What is the best way to regulate practitioners of so-called alternative medicine (SCAM)? When tackling this thorny issue, we first need to ask: what is the main purpose of regulation in healthcare? Practitioners of SCAM often lobby for regulation because they feel it might give them a better recognition (and income). But that is most certainly not what regulation should be about. Any effective regulation must foremost be for protecting the public.
Protecting against what?
I have no doubt that most SCAM practitioners are full of good intentions and only wish the best for their patients. But many are not adequately educated and trained to be medically and ethically competent. And yet, under the self-regulation (that currently governs most types of SCAM practitioners in the UK) they happily diagnose, treat, and advise patients, even those with serious conditions. This overt mismatch of professional competence on the one side and clinical responsibility on the other side must inevitably put patients in danger. Therefore, self-regulation cannot possibly be the best way forward.
The other solution would be regulation by statute (as is currently the case for chiropractors and osteopaths in the UK). The statutes would need to ensure that practitioners abide by the fundamental rules of medical ethics and treat their patients according to the best evidence currently available. But this creates two rather awkward problems:
1) most alternative methods are NOT evidence based, and
In case this sounds a bit harsh, a simple example might explain. Imagine that a patient suffering from abdominal pain consults an osteopath. The practitioner wants to use spinal manipulations but, in order to comply with informed consent, she would need to tell the patient that:
- this treatment has not been shown to be effective for the condition in question,
- it is not free of risks, and
- it lacks plausibility.
In addition, the osteopath would be obliged to inform the patient that she cannot be sure about the cause of the pain which might even be a cancer, and that a proper doctor would be in a far better position to make a full diagnosis and determine the most effective therapy. Does anyone really think that the average osteopath is going to do all this, and lose their patient and fee in the course of it?
Even such a simple example shows how problematic any truly adequate regulation of SCAM practitioners is. Governments across the globe have struggled with this conundrum and have implemented compromises of various types. Without exception, they have one major disadvantage: they create a double standard in healthcare, where strict rules are applied for conventional and more liberal ones for SCAM practitioners. But double standards are far from desirable.
So, is there a solution?
If it was up to me, I would insist on one single standard across the board. This means that sound evidence has to come before regulation. If SCAM practitioners can produce convincing evidence that a particular SCAM, say spinal manipulation, does more good that harm for a defined condition, they should be allowed to use it in the management of that specific problem. If, however, the evidence is absent or unconvincing, the regulation must prevent them from using it.
I am fully aware that this would put many SCAM practitioners out of business – but, as mentioned above, regulation must be for protecting the public and not for boosting the ego or the income of practitioners.
