Volume 195 - Issue 11
Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base?
Author: Chun Wah M Tam
Med J Aust 2011; 195 (11): 660-661. || doi: 10.5694/mja11.11333
Published online: 12 December 2011
Published online: 12 December 2011
To the Editor: I read with interest the contrasting perspectives by Pirotta1 and Dwyer2 on the ethics of prescribing complementary and alternative medicine (CAM) interventions, and the subsequent letters on this subject published in the 17 October 2011 issue of the Journal.
Individual CAM interventions should be assessed with the same evidence-based approach we would use for any other intervention. Furthermore, any evidence should be interpreted with the same caution as we do for conventional medicines. The efficacy of an intervention should be judged by the quality of the clinical evidence in the context of its scientific plausibility. Whether an intervention should be recommended depends on the context of the other known evidence-based management strategies and the patient’s individual clinical scenario.
It is concerning that the supporters of the use of CAM in general practice appear to be willing to make recommendations for treatment in the absence of quality empirical evidence. Both Pirotta and Kotsirilos make the often-used argument that absence of evidence is not evidence of ineffectiveness.1,3 Pirotta suggests that we can turn to tradition1 and Kotsirilos implies that consumer demand indicates effectiveness.3 It should be acknowledged that both tradition and popularity are unreliable forms of evidence. The absence of quality evidence for an intervention should be a major barrier to recommending it, especially when known, effective alternatives exist. This is regardless of the philosophical tradition of the intervention.
Even when there is evidence for efficacy, care must be taken in avoiding overreaching conclusions. For example, Kotsirilos interprets the relevant Cochrane review4 as supporting the use of cranberry for prevention of recurrent urinary tract infections in young women.3 That therapeutic recommendation is unjustified. Although the systematic review did find some evidence for cranberry, it noted problems with its quality and the lack of clarity of dosage and administration. The conclusion of the review in 2008 was that “further properly designed studies with relevant outcomes are needed”.4 A well designed randomised controlled trial was published earlier this year; it does not support the use of cranberry for this indication.5
Competing interests
No relevant disclosures.
References
- Pirotta MV. Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? – Yes. Med J Aust 2011; 195: 78. 0_i1142881
- Dwyer JM. Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? – No. Med J Aust 2011; 195: 79. 0_i1142883
- Kotsirilos V. Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? [Letter]. Med J Aust 2011; 195: 451-452. 0_i1142885
- Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2008; (1): CD001321. 0_i1142887
- Barbosa-Cesnik C, Brown MB, Buxton M, et al. Cranberry juice fails to prevent recurrent urinary tract infection: results from a randomised placebo-controlled trial. Clin Infect Dis 2011; 52: 23-30. 0_i1142891