>>> Posting number 1395, dated 15 Nov 1996 18:40:02 Date: Fri, 15 Nov 1996 18:40:02 -0500 Reply-To: Discussion of Fraud in Science Sender: Discussion of Fraud in Science From: Murray Enkin Subject: Re: Alternative Medicine Mime-Version: 1.0 Content-Type: text/plain; charset="us-ascii" Jim Giglio presented a couple of excellent examples of major triumphs of modern scientific medicine. It would not be at all difficult to add innumerable other examples: blood transfusion, antibiotics, anaesthesia, xray, laparoscopy, to mention ony a few. It is equally easy to point to innumerable examples of false leads, such as internal mammary ligation for coronary insufficiency, gastric freezing for peptic ulcer (to say nothing of the use of a milk diet and antacids for peptic ulcer). I don't think that these examples, or any form of anecdote help us very much. The concept of the randomized controlled trial is a relatively recent one, really initiated by Bradford-Hill about 1950. Since that time, of course, the number of trials has grown exponentially, and the treatments of which we can be confident are those which have been tested by randomized trials. Unfortunately, the number of treatments that have not been so tested is legion. In my own field, of obstetrical care, one might mention, for example, the present pattern of antenatal visits, prohibition of all alcohol intake during pregnancy, screening for gestational diabetes, bed rest for threatened miscarriage, routine repeat caesarean section, routine intravenous infusion during labour, elective forceps for preterm delivery, wearing hospital gowns in nurseries. Some of these interventions are in widespread use, and indeed, some of them may prove to be useful if properly evaluated, but so far that evaluation has not been carried out. Other obstetrical interventions that have been evaluated, and found to be useless or harmful, but are still occasionally used, include dietary restriction to prevent pre-eclampsia, enamas and pubic shaving in labour, electronic fetal monitoring without access to fetal scalp sampling during labour, oxytocin for cervical ripening before induction of labour, samples of formula for breastfeeding mothers. Needless to say, one could add to these lists without difficulty, but also without purpose. Suffice to say, there are treatments in modern medicine just as much in need of evaluation as are those in alternative medicine. I agree with those who point out that the onus for proving benefit should always fall on the proponents of an intervention. But the extent of need for proof should not depend on whether the intervention is orthodox or alternative, but on the costs or dangers associated with it. There is, for instance, no need to evaluate the benefits of a kind word, or a smile. Therapeutic touch, (ridiculous as its underlying theory is to those of us trained in orthodox medicine) is cost-free and almost certainly without hazard. On the other hand, invasive procedures, such as most forms of surgery, expensive diagnostic procedures, etc. most definitely do require evaluation with randomized trials before they are introduced. When alternative therapies are dangerous or expensive, they require rigorous evaluation. Those that are simple, non-invasive, inexpensive, and pleasant to the patient, do not. The same holds for those procedures that "should work" in orthodox medicine. Lets find out if they do. ***************************************************************************** Murray W. Enkin, MD, FRCS(C), Professor Emeritus Depts of Obstetrics and Gynaecology, Clinical Epidemiology and Biostatistics McMaster University, 1200 Main St. W., Hamilton, Ontario, Canada L8N 3Z5 phone: 905 527 1179 fax: 905 577 0471 email: enkin@REDACTED.mcmaster.ca ******************************************************************************