Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base?

To the Editor: The commissioned article by Pirotta, dealing with the ethics of prescribing alternative complementary treatments that may lack an evidence base,1 contains a number of statements which, if the article had been subjected to peer review, might well have finished up on the cutting-room floor. For example, the statement “it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence” is not backed up by the only monograph cited in support of it.2 Whatever relevance a lack of level-1 evidence may have to the practice of dermatology (for which it is claimed), it plays little part in either modern medicine or the revolutionary advances in surgery, few being the result of a systematic review of multiple well controlled randomised trials. Having said that, the reference to complementary or alternative treatments that lack any evidence base as “medicine” gives a misleading legitimacy to practices that may be — and frequently are — based on cultural, historical or spiritual beliefs, or even just plain wacky approaches to healing. Regrettably, Pirotta adds nothing new to the (uncited) definitive 2004 article by Kerridge and McPhee.3

How times have changed. Not only are doctors now expected to have sufficient knowledge of complementary and alternative medicine to be able to advise their patients of therapeutic alternatives, but we may well have reached the stage where a failure to alert patients of such alternative treatment options may constitute negligence at common law.

The New South Wales case of McGroder v Maguire4 is instructive. In that case, the plaintiff, a truck driver, had suffered a neck injury in the course of his employment. Despite a lengthy period of treatment, he continued to suffer from tingling in his arm. The defendant, a general practitioner retained by the plaintiff’s employer, although not having examined the patient, nevertheless referred him to a chiropractor. This referral was held to have been negligent, not because of the referral per se, but because of the patient’s condition. This came to light in the evidence given by a neurosurgeon and orthopaedic surgeon at the trial of the action, both of whom agreed that this case was not one for chiropractic manipulation of the plaintiff’s neck and back. Despite subsequent neurosurgery, the plaintiff became totally incapacitated for work. In the result, both the referring GP and the chiropractor were held to be liable in negligence.