Apr 08 2010

Springtime for Charlatans

Imagine a ring of car thieves lobbying the government to soften the laws against stealing cars. Don’t blame the thieves – people should be more responsible for their own cars, and that is just the chance you take when you own a car. Under the radar, without any comment by the media, in state after state they successfully lobby the legislatures to pass laws that make it more difficult to prosecute and punish car thieves.

Of course this is outrageous, but not just because it’s silly to consider that something like stealing a car should not be a serious crime. It is also outrageous for someone who is violating regulations to lobby for those very regulations to be weakened so that they can continue to break the regulations without fear of action being taken against them. At the very least such action should garner significant attention and debate, and lawmakers should consider carefully if the public’s best interest is being met, or simply the person who doesn’t want to be regulated.

This is exactly what is happening in many states with so-called “health care freedom laws” – practitioners of dubious treatments are lobbying state legislatures to weaken regulations against practicing dubious treatments. There are even specific cases in which an individual practitioner was found to be practicing below the acceptable standard of care, but was able to escape regulation because of laws specifically passed to protect substandard care. This is exactly what happened with Dr. William Hammesfahr – he was found to be practicing substandard care by the State of Florida, but was able to appeal and win on the grounds that his treatment was “alternative” and therefore magically exempt from the standard of care under Florida’s new health care freedom law.

The same thing has now happened with respect to Dr. Rashid Buttar – the North Carolina Medical Board (NCMB) has been investigating him for charging patients tens of thousands of dollars for dubious treatment for cancer, autism, and other indications. These includes using chelation therapy for autism, based upon the discredited notion that autism is mercury toxicity.  The NCMB was making their case that Buttar was using questionable, and at best highly speculative and experimental treatments, while misleading patients into thinking they were effective (creating undue expectations) and charging exorbitant amounts. In fact a board of inquiry recommended that Buttar have his license restricted so that he cannot treat children or cancer patients.

However, that recommendation was set aside for technical reasons. While a hearing before a judge was pending, Buttar and others successfully lobbied the North Carlina legislature to pass a health care freedom law.

Mansfield, the board’s attorney, said a change in state law, which took effect in October, was partly the reason. The law, one of those that Buttar had pushed for, prevents the medical board from disciplining a physician for using non-traditional or experimental treatments unless it can prove they are ineffective or more harmful that prevailing treatments.

Essentially the hands of the NCMB were tied, in the middle of their investigation of Buttar, and he was let off the hook with a slap on the wrist. He is now free to continue to practice his dubious medicine on the unsuspecting patients of North Carolina and beyond. The board now has the burden of proof that a treatment is ineffective, which is impossible for treatments that have not been adequately studied. In fact, such laws create another disincentive for practitioners of dubious modalities to study their treatments.

The Standard of Care

To put this into perspective, we need to back up and discuss the standard of care. Practicing medicine is a profession, which means we grant certain individuals the privilege of practicing but demand from them certain assurances, ethical guidelines, and standards. Without a standard of care, then anything would be fair game and the principle of caveat emptor would rule. If that is what the majority of our society really wants, then so be it. But I don’t think that is the case.

If we agree that there should be some standard of care, then the only question then is how to determine what that standard should be and how to enforce it. For the most part, the standard is determined by the prevailing accepted practice among experts, which in turn should be based upon scientific evidence. Practitioners are expected to know what the standard of care is and to abide by it, unless they have a very good reason for doing otherwise (and are willing to defend their actions in court). In the US each state has a medical board tasked with investigating any practitioners who are alleged to be practicing significantly below the standard of care. In my experience they do not micromanage or get involved in minor cases, but only egregious violations of well accepted standards. It takes a lot to get their attention.

But the standard of care is being steadily eroded in this country, without any media attention or public debate. Practitioners of substandard or dubious methods are successfully lobbying their state legislatures to weaken the boards of health that are supposed to maintain the standard of care. They call what they are advocating “health care freedom” and claim it is the freedom of patients to get whatever treatment they want. But in reality it is freedom for practitioners to practice whatever they want – even outright deception and quackery – without being held to any standard. In most states, as in the slap on the wrist for Buttar, all that is required is that patients are informed that the treatment is “alternative” – but “alternative” is not defined. It’s basically anything the practitioner wants it to be.

In some states specific treatments or practices are targeted. For example, recently Connecticut passed a law exempting practitioners who treat chronic lyme disease from the standard of care. Chelation therapists have also been successful in protecting their pseudoscientific practices. But increasingly, blanket exemption is being granted to anything “alternative.”

Conclusion

The standard of care is vitally important in our complex health care system. We should be looking for ways to enhance it, not erode it. Ineffective treatments victimize patients and are a waste of resources. It is unethical to charge large sums of money for experimental treatments by creating an expectation of benefit, and in fact experimental treatments should only be given as part of research protocols, or under strict conditions of compassionate care.

But Buttar, Hammesfahr, and others have created a lucrative practice out of dubious treatments and have successfully hidden behind laws specifically designed to hamper state regulators. In Buttar’s case he apparently lobbied for such laws while under investigation.

The media is nowhere on this issue. The public is largely unaware. No one I speak to (outside my small group of colleagues) has any idea this is happening.

This is also part of a broader problem – by labeling unscientific or questionable practices (what used to be called “health fraud”) as “alternative” or “complementary”, charlatans have succeeded in getting appointed as the foxes in charge of the hen house. They are now their own gatekeepers in the bizarro world of CAM. On some morbid level I have to admire their chutzpah – they have pulled off the greatest scam in history.

Note:

Orac adds his “insolence” to this issue as well.

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