Downstate Illinois residents, Judith Cramton and her two children, filed suit against chiropractor Vernon R. Mannon, Biotics Research Corporation and Nutridyn, Inc., for their parts in poisoning them with megadoses of vitamin A. Ms. Cramton suffers from pseudo-brain tumors, severe headaches and blurred vision. Her daughter, now 18, suffers from musculoskeletal pain and growth retardation. Her son, now 13, suffers from a liver disorder. The medical malpractice aspects of the case have yet to be resolved, but a part of the case, including product liability charges against the manufacturers has been settled by insurers for $795,000. (Chicago Daily Law Bulletin, 3/1/89). According to the Ecological Illness Law Report, 4:(6):7, 1987, the dosage involved (apparently for the boy) was 750,000 IUs (no time factors given).
Housewife and free-lance writer, Carolyn Copeland, tells her story about the dubious health care she received from a well known holistic health clinic (name changed to avoid reprisals) in Arizona over a period of more than 15 years. Most damaging was nine years of neglect of an ovarian cyst and endometriosis the clinic treated with acupuncture. By the time proper care was obtained, the condition had progressed to the point that the reproductive organs had to be removed. Ms. Copeland notes that the holistic health care provided by the clinic emphasized caring and human contact with a warm, personal touch. She appreciated the polished bedside manner of the medical and nursing practitioners. She notes that they were compassionate listeners, sympathetic to her every complaint, but they failed to provide competent medical care. They had abandoned scientific health care for astrology, herbalism, acupuncture and so forth. A liberal use of liver, iron and vitamin B-12 shots were also employed. The clinic presents itself as a Christian enterprise. It is particularly curious that Ms. Copeland originally located the clinic on the basis of a referral by the county medical society! (J Christian Nursing, Spring, 1989.)
Law enforcement acted quickly to stop the promotion of Cho Low Tea which claimed to be "as effective as medically prescribed drugs in lowering cholesterol" while telling users to "Go ahead, eat your favorite foods." The Los Angeles police arrested Cho Low Tea promoters Peter Clarence Foster and Trevor Brine, both Australian nationals, on June 30 in their Beverly Hills (Calif) offices of the Virginia Investments Management Company. Foster, 26, reported fled England last year after having been charged in connection with a fraud scheme allegedly involving the sale of nearly $7 million worth of a Chinese "slimming" tea. Full-page advertisements for Cho Low Chinese herbal tea ran in various cities across the USA in June. The ad had the celebrity endorsement of Tristan Rogers of TV's "General Hospital" and supporting statements from several MDs including anti-sugar zealot John Yudkin (author of the dubious antisugar book, Sweet and Dangerous) of England. On June 15 it was determined that the company had already received about 2,000 orders totally $58,000 from respondents. The money and 1,000 more order which have come in since then have been seized as evidence. [Arizona Daily Star, 7/1/89]
The province of Ontario is considering a new health professions act that would leave out naturopathy. The new act would make many of what naturopaths do illegal unless done by a licensed practitioner. The practice of naturopathy is too ill-defined and vague to allow proper regulation according to the final report of the review committee. An article in the April 30, 1989 Toronto Star presents the agonized cries of the naturopaths and their followers. The article states that there are 175 NDs providing some 300,000 patient consultations each year.
Susan Schacht details the recent trial of the promoters of the Fat Magnet weight-loss pill in her description of deceptive weight-loss claims and health gimmicks (Transcript Telegram, Holyoke, Massachusetts, June 13, 1989). Schacht also provides useful information on Anorex 2000 which relies upon EAB, a mild anesthetic that numbs the taste buds. Fat Magnet ads ran in 725 newspapers (Schact says that none ran in California because of its aggressive action against health fraud). The Fat Magnet is made of cellulose which allegedly binds with fat and prevents its absorption. A former clinical UCLA cardiologist, Dr. William Shell, is touted as the Fat Magnet's inventor. Its promoter, Martino, was represented during the trial by Kirkpatrick Dilling (General Counsel for the National Health Federation and attorney for several defendants in the Herbert vs. American Quack Association lawsuit. The case was settled when Martino agreed to stop claiming that a user could lose weight from the pills without restricting calories. However, the new ads for Fat Magnet have the same headlines and are still misleading. More regulatory action may be forthcoming. Schacht makes a very strong case for the need for advertisers to take more responsibility in policing deceptive ads. She notes that "the press is the lifeblood of the sellers of useless and sometimes harmful diet aids." Even her own newspaper continues to run Fat Magnet ads. Her advertising director states that it is not the place of the newspaper to "make a decision for our readers." Other newspapers contacted by Schacht are more concerned about credibility. Susan Gill, ad manager of the St. Petersburg (Florida) Times says. "We want readers to have confidence in what we print, regardless of whether it's editorial or advertising." However, the paper recently started running the ads after receiving a portfolio from the company. The Des Moines Register became sensitive about carrying dubious ads after a reader complained about the newspaper's advertising of a dubious product. The ad manager now checks with the Iowa Attorney General's office when it is suspicious about an ad's validity.
Comment: We believe Schacht has put her finger on a very important point. Those who believe in freedom of the press, the free enterprise system, and social responsibility should support self-policing by advertisers. There is no good reason why publications should help hucksters deceive their readers.
Graphology is the study of handwriting based upon the idea that an individual's personality will be revealed and predictions made about behavior. According to media reports, several thousand companies in the USA and abroad use graphoanalysis in hiring. Despite a rather lengthy bibliography of citations provided by proponents, graphology appears to be nothing more than a pseudoscience--in this case, a "pseudopsychology." John Thomas describes, discusses and dubs graphology a pseudoscience in the Jan-April, 1989, Laser, a publication of the Southern California Skeptics. Thomas says that the practice has no place in character assessment or employment practice.
One of the most frustrating aspects of fighting quackery is the lack of action by bureaucrats. We at NCAHF deliberately understate the problem of quackery simply because to tell it just like it is makes us sound as if we are exaggerating -- which can cost us precious credibility. Dr. Charles Davant, III, of Blowing Rock, North Carolina, describes his experience with the operator of a "natural therapy clinic" with a correspondence school "MD" degree, who also claimed to be a naturopathic physician. "Heath fraud: what's going on in North Carolina?" (NC Medical Journal, 50:341-6, June, 1989) is a nightmarish story of inaction and lack of jurisdiction by various agencies which provided "cracks in the floor" through which quacks can escape. Dr. Davant's story is so outrageous that few would believe it could be true--but it is! Credit must be given to the North Carolina Medical Association for publishing his story. Such a story could easily be viewed as too embarrassing for all involved to be published. This article is "must reading" for all interested in basic consumer protection from medical charlatans. As bad as the situation described by Dr. Davant is, NCAHF knows of several situations in the US and Canada that are even worse!
Cherkin and MacCornack compared the satisfaction with providers among enrollees in a Washington state HMO who experienced treatment for low back pain from either family physicians or chiropractors. Patients of DCs were three times as likely as patients of family physicians to report that they were very satisfied with the care they received (66% vs. 22%). DC-patients were much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident in dealing with their problem. The researchers state: "Although the more positive evaluations of chiropractors may be related to differences in the patient populations...it is suggested that a potentially more potent force--the therapeutic effect of the patient and provider interaction itself--may explain the observed differences." (Western J Medicine, 150:351-5, 1989.)
Comment: These results are not surprising, and the researchers' conclusions seem appropriate; however, it is important to bear in mind that the DCs are highly specialized in not only treating low back pain, but many also specialize in the psychology of patient satisfaction. Family physicians are not low back pain specialists. I recall the book Backache Relief by back-pain sufferer Arthur Klein and science writer David Sobel. They consulted 492 back-pain sufferers located through ads placed in 24 newspapers and magazines. This self-selected population rated physiatrists (MDs who specialize in physical medicine and rehabilitation) as 300% more effective than chiropractors and orthopedists. Pain-killers, muscle relaxants, and anti-inflammatory drugs were rated no better than placebos by this group. The problem with physiatrists is finding one!
The U.S. Supreme Court has refused to block the trial of a California Christian Science woman, Laurie Walker, who is charged with child endangerment and involuntary manslaughter because she tried to heal her 4-year-old daughter of meningitis through prayer instead of medical care. By refusing to hear the appeal, the U.S. Supreme Court upholds a landmark decision by the California Supreme Court in November, 1988, which held that "parents have no right to free exercise of religion at the price of a child's life, regardless of the prohibitive or compulsive nature of the governmental infringement."
Comment: Court rulings that limit freedom of religion are always controversial and rarely alter deeply-held beliefs. As a Christian who prizes religious freedom, I would like to state that I am willing to give up a little of that freedom if it means that just one child will live who otherwise would have been sacrificed to a parent's presumptuous faith. Christians believe that they will face Divine judgment. They should consider how they would answer the charge that they let children die unnecessarily to protect some abstract notion of personal freedom.
Jason Gaes was stricken with Burkitt's lymphoma at the age of six. Because of the cancer's rapid growth rate he was not expected to reach his 7th birthday, but after two years of operations, radiation, chemotherapy experimental drugs, and a litany of painful treatments Jason is now fully recovered. After finding that in all of the books he read the kids who had cancer always died, Jason decided to write about his own successful experience. The result is My book for kids with cansur: A Child's Autobiography of Hope (Melius & Peterson Publishing Company, 1987). The book is a typical children's hard-cover book of just over 30 pages, full-page cartoons drawn by Jason, and a hand printed script in Jason's own words. Jason is a recipient of the American Cancer Society's Courage Award and his story has been portrayed in an HBO television documentary. The book has received many favorable reviews including JAMA, 259:1880, 1988. Order from: Melius & Peterson Publ., P.O. Box 925, Aberdeen, SD 57401; $11.95 + $2 postage. A portion of the proceeds are being donated to the American Cancer Society.
Love, Medicine and Miracles, by Bernie Siegel, MD; publisher: Harper & Row, New York, 1986
Siegel's title, Love, Medicine and Miracles, is as hard to criticize as motherhood, the flag and baseball, but it is a sad and disappointing book containing a lot of bitterness, dubious medicine, and few--if any--miracles. Siegel's personal story is a painful account of his bitter life as a surgeon. "The pressure never let up," he says. He had no time to spend with his family. He felt guilt about resenting people who die in the night. Out of "despair" he began keeping a diary, mentioning that "horror sweeps over you (him)" as he sees cancer in a patient. He says that he was thinking seriously about changing his career to teaching, veterinary medicine or psychiatry.
Siegel describes himself as being in near-emotional collapse when he discovered O. Carl Simonton and Stephanie (a psychologist who was Mrs. Simonton at the time). They taught him how to use "directed meditation to find and meet an inner guide." Siegel says that he met "George, a bearded, long-haired young man wearing an immaculate white robe and an skullcap." The technique Siegel describes is identical to the training of spiritualist mediums who are taught to visualize spirit guides through self-induced hallucinations. Such mental self-abuse can be destructive to sound mental health because it blurs the line between fantasy and reality and can lead to psychosis. Later, Siegel attends a workshop of Elizabeth Kubler-Ross who is deeply into spiritualism (now known as "New Age Thinking" and "channeling.")
Through these experiences, Siegel becomes emotionally committed to trying to understand "exceptional cancer patients (ECaPs)" (ie, patients he describes as having "the ability to throw statistics aside"). This brings us to one of Siegel's most fundamental errors in reasoning. He thinks in terms only of measures of central tendency (ie, averages, modes and medians) instead of variability--which is the most important lesson of statistics because it helps us recognize both the common and the unusual. By definition, 50% of terminal patients beat the median survival time, and some by extraordinary amounts. In the real world, 80% of hospice patients live longer than the 6 months life expectancy which is part of the criteria by which they are assigned to a hospice. These people do not beat the odds, they are the odds! Probability alone predicts that such will occur; no one can predict which individuals will survive. Siegel asks a good question when he wonders if ECaPs have identifiable features that can be used to predict extended survival times, but he fails to approach the problem in a manner that might possibly yield an answer. Rather than a systematic, rational approach, Siegel employs selective anecdotes of the crudest kind. He repeatedly uses a "heads I win, tails you lose" psychology in which everyone who does well--even if only temporarily--is used to prove his beliefs; deaths are repeatedly blamed on failure to maintain the healing fantasy or on a skeptic who discouraged the patient by a negative attitude. Siegel does offer some good pointers to physicians on how to relate better to their cancer patients, but rather than showing love, he exhibits hostility to anyone who doesn't accept his beliefs at face-value.
A criticism by Stephen Locke, a psychiatrist friendly to the mind-over-matter approach to healing quoted in New York magazine (6-12-89), is that "Siegel draws his inferences from the weakest form of evidence--patient testimonials and clinical anecdotes. Then he uses scientific studies selectively--and sometimes misleadingly--to support his views." Sherwin Nuland states, "Bernie has carried this to an extreme that is absolutely senseless. He cannot be taken seriously by anyone who knows cancer research well, and his work is dangerous to patients, who will too often abandon effective therapy because they put too much reliance in their own ability to change the course of disease." Nuland says Siegel distorts facts citing an incident in which Siegel claims to have called a patient back from cardiac arrest. Nuland says that the patient was actually revived by proper medical resuscitation. He accuses Siegel of "zealotry, not dishonesty."
Stephen Barrett, MD, Consumer health education expert who edits Nutrition Forum Newsletter, and serves on the NCAHF Board of Directors, advises consumers to steer clear of:
[Quackery: "the practices of pretensions of a quack"; Webster's New Collegiate Dictionary.] Accurately defining quackery is fundamental to NCAHF for we cannot effectively deal with a phenomenon we have not properly defined. Precisely what constitutes quackery is a matter of considerable confusion. Some wrongly believe it to be merely a matter of personal opinion as to who deserves the label of "quack", but this is not so if the term is carefully analyzed.
Origin of the Term
The first definitional problem is that "quack" is too widely generalized. Mathison states, "The word 'quack' originated during the Renaissance, when quicksilver, or mercury, was a popular remedy for syphilis. Wandering peddlers known as 'quacksalvers' sold mercury ointments. They would claim that their unguents cured all illnesses. These men, the calling abbreviated to 'quacks', became symbols of evil medical practice" (1). Evil medical practice includes more than simply quackery. A definition so broad as to include all evil medical practice is of little value. Some dispute over the origin of the term "quack" has come from the similarity between the root words kwiksilver (quicksilver) and kwaksalver (quacksalver). It has been suggested that "quack" evolved from "quicksilver" because mercury was the main ingredient in nostrums peddled by the "quacksalvers." Such confusion is understandable, but the word "quacksalver" describes a quack's behavior in unmistakable terms. It is important to keep in mind that quackery is a way of behaving, and that a person deserves the label only when his behavior fits. History has examples of individuals who behaved responsibly in some fields, but acted like quacks in others.
"Pretender." Although using "quackery" in reference to all evil medical practice is too broad, defining a quack as a "pretender to medical skill" (2) is too limited. Cassileth (3) found that 60% of cancer quacks were licensed physicians. Monaco (4) says that a referral source for dubious practitioners reveals that a majority are trained health professionals, and the largest proportion (36%) are MDs. Further, Victor Herbert, MD, JD, says that for purposes of a defamation lawsuit, in some states, a "quack" may be defined as "practicing medicine without a license," with no consideration given to the validity of his/her practices.
"Fraud." A standard reference for medical terminology, Dorland's Illustrated Medical Dictionary, defines a quack as: "one who fraudulently misrepresents his ability and experience in the diagnosis and treatment of disease or the effects to be achieved by the treatment he offers." The key term used is "fraud" which is legally defined as: "An intentional perversion of truth for the purpose of inducing another in reliance upon it to part with some valuable thing..." (Black's Legal Dictionary). Fraud is deliberate, conscious and intentional. Not all quackery involves fraud and health fraud does not always involve quackery. Providers who bill for services not rendered engage in health fraud, but not quackery, if only valid medical procedures are involved and there has been no overt promotional program. The greatest problem with defining all quackery as fraud is that the most dangerous quacks are the true-believing zealots who will take the poison themselves in their enthusiasm for their nostrums. Sincerity may make quacks more socially tolerable, but it goes far in enhancing their danger to the public.
"Misinformation." The FDA answers the question "What is quackery?" in its consumer education flyer Quackery: Paying for Miracles that Never Happen(5). "Broadly speaking," the flyer states, "quackery is misinformation about health." Webster's defines misinformation as "untrue or misleading information." Undoubtedly, quacks employ untrue and misleading information, but not all untrue or misleading information deserves the label of quackery.
Needed: A Functional Definition
For a functional definition of quackery we need only return to the origin of the term. Funk (6) points to the essence of the term when he writes that "...quack is a clipped form of the Dutch term kwakzalver which is one who 'quacks' like a duck about his 'salves' and remedies." Ducks symbolize quackery, not because of any evil behavioral traits, but because of their sounds. Vultures have been suggested as a more fitting symbol for quackery, but unlike human quacks, vultures have the ethics to wait until someone is dead before beginning to feed; predatory birds behave more like human quacks, but hawks and eagles are noble symbols in our culture making them an unsuitable choice as symbols of quackery.
Promotionalism Defines Quackery. Promotionalism describes quackery perfectly. To promote is "to contribute to the growth or prosperity of; to present for public acceptance through advertising and publicity"(2). Quackery is merely an unethical, dishonest form of marketing. Simply stated: Quacks quack!
The Real Issues. History teaches that the public desires a quality health marketplace in which they can choose with confidence from among safe and effective methods which are accurately labeled and truthfully advertised. It has taken years to develop our consumer protection system based upon these simple expectations, and no one has ever shown that the public expects less regulation in matters involving health. Advocates of "health freedom" who clamor to undo these requirements have largely been the promoters of dubious healthcare themselves. Not even organized quackery has been willing to openly argue against the desirability of accurate labeling, truth in advertising, safety and effectiveness as reasonable consumer health standards. Rather than confronting these issues, quacks work to create the illusion that their nostrums are safe by employing words such as "natural", "organic", "holistic", "health food", and so forth. Quacks feign effectiveness by declaring that "it works," but they fail to provide adequate proof. The use of testimonials and unsubstantiated claims is an identifying characteristic of quackery.
What the "health freedom" advocates actually desire is freedom from accountability, but can only advance their cause by misrepresenting the real issues. The record shows that consumers do not want healthcare providers, whether they call themselves "alternative", "complementary", or "conventional" to market unproven remedies without accountability.
Individuals enjoy full freedom of choice for themselves. Anyone may choose to refuse therapy, use home remedies, self-treat with OTC products, or even seek out the services of quacks. Contrary to misrepresentations by "health freedom" advocates, patients are not in legal jeopardy when they use quack remedies. It is the seller, not the buyer, of dubious remedies who may be subject to prosecution. Only when people deny proper healthcare to their dependents, or step over the line to become purveyors of quackery themselves, do they become legally liable.
Folk Medicine is not Quackery. Although folk medicine (ie, self-care, home care and friendly neighborly health advice) may be erroneous, it is not quackery per se. Only that which is offered with some anticipation of financial gain is quackery. Young points out that folk medicine has traditionally provided great marketing opportunities for quackery (7) as hucksters fulfill commonly misperceived notions of what constitutes useful healthcare.
Ethical Clinical Practices are not Quackery. Definitions of quackery should focus upon the "promotion", and not simply the use of unproven methods because the clinical management of chronic, incurable conditions often involves art and empiricism. Good clinicians often employ psychological strategies. Offering reassurance or instilling optimism and hopefulness are part of the clinical art of patient care. Unlike quacks, ethical practitioners do not use artful psychology to exploit patients but to enhance care.
Placebo administration involves the use of a medically-ineffective substance, yet it would be unreasonable to accuse physicians who appropriately employ placebos of quackery. Clinicians must also have freedom to be responsibly innovative. This may mean going beyond that which is scientifically proven for the condition being treated. Also, clinical research involves testing unproven methods on patients. None of these practices are quackery because they do not involve promotionalism.
The Pepper Committee's Definition
The Pepper Committee defined a quack as "anyone who promotes medical schemes or remedies known to be false, or which are unproven, for a profit."(8) This definition rightly focused upon the operational term "promotes", but has several inadequacies:
"Medical schemes and remedies..." The "schemes and remedies" phrase seems sufficient to include the products, services and practices that companies, practitioners and authors attempt to "contribute to the growth and prosperity of, or present for public acceptance." A scheme is defined as "a plan or program of action" (2), and remedy means, "a medicine, application, or treatment that relieves or cures a disease; something that corrects or counteracts an evil."(2) However, the word "medical" is too limiting because many quack promotions are aimed at enhancing beauty, physical performance, disease prevention or health promotion, not simply treatments and cures.
"False" and "Unproven..." There is little dispute over curtailing schemes and remedies that are "known to be false" (although quacks are usually unwilling to accept scientific judgments about such matters--eg, laetrile is still promoted even though disproved as cancer therapy), or that are inherently unsafe (here again, quacks generally reject scientific judgments about lack of safety--eg, laetrile's potential for cyanide-poisoning). However, some dispute exists regarding the promotion of remedies of unproven effectiveness.
There has been considerable public debate on the acceptability of marketing experimental remedies for both cancer (eg, Biotherapeutics, Inc.) and AIDS (ie, due to the absence of effective therapies for this currently-believed-to-be universally fatal condition). In the past it has generally been agreed that patients should not have to pay for experimental procedures. Serving as "guinea pigs" for others has been regarded as payment enough since adverse side-effects often are discovered during clinical trials.
From the perspective of curtailing quackery, taking the financial incentive out of testing unproven remedies is an important safeguard few are willing to relinquish. The NCAHF Board of Directors has expressed itself as against the marketing-for-gain of experimental remedies. It believes there are better ways to accomplish the laudable goals of wider testing and availability (eg, philanthropy).
"Profit." Another criticism of the Committee's definition was its use of the word "profit. Several state Attorneys General correctly pointed to the fact that many quacks pose as being "nonprofit"(9) or use some other clever means of avoiding the appearance of profit-making. In fact, the Pepper report covered such creative evasions in its review of "Foundations." The Committee employed the term "profit" to exempt home remedies from quackery because these are not associated with an anticipation of financial gain.
A Better Definition. A better definition of a quack is: "anyone who promotes health schemes and remedies known to be false, unsafe, or unproven for financial gain."
Importance of a Proper Definition
A proper definition reflects a clear understanding of quackery. Such helps guide us to solutions to the problem. Quacks accomplish their purposes through advertising and publicity. More reforms should be aimed at curtailing these activities. First Amendment rights do not extend to commercial language to the same extent as ordinary communication. Some ways that the abuse of advertising and publicity might be remedied are to make the media more accountable for ads that they run. There is a substantial amount of advertising that is so blatantly fraudulent that anyone with a modicum of training could easily recognize and refuse to accept. Examples include those perennial full-page ads promising easy, dramatic, rapid weight-loss and ads making obvious drug claims. Freedom without responsibility becomes a license for abuse. To balance the freedom of expression of authors, prominent warning labels reminding readers that the First Amendment protects the writers much more than the readers of published materials would be a minimal requirement.