitals had policies on dietary supplement use during hospitalization and 40% for use surrounding surgery, despite the well-known risks.

Criteria for selecting therapies were:

  • Evidence base (73%)
  • Patient demand (65%)
  • Practitioner availability (69%)
  • Market research (4%)
  • Other (12%)

Just what "evidence base" was required to make the cut is not discussed. I will note, however, that the criteria for what constitutes "evidence" sufficient for CAM use do not seem to be particularly rigorous, such things as prior plausibility being regularly discounted.

All of this led the authors to conclude that "studies" (actually, it was a survey, not a study) such as this

"can help children's hospitals offer expanded, integrated, and coordinated services for their patients and families. Increase in research of the medical effectiveness and cost-effectiveness of CAM services could help improve the quality of CAM services in children's hospitals."

Because CAM in pediatric hospitals is a good thing, remember. It treats the "whole person" and all that.

Here's a different view, one especially refreshing given the fact that hospitals seem to be stepping all over each other to establish "integrative medicine" programs, even though, as the survey noted, a majority of the hospitals participating do not expect to break even. Which means the cost is being absorbed in some other manner like, for example, raising the charges for other services.

I found Unethical Prescriptions: Alternative Therapies for Children With Cerebral Palsy quite by accident, and am so glad I did. It was written by pediatric neurologist Pedro Weisleder, MD, PhD, FAAP, of the Nationwide Children's Hospital and Ohio State University and published in 2010.  Dr. Weisleder has the gall to question the ethics of CAM use in pediatric medicine, a seeming rarity these days.

About that "patient demand" and "whole person" thing – the article starts right off the bat with a quotation from developmental pediatrician, Peter Rosenbaum, MD, who has also written on alternative treatments for children with cerebral palsy,

"Good intentions are not a substitute for good scientific evidence."

Indeed!

Similar to the SBM post by pediatrician John Snyder, MD, Dr. Weisleder uses three patient encounters to discuss three different CAM treatments for cerebral palsy: dolphin-assisted therapy, hyperbaric oxygen therapy ("HBOT"), and suit (also known as the "Adeli suit") therapy. I won't go into detail on the patients or the treatments, although if you can get your hands on a full copy of this article, it is a must read.

"Dolphin-assisted therapy" (or, "DAT") is one I had not previously encountered. There are no studies evaluating its claims. Its creator posits that its putative beneficial effects on the brain's "psycho-neuro-immunological alpha state" are due to

"sono-chemical changes that occur at cellular boundaries in living tissue as a direct result of the dolphin's echolocation output."

Dr. Weislander finds this "explanation" a good example of Dr. Rosenbaum's observation that some CAM treatments are based on

"rather unusual ideas about the biology of the conditions to which they are being applied."

In other words, Dr. Weisleder adds, an example of 

"instances when technical words strung together produce incoherent statements."

Oh, I do love me some plain-spokeness in response to the bio-babble of CAM!

He finds the "theory" underlying the use of HBOT – that the damaged neurons causing cerebral palsy are inactive or dormant cells with the potential to recover -- similarly nonsensical:

"The assumption that pressurized oxygen reactivates the dormant cells so they can function normally . . . again, is a peculiar interpretation of biology."

For one thing, he points out, cells in the injured tissue causing cerebral palsy are not neurons, they are glia cells.

Sweet!

And, finally, he notes that any benefits ascribed to Adeli suit treatment (another new one on me) are due to increased parental involvement in a child's treatment paired with intensive therapy. These elements, not the treatment itself, will result in beneficial effects on youngsters with a host of medical conditions. Indeed, it did not provide significant benefits in motor developmental function when compared with the use of standard neuro-developmental treatment. 

Dr. Weisleder uses these cases as a springboard to discuss the ethics of CAM use in children with cerebral palsy, a discussion that just as easily applies to all pediatric CAM. (In fact, all CAM.) He finds five basic ethical principles violated.

Autonomy or self-determination: The lack of data on many CAM treatments does not allow parents to make informed decisions on behalf of their children. Exposing children to treatments that are not based on facts is contrary to this principle.

Beneficence: Medical decisions for those who cannot make those decisions for themselves, such as children, must be made in their best interest. This is not possible when rigorous data are not available. (And, I would add, won't ever be available because of their scientific implausibility.)

Nonmalfeasance: Unnecessary suffering and other forms of harm are unavoidable when many CAM methods have been associated with "significant untoward effects."

Justice: The individual patient's needs must be balanced against the expense to society in staff and costs. With CAM, the financial burden usually falls on parents, who "willingly open their wallet for remedies akin to snake oil."

And, finally, two other observations from this author that made me want to shout: "Yes!"

First, the "disappointing, yet common trend" in answer to studies that reject purported benefits of CAM: "more studies are needed." No, he says, they aren't.

"How many times does the null hypothesis have to be accepted before we acknowledge that the results are genuine? Alternatively, would we disregard all prior data if, in a single instance, the null hypothesis is rejected?"

Second, this acute observation about CAM treatments I'd not noticed before:

"regardless of treatment modality, the cost of a therapy course oscillates between $3500 and $4500."

He astutely notes that, based on information from an MSN financial website, if one or both parents gets a new credit card, the family is suddenly able to take on $3500 to $7000 in new debt. Quite conveniently, this is enough money for one round of therapy and, if needed, associated travel expenses. Clever marketers, those CAM promoters are.

In sum, offering CAM treatments with insufficient evidence of safety and effectiveness (which is what makes it "CAM" in the first place) is unethical, no matter the "patient demand" or "market research" or desire to treat "the whole person." Freestanding children's hospitals, take note. 

Points of Interest 06/06/2016
Death by Acupuncturist

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