Seeing as complementary therapies are supposedly interested in treating disease and maintaining health, I’ve always just assumed that there was some degree of regulation to their practice just like there is for real medicine. Surely when some of these therapies claim to be able to cure serious diseases like cancer and diabetes, practitioners are required to be members of a professional association which has outlined codes of practice, education requirements and ethical standards. I suppose I shouldn’t have been too surprised when I found out there was no such requirement and that practice of complementary and alternative therapies in Ireland is completely unregulated. This is a result of Ireland’s common law tradition which allows CAM therapists to practice without any form of state regulation until laws are passed specifically legislating for these therapies. This is despite calls from the European Commission as far back as 1999 to “protect citizens against unjustifiable claims and quackery while at the same time recognising their freedom to choose from a variety of healthcare options.” In fairness to complementary therapists though, it would be a lot like pickpockets and conmen forming their own organisations. Why form an organisation and expose your dubious practices to unwanted scrutiny when you can go about your day selling ineffective treatments and therapies without anyone looking over your shoulder?
Acting on the recommendations of the European Commission, the Department of Health published the “Report on the Regulation of Practitioner’s of Complementary Medicine in Ireland” in 2002. This report was bases on the opinions obtained from a forum of complementary and alternative practitioners held in 2001. Unsurprisingly, the forum recommended self-regulation where practitioners of each therapy would come together to “develop their own statistics, educational programmes, codes of ethics, research programmes and competency standards.” Self-regulation seemed fair enough really and is commonplace among other professions. It does, however, rely on the integrity of practitioners and assumes that they will act in the interest of the public through ethical practice, reliable research and the maintenance of high educational standards. It was at this point that complementary medicine’s abysmal track record in ethics, research and education was once again revealed.
A Working Group was established to devise a plan for implementing self-regulation of complementary therapies in Ireland. At the request of this Working Group, again made up almost completely of complementary medicine practitioners, the Higher Education and Training Awards Council (HETAC) is currently reviewing the regulation and academic recognition of ineffective therapies such as osteopathy, chiropractic and acupuncture. In a blatant abuse of their power to self-regulate, however, a planned review of the therapeutic effectiveness, safety and contemporary public policy of these practices was quietly scrapped as it was deemed “unnecessary”. CAM organisations effectively sidestepped any requirement to provide a base of evidence for their therapies while still improving their credibility by engaging in a government-approved regulation process and the development of HETAC-approved training courses. Osteopaths, chiropractors, acupuncturists and practitioners of herbal medicine will soon be able to sell the same ineffective and sometimes dangerous products and services but with an effective government stamp of approval.
There can be no reason why a review of the effectiveness and safety of these practices was “unnecessary”. Given the controversy that has surrounded many of these therapies, surely the review was critical to the process of recognising them as legitimate treatment options for the public. As you’ve probably heard before, extraordinary claims require extraordinary evidence to back them up. If a doctor claimed they could cure cancer by pouring treacle up your backside and hanging you upside-down in a wardrobe, the Medical Council of Ireland would require them to provide mountains of proof before a clinical trial could even be performed. The Working Group, however, decided that no evidence was required to support the equally baseless and ridiculous claims of complementary therapies before their practitioners could be released on the public.
Was the Working Group so convinced of the effectiveness of their therapies that they decided no further investigation was required? This could only mean that CAM organisations in Ireland are directed by well-meaning idiots as even a cursory review of the evidence their therapies to be almost completely ineffective. What evidence there is to support such treatments such as chiropracty and osteopathy is almost without exception biased and of poor quality. Any organisation so completely incompetent and obviously ignorant of the facts related to their own profession should not be trusted with maintaining the health of any individual.
The only other reason for not conducting this review is that the Working Group feared that a review of their therapies would expose them as fraudulent and ineffective. Why take the risk of compiling a report based on unreliable and inaccurate evidence which would then be released to the public when you can quietly abandon it and hope no-one notices. While this would reveal practitioners of complementary medicine to be at least intelligent, it would also show a complete disregard for public safety and even the most basic ethical standards.
While specific legislation governing the practice of complementary therapies does not yet exist in Ireland, existing legislation should provide some degree of protection to consumers. The Department of Health states that while customers are not protected by any professional statutory regulation of CAM practitioners, they are afforded security by consumer, competition and criminal law. The “Consumer Protection Act, 2007” protects from consumers from misleading advertising and from false claims about goods or services. Many CAM therapies could be deemed illegal on this basis alone as while practitioners claim they are effective in the treatment of various diseases, the most reliable evidence reveals them to be at best no more effective than a placebo.
Consumers should also be protected by the “Sale of Goods and Supply of Services Act, 1980” which states that the service supplier must possess “the necessary skills to render the service”. CAM therapists are also in breach of this legislation as it is impossible for any individual to attain the skill required to turn ineffective therapies into effective remedies for pain or illness. The act also states that any products sold must be “sound and reasonably fit for the purpose for which they are required”. Given that homeopathic remedies are effectively just water or sugar pills and herbal medicines are with only a few exceptions ineffective, any claims that they can improve any condition or illness is once again a blatant breach of this legislation.
In theory the present legislation should protect consumers from both well-meaning idiots who unknowingly practice ineffective therapies or calculating conmen only looking to separate people from their money but in practice it doesn’t really work. For a start the onus is placed on the consumer to make a complaint and while we’ll all happily grumble away to ourselves about poor service or products, we’ll rarely take any action. Just think of the last time you got poor service or food in a restaurant and still told the waiter that everything was great. Whether it’s just to avoid the hassle or avoid making a scene, as a nation we’re terrible at standing up for ourselves and demanding better. I’d imagine for most people, the failure of a complementary medicine therapy to have any effect is much the same. We put it down to experience, cut our losses and move on. Meanwhile, complementary therapists continue to profit from unsuspecting consumers willing to try whatever quackery they have to offer.
What makes it even more difficult to determine whether complementary therapies are beneficial or not is the complexity of factors involved. As Thaler and Sunstein demonstrate in their book “Nudge”, people often make poor decisions when left to decipher complex information without any help and CAM therapists use a number of practices to take advantage of this fact. First of all, the enormous variety of complementary therapies makes it almost impossible to determine which may actually be beneficial. In addition to this CAM therapists are constantly rehashing and rebranding old ideas with the result there may be many variations of what is effectively the same ineffective treatment. Secondly, many complementary therapists appear to intentionally imitate conventional medical practitioners by wearing white coats, calling themselves doctors or practicing in settings designed to imitate your normal hospital or doctor’s clinic. These practices may make the treatment appear more trustworthy and legitimate by exploiting the patient’s associations between these factors and reliable medical treatment. Finally, the claims made by many complementary therapists may be difficult to interpret for the majority of people who do not have any scientific or medical training. A quick google will provide an endless list of websites and journal articles supporting alternative therapies. To the untrained eye, these sources may appear respectable and authoritative when in reality all they do is churn out unreliable, flawed and biased articles.
The very nature of illness and our expectations of treatment may also make determining which therapies are effective even more difficult through a combination of factors including the placebo effect and spontaneous resolution of illness or regression to the mean. It’s common sense that people generally seek treatment for an illness when their symptoms become too severe for them to put up with anymore. You may go along to your friendly neighbourhood complementary therapist for “treatment”, notice some improvement and be back to normal within a few days. Understandably, you may attribute your improvement to the “treatment” but in reality it may not have made any difference. The majority of common illnesses, aches and pains are self-limiting and will resolve themselves in time with a little rest. The fact the worst point in the illness and the “treatment” occur at the same time is merely coincidence and provides little evidence to support the effectiveness of the therapy. Doctors are also guilty of this when prescribing antibiotics for minor respiratory infections such as the common cold. Most of these infections are viral in origin and antibiotics will have little effect but when faced with a full waiting room and a patient expecting some kind of treatment, some doctors will prescribe a course of antibiotics to avoid a discussion and possible argument with a patient.
As for the placebo effect, we are only beginning to understand its potency and possibly utility. It basically means that just by taking some action or receiving some treatment for an illness, you will feel better regardless of whether the treatment was effective or not. While this is a pretty simple concept that most people can understand, the true complexity of the placebo effect is incredible and sometimes scary. Just listen to some of Ben Goldacre’s examples in his Nerdstock talk for a better explanation than I could give. Reliable medical research must take the placebo effect into account when attempting to determine the effectiveness of a treatment. Performing a trial of a treatment without controlling for the placebo effect is really just an expensive waste of time as a sugar pill may have been just as effective but you won’t know because you didn’t consider it. This is where most of the research supporting complementary therapies fails. More reliable research allowing for the placebo effect and other factors generally finds that the large majority of complementary therapies are no more effective than a placebo. Complementary therapists, however, tend to ignore this and will instead quote impressive sounding studies that actually provide no support for their treatment. While complementary therapies such as homeopathy and acupuncture may provide some genuine benefit through the placebo effect, advertising these treatments as anything more than this and subsequently charging for them is blatantly unethical. It is also another reason why complementary therapists cannot be trusted to regulate themselves adequately regardless of whether they are incapable or just unwilling to distinguish between real and placebo effects.
As a result of the factors I’ve outlined above, existing consumer legislation is surely inadequate for protecting consumers from the fraudulent claims and ineffective treatments of complementary therapists. Providing government-approved regulation without any requirement for the provision of adequate evidence is merely providing complementary therapists with a more complicated and more efficient system of financial exploitation. While consumers may be fairly well-educated when it comes to their rights, this makes little difference when alternative therapists can easily convince them they have received a satisfactory service or treatment when in fact a sugar pill or a couple of days off work would have had the same effect. Again as shown by Thaler and Sunstein, in order for consumers to truly exercise free will and their right to protection from exploitation they must first be provided with accurate and easily digestible information. The unreliable information and confusing practices of complementary therapists is just as serious a constraint on this free will as banning alternative therapies completely as it makes the process of making an informed decision more confusing and difficult than it has to be.
Protection of the rights of consumers could be accomplished through a number of simple measures. First of all, if complementary therapists are to be allowed to regulate themselves, they must also be required to provide a base of evidence for their therapies before they can be offered to the public. This evidence should be reviewed by an independent body as CAM organisations in Ireland have so far been unwilling or unable to produce or interpret accurate and reliable research. This would have the added benefit of providing complementary therapists offering approved therapies with a justified level of authority and respect and aid in the development of effective therapies by creating a culture that does not allow quackery or bullshit. Consumers also need to be better educated about making healthcare choices and where to obtain reliable healthcare information. To accomplish this, a list of approved complementary therapies could be made available both online and in printed format as well as approved sources of health information. There would be no need for the Department of Health to compile an extensive (and expensive) resource of its own as this information is already available from sources such as the NHS and American Cancer Society.
While these measures could be easily-implemented and cost-effective, they would require greater will from the Department of Health to protect patients and consumers from financial exploitation and potentially dangerous treatments. Complementary practitioners would also surely oppose any interference and portray these measures as dictatorial and unfair instead of taking the opportunity to enhance patient welfare and the efficacy of their practice. Until changes are made, be sure to make the effort of reporting any dubious claims from complementary therapists to the Advertising Standards Authority of Ireland and National Consumer Agency. With just a call or email you’ll have the personal satisfaction of knowing you’ve given a quack a real pain in the arse and hopefully bring more attention to the true extent of bullshit and quackery in the country today.
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