Science-based regulations are good, actually

The College of Physicians and Surgeons of Ontario (CPSO) – the mandated regulator for the medical profession in Ontario – is currently reevaluating their standards governing the use of “Complementary and Alternative Medicine” or CAM. As others have pointed out, this classification of therapies is really quite dubious. Someone not familiar with the distinction between what we might call traditional medicine and CAM might wonder how such a distinction arose. From a scientific standpoint, would it not make more sense to classify therapies based on the level of evidence supporting them?

The key component often missing in the discussion surrounding CAM is that, while therapies traditionally categorized as CAM tend to lack robust supportive scientific evidence, there are many therapies with low levels of supporting evidence or plausibility that are not generally designated as CAM. Take, for example, the recent controversy surrounding off-label use of hydroxychloroquine to treat COVID-19. Though based on weak evidence and plausibility, the treatment was never promoted under the banner of alternative medicine. This is generally the case for treatments – even lacking robust science – that are at least founded on conventional models of human biology. CAM, on the other hand, tends to include therapies that are not just weakly supported by the body of evidence, but which are based on philosophies of health and science conjured up outside our mainstream scientific understanding.

Homeopathy is a perfect example of this. If one looks to the literature for clinical data supporting homeopathy, the outcome of such a review might yield similar levels of supportive evidence when compared to hydroxychloroquine. Yet, homeopathy is distinctly a CAM therapy because its suggested mode of action in the human body cannot be reconciled with our current understanding of biology and chemistry. Instead, homeopaths posit an alternative model of human biology and chemistry that lacks a supportive body of evidence. In essence, what distinguishes homeopathy is not the lack of clinical evidence supporting it, but the underlying ideology that ultimately calls into question the plausibility of a therapy.

Of course, homeopathy is so far-fetched and lacking in plausibility and supportive evidence that it should not be found in any physician’s practice (nonetheless, it persists). But it’s perhaps not appropriate to dismiss all therapies simply because they were founded on pseudoscientific models of health. Acupuncture (now often referred to as “dry needling” to discard the historical baggage), for example, has moved somewhat into the mainstream as its mechanism of action has been reframed as biomedical, rather than vitalistic. I personally find the supportive clinical evidence unconvincing in demonstrating a meaningful benefit from the therapy, but it may be a treatment more worthy of reconsideration given the mixed evidence and recontextualization within the modern medical paradigm. (As an aside, I highly recommend the book Snake Oil Science as an introduction to looking skeptically at such clinical evidence.)

The CPSO’s current CAM policy does not make the distinction on ideological grounds, but defines CAM as a nebulous grouping of practices and products that are simply not considered conventional medicine. The policy does not require any specific standard of evidence but stipulates that CAM-related decisions must be “informed” by evidence and science. The policy was put to the test not that long ago when Anne Borden King challenged a physician offering chelation therapy to autistic children. The therapy is without evidence of benefit, based on pseudoscientific principles around vaccines and autism, and comes with moderate risk, yet both the CPSO and the provincial’s appeal board took no action against the physician, indicating that no harm has been done yet.

The potential consequences of this inaction are worth considering. In this case, a physician was able to subject patients to a risky therapy justified not by robust science, but by the physician’s personal beliefs. The regulatory system made clear that there is no real scientific threshold by which therapies are judged. Instead, they appear content to let physicians sell any therapy – no matter how absurd – until it results in a direct (and documented) injury. Besides the obvious consequence of demonstrating that any nonsense is permitted under such terms, the decisions also implicitly rejected consideration of harms besides the immediate side effects of the given treatment.

Let’s further examine this specific case: the treatment of autism with chelation therapy. The treatment is typically predicated on a number of dubious axioms:

  • Heavy metal exposure plays a causal role in autism
  • Vaccinations expose children to heavy metal toxicity
  • Removal of heavy metals can treat or cure autism in children

Of course, all of these claims are not supported by the science and by merely presenting this theory to patients, physicians are doing harm. The harm of such misinformation is not isolated to the clinic. Besides the unnecessarily expended time and money on useless treatments, patients (and their parents in this case) who adopt these views are prone to what we might refer to as secondary harms. How might these beliefs impact their willingness to vaccinate against deadly diseases? How might the idea that autism is a disease to be cured drive concerned parents to subject their children to unscientific and unethical “treatments”? To what extent do these beliefs drive patients away from conventional health professionals and services they may truly need? What is the societal impact of health misinformation?

These are just some of the questions that any serious health regulatory agency should consider when determining how best to protect patients and the public, yet Canada’s various self-regulating agencies have apparently not reckoned with the true reality of pseudoscience. It is perhaps with these concerns in mind that the CPSO drafted their proposed update to the CAM policy, which includes the requirement that physicians must practice “in a manner that is supported by evidence and scientific reasoning.” To what extent members are held to this, assuming it becomes policy, remains to be seen, but at least it codifies a standard necessitating that practitioners adhere to reality. A companion document, Advice to the Profession: Complementary and Alternative Medicine, provides guidance with respect to the levels of evidence. By suggesting the consideration of high quality scientific evidence, it’s a welcome addition.

Naturally, not all feedback has been positive. Despite its largely unsuccessful history in disrupting conventional care with useful therapies, CAM remains widely popular and is supported by a strong industry. We can find such support from a Toronto Sun article that palpably rejects the proposed reforms, arguing that the policy unfairly targets CAM providers, causing “fear they will be unjustly disciplined.” The article primarily relies on the trope that CAM offers a chance to patients who have otherwise fared poorly with conventional treatment. Unfortunately, people are not drawn to CAM treatments because they are effective, but because patients are dissatisfied with conventional care, wish to feel in control, and are sold hope in the face of despair. In essence, many of these practices are simply comforting myths, which can be quite convincing when paired with charismatic and empathetic practitioners.

A further argument made by the article is that the science-based standards would be too restrictive for a field where there is no money to be made from patents and, hence, “no incentive to finance the required evidence.” This is patently false. Ignoring the fact that the CAM-adjacent wellness industry is well funded, the recent history of scientific inquiry tells us that the issue is not a shortage of funding, but a shortage of plausibility and useful results. Take hydroxychloroquine again as an example. This drug is old, cheap, and patent-less, yet it received an extraordinary amount of research resources because it was at least a plausible treatment for a serious condition. Even outside of the pandemic, CAM treatments have not evaded research funding. Just look at the large literature base for acupuncture or homeopathy. Indeed, if anything, I would argue that such therapies have received a disproportionately high share of research funding when you consider their plausibility and outcomes.

Virtually all points raised in this article are similarly speculative; the author makes postulations that – just like the therapies alluded to – are not backed by strong evidence. She notes CAM providers fear they will be “unjustly disciplined”, but the CPSO’s failure to regulate even the most egregious pseudoscience is evidence that the opposite is true. Further, there would be nothing unjust about setting a universal science-based standard and disciplining practitioners who do not adhere to it. If practitioners think that medicine should not be based on scientific inquiry, I would suggest they find another career. After all, science is the method by which we determine which therapies work and which do not. The quoted anonymous practitioners claim to be “targeted” but they are only targeted insofar as they provide dubious treatments for profit. The choice is theirs.

I will agree with the author on one point: if physicians are always bound to making science-based decisions, why is a distinct policy needed for CAM? Shouldn’t physicians universally be required to make science-based judgements? Perhaps the policy is an implicit acknowledgement that practices categorized as CAM are those founded on pseudoscientific frameworks, but this would create a contradiction with a policy requiring a science-based interpretation and justification.

Regardless, the proposed policy has not yet been codified. If you are passionate about this issue, you have one more week (as of writing) to complete the online survey or post comments on the discussion page. I implore fellow Canadians to let the CPSO know that science-based standards are in the interest of patients and the public.