When Does a Sham Treatment Become Respectable Medicine?

A different perspective on the quackery debate

I have always been rather passionate about quackery. In fact, I have written about it recently.

But increasingly, I find myself wondering whether our definition of quackery has become too dependent on who is giving the treatment rather than what treatment is actually being given.

One of my uncles was a very well-known MBBS doctor with a roaring general practice. His clinic would run until midnight, and patients loved him. He was popularly known as the “Soodi Mandu Doctor” — the injection doctor — because an extraordinary number of patients who walked through his door received an injection. Sometimes it was B-complex. Sometimes, I am told, it was essentially saline. And they got better.

Of course they did. A large proportion of everyday ailments get better anyway. Viral fevers settle, body aches resolve, minor gastrointestinal illnesses pass and respiratory infections run their course. The injection acquires the credit, the patient associates recovery with treatment, and the doctor develops a reputation for producing dramatic results.

Was that quackery? Perhaps. But he was a qualified MBBS doctor, so nobody would ordinarily have called him a quack. If precisely the same therapeutic ritual had been performed by someone without a recognised medical qualification, however, we would probably have had no hesitation in using that word.

That is the contradiction that interests me. The practitioner may be legitimate, while the treatment itself may still be irrational, unnecessary or essentially placebo.

An injection of B-complex into someone with a self-limiting illness does not acquire scientific validity because the person holding the syringe has an MBBS degree.

Normal saline does not become pharmacologically active because a qualified doctor administers it.

I encountered a more institutional version of the same problem as a house surgeon in 2001. At one government primary health centre, patients presenting with a wide variety of complaints were being given whatever injectable medicines happened to be available — typically things such as B-complex or paracetamol, often with little meaningful relationship to the underlying illness. I was sufficiently disturbed that I complained about it to the then Chief Minister, N. Chandrababu Naidu. I have written about that episode previously.

What was happening there was not unlicensed medicine. It was medicine being practised within the legitimate healthcare system, by legitimate healthcare personnel, using treatments that in many instances were little more than therapeutic theatre.

The white coat and the government building did not magically improve the evidence base.

The same issue persists in subtler forms today. In resource-constrained government hospitals, the appropriate treatment may simply not be available. A patient with vitiligo may attend a dermatology outpatient department and eventually leave with nothing more than a vitamin C capsule because that is what the pharmacy stocks. I have written about this too:

Nobody involved may be deliberately deceiving the patient, and the dermatologist may know perfectly well that the treatment is inadequate. But from the patient’s perspective, they have travelled to a hospital, waited, seen a qualified specialist, and received a medicine that may contribute essentially nothing towards treating the disease for which they sought help.

Now extrapolate this to modern cosmetology. Consider the fashionable IV “glow drip”. Vitamins, antioxidants and assorted compounds are infused intravenously with promises or implications of brighter skin, rejuvenation, detoxification or wellness. If an inadequately qualified cosmetologist (even if he/ she is a MBBS doctor) administers the drip, many dermatologists will immediately call it quackery. If exactly the same drip, with exactly the same evidence base and exactly the same claims, is administered by a dermatologist, does it suddenly become legitimate medicine?

The evidence has not changed. The pharmacology has not changed. The risk-benefit equation has not changed. Only the qualification of the person holding the cannula has changed.

This is where I think the anti-quackery debate becomes muddled. There are really two separate issues. One is practising medicine without the legally required qualification or outside one’s permitted scope of practice. That is fundamentally a regulatory issue, and it is entirely legitimate to enforce it. The second issue is providing ineffective, irrational, unsafe or misleading treatments. That is a question of medical quality and patient welfare. The two overlap, but they are not the same thing.

A person can be inadequately qualified and occasionally give an appropriate treatment.

A highly qualified doctor can repeatedly prescribe nonsense.

Qualification matters enormously because proper training should improve diagnosis, appraise evidence, risk assessment, recognition of complications and understanding of when not to treat. But a degree certifies training; it does not confer lifelong immunity from bad medicine.

This is also why I remain uneasy with much of the rhetoric around anti-quackery campaigns, which I discussed in my earlier post on quackery. Too often, the debate is framed less around whether a treatment is rational, evidence-based and safe, and more around who is entitled to deliver it. Who may inject, who may use a laser, who may prescribe a drug, who may perform an aesthetic procedure. Those are legitimate questions of regulation and scope of practice.

But they are not the same as the more fundamental question of whether the intervention itself has any scientific merit.

If our outrage disappears the moment the same dubious treatment is offered by someone with the correct degree,

then we are not really policing quackery,

we are policing professional territory.

If patient welfare is genuinely the principle at stake, then the scrutiny has to turn inward as well.

Irrational prescriptions, unnecessary injections, IV “wellness” or “glow” drips with dubious claims, unsupported aesthetic procedures, expensive interventions marketed far beyond their evidence, and placebo treatments dressed up as active therapy do not become respectable medicine simply because they are delivered in a clinic by a qualified doctor. A medical degree may qualify someone to diagnose, prescribe or perform a procedure; it does not confer scientific legitimacy on whatever they choose to offer.

Quackery should not become respectable merely because it is practised by someone qualified to perform it.