4 questions | Applied Sciences homework help

1. How the placebo is given and by whom can influence the outcome. However, it is not possible to characterize who will respond.

Part One Dynamics of the Health Marketplace40 Many studies have shown that placebos may relieve a broad range of symptoms. However, they do not cure disease. The psychologic aspects of many disorders also work to the healer’s advantage. A large percentage of symptoms either have a psychologic component or do not arise from organic disease. Hence, treatment offering some lessening of tension can often help. A sympathetic ear or reassurance that no serious disease is involved may prove therapeutic by itself. Beyerstein15 has observed: Pain is partly a sensation . . . and partly an emotion. . . . Any- thing that can allay anxiety, redirect attention, reduce arousal, foster a sense of control, or lead to . . . reinterpretation of symptoms can alleviate the agony component of pain. Modern pain clinics put these strategies to use every day. Successful quacks and faith healers typically have charismatic personali- ties that make them adept at influencing these psychological variables that can modulate pain. . . . But we must be careful that purely symptomatic relief does not divert people from proven remedies until it is too late for them to be effective. Confidence in the treatment—on the part of the patient and the practitioner—makes it more likely that a placebo effect will occur. But the power of suggestion may cause even a nonbeliever to respond favorably. The only requirement for a placebo effect is the awareness that something has been done. It is not possible to predict accurately or easily a particular patient’s reaction to a placebo at a particular moment. However, the psycho- logic predisposition to respond positively to placebos is present to some extent in most people. Some are very likely to obtain relief from placebos in a wide variety of situations, whereas others are very unlikely to do so. Most people’s response lies somewhere in between. Another factor that can mislead people is selective affirmation—a tendency to look for positive responses when improvement is expected. As Jarvis16 has noted: A culturally significant setting can also produce a potent ef- fect, as folk healers know well. Effective settings can be as divergent as the trappings of an oriental herb shop to Asians, a circle of witchcraft paraphernalia to a primitive tribesman, or the atmosphere of a modern clinic to a modern urban American. Social expectations can also play a role, as occurs in stoic cultures where people are taught to endure pain and suffering without complaining. . . . Operant conditioning can occur . . . when behavior is rewarded. . . . Thus, people with a history of favorable re- sponses to treatment are more apt to react well to the act of treatment. Responses to the treatment setting can also be negative (“nocebo effects”). In one experiment, for example, some subjects who were warned of possible side effects of a drug were given injections of a placebo instead. Many of them reported dizziness, nausea, vomit- ing, and even mental depression. A 1993 study of 109 double-blind drug trials found that the overall incidence of adverse events in healthy volunteers during placebo administration was 19%.17 Placebo responses, such as feeling less pain or more energy, can occur without affecting the actual course of the disease. Thus placebo responses can obscure real disease, which can lead to delay in obtaining appropriate diagnosis or treatment. The placebo effect is not limited to drugs but may also result from procedures.18 Devices and physical techniques often have a tremendous psychologic impact. Chiropractors, naturopaths, and various other nonmedi- cal practitioners use heat, light, diathermy, hydrotherapy, manipulation, massage, and a variety of gadgets. In addi- tion to producing physiologic effects, their use can exert a potent psychologic force that may be reinforced by the relationship between the patient and the practitioner. Of course, devices and procedures used by scientific practitioners can also have placebo effects. Barrett19 has expressed serious misgivings about over-reliance on the placebo effect in clinical practice: Doctors are confronted by many people who complain of tiredness or a variety of vague symptoms that are reactions to nervous tension. Far too often, instead of finding out what is bothering them, doctors tell them to take a tonic, a vitamin, or some other type of placebo. Quacks who rely on the placebo effect pretend that (a) they know what they are doing, (b) they can tell what is wrong with you, and (c) their treatment is effective for just about ev- erything. Many of their patients play the equivalent of Russian roulette. Medical doctors who use vitamins as placebos may not be as dangerous, but they encourage people to habitually use products they don’t need. Because most people who use placebos do not get relief from them, their use is also a finan- cial rip-off.

Canter20 has added:

Deliberate use of placebos is resisted by doctors because it involves deceit. It is also paternalistic and inconsistent with treatment with informed consent. Nor can it be squared with a holistic and respectful approach to patients that treats them as intelligent and active participants in their own pursuit of health and well-being. If the placebo effect accompanies any therapeutic intervention, then the logical and ethical course of action is to choose treatments where there is a demonstrable specific effect, and to take steps to maximize the accompany- ing placebo response. In many disorders, one-third or more of patients who receive a placebo will report improvement. How- ever, most placebo-controlled trials compare the active Chapter Three Frauds and Quackery 41 treatment with a placebo, not with no treatment. This design cannot distinguish an effect of placebo from the natural course of the disease, regression to the mean (the tendency for very high or low test results to be followed by results closer to the average), or the effects of other factors. An analysis of 114 randomized trials that had a “no-treatment” group in addition to active treatment and placebo groups concluded that some of the reported benefit attributed to placebos might have resulted from patients wishing to please their doctors. The study’s au- thors also concluded that there is no justifiable placebo use outside of clinical trials.21 recognizing Quackery Fraud and quackery are so pervasive that laws and en- forcement agencies are unable to adequately police or resolve the problem by themselves. Consumers must be alert for the purveyors of quackery and be able to recognize how they operate in the health marketplace. Table 3-2 describes their characteristic behavior. Quacks can be classified into three groups: dumb quacks: These people know not, and don’t know that they know not. They may be uneducated, ignorant people who believe they have the secret formula or cure-all that no one else possesses. Generally they are small-time operators. deluded quacks: These people know but have been misled into knowing not. They often have some educational background and may even have a medical degree. Their beliefs are based on faulty observations and equally faulty reasoning. They may command large audiences and thereby be dangerous. dishonest quacks: These people know not, and know that they know not. Their primary goal is money. They have no scruples.

Jarvis and Barrett12 warn that modern health quacks are super-salespeople:

Seldom do their victims realize how often or how skillfully they are cheated. Do viewers of an ad for a weight-loss “breakthrough” stop to think that a real breakthrough would be headlined in the news? Does the mother who feels good as she hands her child a vitamin pill think to ask herself whether it is really needed? Do buyers of “extra-strength pain relievers” wonder what’s in them or whether an unadvertised brand might cost less? Do users of “herbal energizers” realize that many herbs contain potent chemicals that may be harmful? Do subscribers to “health food” publications realize that articles are slanted to stimulate business for advertisers? Do people who hear testimonials stop to think that for every success there may have been dozens of failures? Do chiropractic patients who sign up for “preventive maintenance” know there is no sci- entific justification for such care? . . . . Do people who lobby for “health freedom” laws realize these are intended to excuse quacks from accountability rather than to improve consumer choice?

• They promise quick, dramatic, simple, painless, or drugless treatment or cures.
• They use anecdotes, case histories, or testimonials to support claims. Prominent people such as ac- tors, writers, athletes, and even physicians may be involved.
• They use disclaimers couched in pseudomedical or pseudoscientific jargon. Instead of promising to treat or cure specific illnesses, they offer to “detoxify” the body, “strengthen the immune system,” “balance body chemistry,” or bring the body into “harmony with nature.”
• They may display credentials or use titles that could be confused with those of reputable practitioners. Their use of the terms professor, doctor, or nutrition- ist may be spurious. Their credentials may be from a nonaccredited school or an organization that pro- motes nonscientific methods.
• The results they claim have not been verified or pub- lished in a reputable scientific journal.
• They claim that a single product or service can cure a wide range of unrelated illnesses.
• They claim to have a secret cure or one that is recog- nized in other parts of the world but not yet known or accepted in the United States.
• They claim to be persecuted by organized medicine and drug companies (“big pharma”) and that their treatment is being suppressed because it is controver- sial or because the medical establishment does not want competition.
• They state that medical doctors should not be trusted because surgery, x-rays, and drugs cause more harm than good. They say most doctors are “butchers” and “poisoners.”
• They claim that most Americans are poorly nourished and should take vitamins for “nutrition insurance.”

Any of these behaviors should make you highly suspi- cious. Additional signs of nutrition quackery are listed in Table 11–2. Table 3-2 characTerisTic behaVior oF pracTiTioners and proMoTers oF Quackery Part One Dynamics of the Health Marketplace42 Not usually. Quackery confuses people with double- speak—language that makes bad things sound good. Most people think that quackery and health frauds are easy to spot. Some are, but most are not. Today’s promoters wear the cloak of science. They use scientific terms and quote (or misquote) scientific references. On talk shows, they may be introduced as “scientists ahead of their time.” The very word “quack” helps their camouflage by making us think of an outlandish character selling snake oil from the back of a covered wagon—and, of course, no intelligent people would buy snake oil nowadays, would they? Well, maybe snake oil isn’t selling so well. But acu- puncture? “Organic” foods? Hair analysis? The latest diet book? Megavitamins? “Stress” formulas? Chelation therapy? Cholesterol-lowering teas? Homeopathic remedies? AIDS cures? Products that “cleanse your system”? Or vitamin shots to pep you up? Business is booming for health quacks. . . . Spot-reducers, “immune boosters,” water purifiers, “ergogenic aids,” bust creams, spinal adjustments for “preventive main- tenance,” devices to increase manhood, systems to “balance body chemistry,” cults to give life new meaning, special diets for arthritis. The list is endless. What sells is not the quality of their goods and services, but their ability to influence their audience. To those in pain, they promise relief. To the incurable, they offer hope. To the nutrition-conscious, they say, “Make sure you have enough.” To a public worried about pollution, they say, “Buy natural.” To one and all, they promise better health and a longer life. Modern quacks can reach people emotionally, on the level that counts the most. Many people lack knowledge of what should pass for proof that something works.22 Because people tend to believe what they hear about the personal experience of others, testimonials can be powerful persuaders. Viss- ing and Petersen23 stated that testimonials offer the most powerful type of persuasion to try an unconventional method. Many years ago, Smith9 made this observation, which is still noteworthy: Personal testimonials are not used in scientific medicine to prove or disprove the validity of therapies, and for good reason. There has never been a worthless or fraudulent treatment that could not produce a legion of persons who would swear that it helped or cured them. conspiracy claiMs Quacks typically charge that the medical profession, drug companies, the food industry, government agencies, and/or other “vested interests” are conspiring against “alternative medicine,” dietary supplements, and “natu- ral” health cures and that these alleged conspirators put profits ahead of public safety. Some practitioners, for example, charge that the American Medical Association (AMA) and mainstream physicians are against them because their cures would cut into the incomes that doc- tors make by keeping people sick. Chelationists charge that doctors oppose chelation therapy because it would destroy the very profitable cardiac surgery industry, and cancer quacks claim that their methods pose an economic threat to the multi-billion-dollar “cancer industry.” Many quacks charge that their critics have been “bought off” by drug manufacturers who view “natural” methods as a threat to their enormous profits. Antifluoridationists falsely claim that the driving force behind water fluori- dation is a desire by the aluminum industry to sell waste products that are used to fluoridate public water supplies. Claims of “suppression” are used to market publica- tions as well as treatments. Many authors and publishers purport to offer information that your doctor, the AMA, and/or government agencies “don’t want you to know about.” The most noteworthy example is the book Natu- ral Cures “They” Don’t Want You to Know About,24 by Kevin Trudeau, a repeated lawbreaker whose activities are described in Chapter 25. Despite the extremely poor quality of its advice, it topped bestseller lists during much of 2005. The “conspiracy” charge is an attempt to gain sym- pathy by portraying the quack as an “underdog.” Jarvis25 has observed that, “Whereas individuals who complain about conspiracies directed toward themselves are likely to be regarded as mentally ill (paranoid), those who per- ceive them as directed against a nation, culture, or way of life may seem more rational.” Novella26 has noted: Patients, especially those with a disease which is not curable by standard medicine, are eager to believe such conspiracy theories because they offer the hope they crave. It is far better to believe that there is a cure out there for you, with a small but dedicated band of rebels who will defy the establishment to bring it to you (for a fee of course), than to believe that no cure exists anywhere. Although many people profit from health-related activities, the idea that great numbers of independent individuals, companies, and government agencies would—or could—conspire to suppress progress is complete fantasy. The elimination of serious diseases, for example, is not a threat to the medical profession. Researchers have much to gain financially and in terms of prestige by discovering therapeutic breakthroughs. Doctors prosper by curing diseases, not by keeping people sick. Moreover, all of the alleged conspirators and their families get sick themselves and would stand to lose if genuine treatments were suppressed. It should also be apparent that modern medical tech- nology has not altered the zeal of scientists to eliminate Chapter Three Frauds and Quackery 43 disease. When polio was conquered, iron lungs became virtually obsolete, but nobody resisted this advance- ment even though it meant that hospitals would have to change. Actually, the greatest threat to quacks would be for the medical profession to adopt their methods and compete with them for patients. The FreedoM-oF-choice issue Promoters of quackery tend to disparage accepted scien- tific methods as well as consumer-protection laws. They argue that personal experience determines what works and that patients should be free to select any therapy they wish (Figure 3-1). They also argue that everyone should be free to market methods without the responsibility of ensuring that they are effective. The American Council on Science and Health27 described this version of “health freedom” as “nothing more than a hunting license for quacks.” Jarvis1 describes it as a ploy: The “health freedom” argument is a classic example of de- ception by misdirection. . . . The reality is that patients may freely choose to do a variety of things. Patients may refuse treatments, swallow vitamins, eat apricot pits or the whole tree if they wish. However, they may not sell their pet remedies in the marketplace if those remedies have not been proven safe and effective. The reason that patients clamor for dubious treatments is that they have been deceived into believing that these therapies offer hope. By focusing attention on the patients, the deceivers direct attention away from themselves. Many groups that espouse unscientific methods have crusaded to weaken consumer-protection laws. These include the Alliance for Natural Health, the National Health Federation (NHF), the HealthKeepers Alliance, and the now-defunct Committee for Freedom of Choice in Medicine (CFCM). To promote their legal strategies these groups lobby, stage news events, and generate letter-writing campaigns to legislators and government agencies. During the mid- 1970s, for example, NHF and CFCM (then called the Committee for Freedom of Choice in Cancer Therapy) spearheaded passage of laws to permit the marketing of Laetrile (a bogus cancer remedy) within the borders of nearly half the states. In the 1990s several of these groups combined with health-food industry organiza- tions to generate a massive letter-writing campaign that led to passage of the Dietary Supplement Health and Education Act of 1994, which greatly weakened the ability of the FDA to protect consumers against useless and dangerous dietary supplement and herbal products (see Chapter 11). In recent years a few states have passed laws preventing their medical licensing board from disciplining physicians solely because they engage in “alternative” practices. Some have even authorized unlicensed individuals to offer health care. Chapter 8 discusses some of these anti-regulatory strategies. Consumers should have considerable right to choose the health products and services they wish to use. How- ever, they will benefit from this only to the extent that the marketplace is trustworthy. The fundamental principle of consumer protection (and federal law) is that methods One of your parents is seriously ill with cancer, with little hope of recovery. Treatment at a large medical center has not succeeded in curing or alleviating the condition. A friend of your parents told them he was helped by a clinic in Mexico that uses a substance, unavailable in the United States, that cures a high percentage of cancer patients who receive it. Despite its high cost, your parents are considering a trip to Mexico. What can you do to help them reach an intelligent decision? How sensible would it be for them to spend their life savings for the treatment? It’s Your Decision WE—THE PEOPLE of the United States, propose AMENDMENT XXVII to be known as the HEALTH- CARE RIGHTS AMENDMENT, which should read as follows: HEALTHCARE RIGHTS AMENDMENT SECTION 1. The Congress shall make no law which restricts any individual’s right to choose and to practice the type of healthcare they shall elect for themselves or their children for the prevention or treatment of any disease, injury, illness or ailment of the body or the mind. Figure 3-1. “Healthcare Rights Amendment.” A now-defunct “consumer group” gathered approximately 100,000 signatures supporting a constitutional amendment to establish “health freedom.” If it were enacted, government agencies could no longer stop the marketing of unproven or dangerous remedies if even one consumer wanted them. Anyone, licensed or not, could engage in any practice labeled “health care” so long as a single consumer wished it to continue. Compulsory immunization would end, and courts could no longer protect children from parents who deny them access to effective treatment, even if such neglect would result in their death. Part One Dynamics of the Health Marketplace44 should not be marketed until they have been proven safe and effective by scientific study. Abolishing this safe- guard would have disastrous consequences, especially for seriously ill people who must quickly decide what to do. Such people should not have to sort through a mix that includes cleverly worded but empty promises. suMMary Despite the tremendous advances in medical science and health education, health frauds and quackery are still common. Americans waste huge amounts of money on unproven and unscientific approaches to health care. Faced with the prospect of chronic suffering, deformity, or death, many individuals are tempted to try anything that offers relief or hope. Health frauds and quackery can cause financial, physical, and psychologic harm. It is extremely important for consumers to under- stand the concepts of spontaneous remission and the placebo effect. The mere fact that someone feels better after trying a remedy does not prove that the remedy was effective. Most diseases are self-limiting, and placebos can relieve a broad range of symptoms. Modern quacks can be difficult to recognize. How- ever, certain behavior patterns should help consumers identify them. It is important for consumers to complain to appro- priate authorities when they encounter deception in the marketplace.

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