Physicians and Alternative Methods of Treatment: Do They Go Together?

Introduction:The Silvia Millecam case

In August 2001, Sylvia Millecam died of breast cancer at the age of 45. Millecam was a famous Dutch comedienne and had
been voted the most popular woman in the Netherlands many times. Her death came all the more as a shock when it was revealed
that her chances of recovery were good in the early stages of her illness. At the start of her illness in 1999, more than 30(!) differ-
ent physicians – the majority of whom were alternative practitioners – were involved in treating her. Many of the practitioners, in-
cluding a Dutch faith healer known by her stage name ‘Jomanda’, repudiated the diagnosis of breast cancer. They referred to a
‘bacterial infection’, ‘fibrositis’ or a ‘reaction to silicone breast implants’. These ‘therapists’ then provided her treatments such
as salt therapy, electro-acupuncture and magnetic field therapies. These all failed to produce results, resulting in a medical event
and death which an oncologist described as ‘mediaeval’.
What made the case more complicated was that Millecam rejected conventional treatment comprising surgery and chemo-
therapy from the start of her illness.She had observed the side effects of chemotherapy among her circle of friends and she herself
wanted to avoid this. A second salient detail is that a number of the alternative practitio-
ners were also doctors. Their title of Doctor
of Medicine instilled in Millecam trust in
the alternative treatment. ‘He is a doctor, so
it should be fine,’ was the way she looked
at it.
The Netherlands Healthcare Inspectorate,
an organisation associated with the Minis-
try of Health which supervises the quality
of health care, conducted an extensive in-
vestigation into the course of events sur-
rounding her treatment and published an
exceptionally detailed report (IGZ 2004),
which incidentally raises a number of in-
teresting privacy concerns. Three doctors
were called to account by the Disciplin-
ary Committee for the Healthcare Sector,
which assesses the professional competence
of physicians. Following an appeal, two of
the physicians permanently lost their title
‘Doctor of Medicine’. A third physician was
suspended for one year.
Apart from the Disciplinary Commit-
tee, the case was also handled by the Pub-
lic Prosecution Service, which found that
criminal errors had also been made as well
as medical and professional errors by the
practitioners treating Millecam. Following
countless legal proceedings, in December
2010 two doctors were sentenced to three
and six-week suspended prison sentences.
The court found sentencing advisable ‘in
view of the seriousness of the facts and the
consequences thereof, and in view of the
importance of marking standards, not only
by means of adjudication but also through
punishment’. Faith healer Jomanda, howev-
er, was acquitted because the court deemed
that it had not been proven that she had
dissuaded Millecam from undergoing con-
ventional care, nor had she left Millecam in
a helpless state.

Freedom of choice
Sylvia Millecam’s tragic death created a great
deal of social unrest in the Netherlands and
spurred social debate that continues to this
day. Her death provoked a turning point
in the debate about alternative and con-
ventional medicine. Since that time, it has
in fact become clear that the often-heard
words ‘it doesn’t hurt to try’no longer holds
true. Alternative methods of treatments can
actually inflict harm, simply because of the
fact that they may cause patients to miss out
on meaningful conventional treatments, or
they could delay the start of such treatment.
Numerous people have therefore become
more critical of alternative practitioners.
Following the disciplinary and criminal
court judgements, an important standards
and legal framework was developed for the
acts of alternative practitioners. Yet these
judgements have not curtailed a patient’s
right of self-determination in choosing his
or her own healthcare provider: after all,
patients will always retain leeway to ap-
proach an alternative practitioner. But the
leeway for alternative practitioners, both
physicians and non-physicians, has been
more clearly defined: they must inform
patients correctly about the effectiveness
of their treatment and distinguish clearly
between conventional and alternative treat-
ments. Practitioners are also not permitted
to blindly concur/agree if the patient refuses
to face the facts. If the patient clings to an
illusion, practitioners must endeavour to re-
fute the illusion and point out to the patient
the importance and necessity of undergo-
ing conventional treatment. If need be, the
practitioner should sever the treatment rela-
tionship. The refusal of patients to undergo
conventional treatment does not grant al-
ternative practitioners a licence to practise.
The reason primarily being the vulnerability
of patients suffering from a life-threatening
disease.The position of such patients makes
them grasp at straws all too easily.The court
stated in its judgement that ‘freedom of
choice no longer applies in such a vulner-
able situation’.
The Millecam case raises a number of im-
portant questions, i.e. how much leeway
do physicians still have in diverging from
the professional standard, and what should
physicians do with patients who reject con-
ventional medicine? Partly prompted by the
Millecam case, the Royal Dutch Medical
Association published guidelines in 2008
which were preceded by substantial debate
in the medical profession.

What are alternative and
complementary treatments?

The terms ‘alternative treatments’ and ‘com-
plementary treatments’ are catch phrases,
covering over three hundred different meth-
ods of treatments. A number of these meth-
ods of treatment claim to employ a ‘holistic
concept of mankind’,which revolves around
the patient as a whole rather than the spe-
cific illness. Other methods of treatment,
such as chiropraxy, place less emphasis on
this aspect. Some forms of treatment, such
as bioresonance therapy, acupuncture and
homeopathy, conflict with empiricism, the
biological principles or the laws of physics.
Homeopathy,for instance,assumes that wa-
ter has a ‘memory’which is capable of spur-
ring the body to self-heal. Many alternative
treatments are based on various, conflicting
effectiveness principles. Homeopathy, for
example, assumes extreme dilution, while
orthomolecular medicine in fact uses high
dosages of vitamins and dietary supple-
ments. Some forms of treatment are harm-
less from a medical point of view, such as
homeopathy, which is chemically identical
to the solvent, generally water or alcohol.
Other forms of treatment, such as chelation
therapy or herbal therapy, may cause life-
threatening complications, or interfere with
regular treatments, such as anti-conception
or chemotherapy. Many alternative forms
of treatment lay claim to an aura of ‘natu-
ralness’, even though a description of what
this means is rarely given.All things consid-
ered, alternative or complementary forms of
treatment do not have much in common –
except that there is no scientific proof of
their effectiveness, and for that reason they
are not accepted by conventional medicine.
The main difference between conventional
and alternative forms of treatment is that
conventional medicine seeks to work in line
with the requirements of evidence-based
medicine (EBM). This implies that physi-
cians are guided by the state of the art in
medical science, combined with their clini-
cal expertise, including taking account of
the patient’s expectations, wishes and ex-
periences. Many alternative practitioners
claim that their forms of treatment cannot
be scientifically substantiated because they
work in accordance with a ‘different para-
digm’ or because each patient is different,
and for that reason randomised trials can-
not be conducted. In recent years this line
of reasoning seems to be waning, and alter-
native practitioners are similarly claiming to
employ evidence-based working methods,
and referring to ‘evidence-based comple-
mentary and alternative medicine’ (EBM-
CAM). Despite the purported scientific
proof thereof, alternative practitioners gen-
erally attribute the fact that these forms of
treatment do not belong to conventional
medicine, to ‘conservatism’ or ‘pharmaceuti-
cal industry interests’.

Conventional medicine has always heavily
criticised the term ‘alternative medicine’.
After all, there is no such thing as ‘alterna-
tive physics’ or the ‘alternative legal profes-
sion’. Who in their right mind would board
an aircraft if the pilot were to use alterna-
tive methods to steer the aircraft? And, if
the non-conventional practitioners were to
actually offer alternatives, why are they not
conventional? Moreover, numerous conven-
tional practitioners hold the view that it is
dangerous to suggest that alternative forms
of treatment exist for serious illnesses. To
avert these issues, nowadays alternative
practitioners prefer to talk about ‘comple-
mentary treatments’ to suggest that these
forms of treatment should be viewed as be-
ing supplementary to conventional medicine,
and not as an alternative for the latter.
The term ‘complementary’ too, however, is
subject to criticism. Astrology is also not
‘complementary’ to astronomy, is it? And, if
such medicine can only be complementary,
does the term ‘medicine’still apply? For that
reason the Royal Dutch Medical Associa-
tion KNMG would prefer to refer to ‘non-
conventional forms of treatment’, versus
‘conventional forms of treatment’ (KNMG
2008). Since it is uncertain whether these
treatments also actually cure an illness, the
term ‘form of treatment’ is more neutral
than ‘treatment’. According to the defi-
nition applied by KNMG, conventional
forms of treatment are ‘the forms of treat-
ment based on the knowledge, proficiency
and experience required for the purpose of
obtaining and retaining the title of Doctor
of Medicine, which is generally accepted by
the medical profession and forms part of
the professional standard’ (KNMG 2008).
In other words: conventional medicine is
what physicians who practice conventional
medicine do. This also includes experimen-
tal forms of treatment, the effectiveness of
which still is subject to medical and sci-
entific research, to the extent these have
been tested within the statutory assessment
framework. ‘Non-conventional forms of
treatment’are those forms of treatment that
fall outside the scope of the above defini-
tion. The nature of the definition is purely
procedural, and says nothing about any
methods or concepts of mankind embraced
by the various forms of treatment. The ad-
vantage of the above definition is that it
is neutral, and does not lay down for once
and for all what definition should be applied to conventional medicine. This leaves
open the possibility for incorporating in the
professional standard certain treatments,
which initially were non-conventional, if
it emerges that there is sufficient scientific
proof thereof. Another advantage of such a
neutral definition, which avoids words such
as ‘alternative’ or ‘complementary’, is that it
does not make a statement on the value or
position of alternative forms of treatment.
Legal situation
The Individual Healthcare Professions Act
(Wet op de beroepen in de individuele gezond-
heidszorg, BIG) dating from 1999 regulates
the competence of a wide range of health-
care providers in the Netherlands. In addi-
tion to safeguarding a patient’s freedom of
choice, the key objective of the Act is to en-
sure and monitor the quality of healthcare
provision. A third objective is to protect the
patient against incompetent and improper
conduct by a healthcare provider.According
to the BIG Act anyone is allowed to prac-
tice medicine. The performance of certain
medical acts (such as obstetric and surgical
treatments, punctures, injections and anaes-
thesia) is the preserve of specific profession-
al practitioners. In the Netherlands, making
a medical diagnosis is not an act reserved
for a specific group of practitioners, and it
therefore may be performed by anyone. Be-
cause alternative treatments are not the pre-
serve of a specific professional practitioner,
alternative treatments may be administered
by physicians as well as non-physicians.
Medical disciplinary rules only apply to
professions protected by the BIG Act, such
as doctors and nurses. Alternative practitio-
ners who do not hold a protected title, such
as that of a Doctor of Medicine, fall out-
side the scope of the medical disciplinary
rules. They also do not need an official reg-
istration. Since the BIG Act is also geared
towards the patient’s freedom of choice, a
situation has arisen in which extremely
stringent requirements are imposed on phy-
sicians but where non-physicians virtually
have free rein. They also do not carry a title
protected by law,and consequently also can-
not be discharged from their duties – un-
like physicians. The Healthcare Inspector-
ate does not have any tools for intervening
in the practices of alternative practitioners.
Consequently, in day-to-day practice it has
proven to be extraordinarily difficult to take
legal action against alternative practitioners,
partly because patients often find it diffi-
cult to file a complaint. Moreover, it often
is difficult to prove that the treatment has
inflicted harm on patients.
The legal situation in which everyone is per-
mitted to practice medicine, barring medi-
cal acts reserved for specific practitioners, is
not unique to the Netherlands but occurs in
other Northern European countries as well.
In many Southern European countries,only
physicians are permitted to practice medi-
cine.
Seven percent of the Dutch population
is estimated to visit a non-conventional
practitioner who is not a physician (Statis-
tics Netherlands StatLine database 2007).
Countless people do so for ‘harmless’ ail-
ments, such as the common cold or for
chronic complaints, such as rheumatism or
arthrosis for instance. For more serious ail-
ments, the conventional physician appears
on the scene.There are few people who sole-
ly undergo alternative treatment. A declin-
ing number of Dutch physicians (currently
estimated to be less than one thousand) ap-
ply non-conventional forms of treatment
themselves, usually combined with a con-
ventional practice.
The professional standard
Physicians are required to comply with
the ‘medical professional standard’, which
means: ‘to act with due care in accordance
with the knowledge of medical science and
experience as a reasonably competent phy-
sician in the same medical category, in the
same circumstances with medicines that are
reasonably proportionate to the concrete
treatment objective’ (Netherlands Health
Law Handbook 2000, 41-2, Handboek ge-
zondheidsrecht). The definition that applies
to the above has become increasingly clear
from case law in recent years, as well as how
much leeway physicians still have in apply-
ing alternative treatments.
The first key requirement imposed on
physicians is that each medical treatment
should be based on a conventional diagno-
sis, which must be conducted in the ‘proper
manner’. Physicians are therefore not per-
mitted to begin a treatment ‘out of the blue’,
nor are they permitted to use non-accepted
diagnostic methods. ‘Bioresonance tests’
or ‘vega testing’ are therefore off limits for
physicians.
Once a conventional diagnosis has been
performed, physicians are only permitted to
apply treatments for which a medical indi-
cation exists. There must also be a concrete
treatment objective. For instance, a physi-
cian is therefore not permitted to prescribe
chemotherapy if there is no indication for
doing so, or if this does not, or no longer
serves a purpose. The concrete treatment
objective may obviously also be palliative
care, or removing or relieving the existential
pain suffered by the patient.
According to the rules of evidence-based
medicine (EBM),the treatment indicated at
a certain point in time, is determined by the
state of the art in medical science, the clini-
cal experiences of the medical profession
and the patient’s wishes and expectations.
The professional standard may incorporate
several treatments for a specific diagnosis.
As a rule, the physician will focus on the
treatment that will yield the best results,
having the least burden on the patient. If a
medical indication exists for several treat-
ments, the choice is determined in a meet-
ing between the physician and the patient.
As stated, evidence-based medicine is
founded on three underlying pillars: proof,
experience and the wishes and expectations
of the patient. The patient’s wish can thus
never form an adequate reason for adminis-
tering a treatment.The fact that a patient has
asked for a particular treatment or the fact
that a patient has consented to a particular
treatment, does not discharge the physician
from his duty to assess the indication and
determine whether a particular treatment
would be meaningful from a medical point
of view. A physician who is confronted with
a patient asking for chemotherapy while
there is no medical indication for doing so,
or in cases where concrete treatment results
cannot be expected based on the state of the
art in medical science, is not permitted to
comply with the patient’s wish. Even if a
patient requests a futile medical treatment,
such as injecting soda into tumours, the
physician is not permitted to comply with
the request.
The aspects incorporated in the professional
standard at a certain point in time have not
been set in stone, and there are always grey
areas too where physicians do not agree with
the prescribed treatment. The professional
standard consequently is not a mandatory
rule or ‘cookery book medicine’. Each pa-
tient is different, and each situation requires
another solution. Physicians therefore defi-
nitely have the necessary leeway to diverge
from the professional standard. If they do
so,they must be able to justify to their peers,
the patient and society as to why they chose
to diverge from the standard.Proper records
and informed patient consent are vital in
this context.
Physicians and alternative
treatments
There are patients like Sylvia Millecam,
who reject conventional treatment and wish
to undergo alternative treatment – even if
they are suffering from a serious disorder.
What should physicians do in such cases?
Physicians should be the first to earnestly
point out the consequences to the patient
if they wish to be treated by an alternative
therapist. They are required to continuously
highlight the need for conventional treat-
ment. In the Millecam case the alternative
healers stated that Millecam herself had re-
fused conventional treatment and they felt
that this served as a licence for them to ad-
minister their treatments. In the Millecam
case, the Disciplinary Committee, however,
stated the following in respect of the above:
‘A physician can no longer provide a person
alternative treatment with impunity if the
patient proves to need help which clearly
can only be provided in conventional medi-
cal circles.’ If conventional treatment exists,
physicians are not permitted to simply ig-
nore it. And if the patient refuses conven-
tional treatment, this should not serve as
a licence permitting physicians to offer all
kinds of non-conventional treatments. Af-
ter all, by doing so they wrongfully raise
the patient’s hope and expectations. The
Amsterdam Court of Justice formulates the
above as follows:
“The law gives precedence to the well-in-
formed patient’s right of self-determination.
This does not mean to say, however, that the
physician or the party providing individual
healthcare does not carry any further re-
sponsibility. If he is asked to provide insight
into the motives underlying his choice for
applying a certain method of diagnostics or
therapy, it will not suffice for the physician
or healthcare provider to refer solely to the
wish expressed by the patient.’
Another aspect that has emerged from the
Millecam case is that patients have faith
in the title of Doctor of Medicine. ‘He is a
doctor, so that should be fine,’ Sylvia Mil-
lecam’s doctors were insufficiently aware
of that fact. Physicians must at all times
understand that their title of Doctor of
Medicine carries a certain authority with it.
This imposes heavy demands on what they
advise and offer the patient. As the Disci-
plinary Committee stated in the Millecam
case: ‘A physician, who also practices in the
domain of alternative medicine, is thus not
discharged from acting in the capacity of a
physician.’ The KNMG formulates this as
follows: ‘Physicians are constantly aware
that the diagnostics, methods of treatments
and advice they offer revolve around the
authority of the medical doctor/medical
specialist education programme and the
title of Doctor of Medicine or Medical
Specialist.’
Are physicians allowed
to offer alternative
methods of treatment?
Coming to the key question: are physicians
still permitted to apply alternative treat-
ments, such as homeopathy or acupunc-
ture? Clearly, such treatments may only be
administered under very strict conditions.
Doctors should always first ask themselves
whether conventional treatment exists for
the relevant diagnosis, and advise the pa-
tient thereof. After all, according to the
KNMG rules of conduct ‘the doctor is not
permitted to apply treatments and disregard
generally accepted diagnostic and treatment
methods in the medical world’. The doctor
must provide clear information to patients
about the nature of their illness. The doc-
tor must also make clear to the patient what
the consequences are of not undergoing
conventional treatment. But even if there
is no conventional treatment, or this no
longer exists, or if the patient rejects such
treatment, the doctor cannot simply offer
all kinds of treatments, the benefit of which
has not been proven. Patients who are dying
or whose treatments have finished are still
required to be treated in accordance with
the professional standard. After all, atten-
tion, comfort, pain control and palliative
care fall within the scope of conventional
medicine.
Furthermore, doctors must at all times
avoid inflicting harm on the patient when
providing non-conventional treatment.
Harm is more than simply immediate
medical damage caused by the treatment
itself. When providing conventional treat-
ment, the benefit of the treatment always
counters harm. That benefit has not been
proven in non-conventional treatments,
which makes it more difficult to justify
any harmful effects. Harm is also inflicted
if the doctor offers false hope of improve-
ment, or recovering from the complaints.
And if, as a result of the non-conventional
treatment, the patient does not start un-
dergoing a meaningful conventional treat-
ment or does so too late (doctor’s delay),
this is also viewed as inflicting harm. The
doctor is likewise not permitted to provide
misleading information about the effec-
tiveness of the non-conventional treatment
or substitute a conventional diagnosis for
a non-conventional diagnosis. Doctors are
also not permitted to attribute a thera-
peutic effect to a particular treatment if
this has not been scientifically proven.
The proof must be stronger than the evi-
dence of a certain method. Stating that it
has been proven that homeopathy works,
therefore will not suffice. So, this rules out
‘there is scientific evidence that homeopa-
thy works’. A statement of this nature is as
meaningless as the statement saying that
‘there is scientific evidence that conven-
tional medicine works’. Doctors will have
to specify what scientific evidence exists
for a particular treatment and a particular
dosage for a particular indication.
All in all, the leeway doctors have in apply-
ing non-conventional treatments therefore is
not that large. And that leeway will probably
become even smaller with the continued pro-
tocols and professionalisation of the profes-
sion of medical doctor,and the continued ad-
vancement of EBM. EBM will undoubtedly
prove that parts of conventional medicine
will likewise not prove to be meaningful, and
they will be deleted from the professional
standard as a result. That is what progress
is all about. The scientific underpinning of
other parts of conventional medicine will see
further improvement,and that will only serve
to enlarge the gap between non-convention-
al and conventional methods of treatment.
Continued scientific research may possibly
also show that certain non-conventional
treatments are effective, and they will be in-
corporated in the professional standard as a
result. But many non-conventional methods
of treatment will end up in the circular files
of history – joining the countless others that
havebeenlaidtoresthere.That too is progress.

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Erasmus Medical Centre, Rotterdam