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The SkeptVet vs Dr. Shawn—A Paradigmatic Kerfuffle
Posted: 20 February 2010 03:29 AM   [ Ignore ]   [ # 46 ]
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mckenzievmd - 19 February 2010 05:44 PM

skepticeye,

You keep claiming I want to “ban CAM alltogether” and that isn’t my position. My position is that one should not be allowed to make false or unproven claims when marketing a medical therapy. DSHEA bans “prevent and treat” claims, though this is often ignored by CAM providers and certainly rarely enforced by the FDA. However, even within the lettter of the law are many claims that are false and misleading, and as far as I’m concerned constitute lying for profit (aka false advertising), and I don’t see the legitimacy to the argument that such deception is a right to be protected from government interference. I’m not for banning CAM if it can demonstrate it does what it claims. Chiropractic reduces idiopathic lower back pain, acupuncture can reduce the perception of pain and nausea, and there’s nothing wrong with selling or using these CAM methods for these purposes. But homeopathy doesn’t prevent malaria or treat AIDS, and selling it for this purpose is unethical and should not be legal.

Ultimately there are criminal laws that apply in case real harm has been done from the use of any product. There are manufacturing mistakes, false advertising claims among just about all competitve products of any kind. Should we outlaw all cars because Toyota cars have failing brakes or sticky gas pedals? Should we outlaw all vegetables because at one time or another they were infected with e-coli from unclean packaging conditions? Should we outlaw all pharmaceuticals because, some reputable manufacturers marketed some medicines with deadly side effects? There have been numerous occasions of scientifically tested and approved products that were harmful.
Moreover, I don’t quite understand the insistence that ALL CAM products are either ineffective or downright harmful. If we were to enforce that notion worldwide, 80% of the world population would have no medicine whatever. Is that preferable over century old local remedies that have proven (if not scientifically verified) to be beneficial? Thousands of years of sincere experimentation and observation doesn’t count for anything? Again, if some 40 % of current medicine is plant based, why would there be need for the practice of herbal medicine to be deceptive? Granted, the curative powers maybe not as effective as derived from modern methods of processing, but certainly not all are ineffective or harmful. There are several reputable, modern and ethical laboratories and packaging facilities, which observe a high degree of quality control, albeit not as sophisticated as the big drug companies. But there are many modern parmaceuticals that have a built in risk factor (acceptable risk to benefit ratio). Is that ethical? And there have been many instances where approved modern medicine had to be withdrawn from the market for deadly side effects. How did those slip by? False advertising? Sloppy testing? Pay offs? As long as medicine is among the for profit industries, there will be unethical practises in the manufacture and delivery of products, just as there are in any other industry.
I do believe in strong oversight and enforcement of dangerous products or deceptive practices, but to apply blanket prohibitions to the manufacture of minimally altered natural products seems overly aggressive.

[ Edited: 20 February 2010 03:43 AM by Write4U ]
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Posted: 20 February 2010 07:53 AM   [ Ignore ]   [ # 47 ]
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Write4U - Very well written explanation of why the fundamentalist opposition to CAM is misguided and doomed to failure because of it’s black and white, irrational, viewpoint.

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Posted: 20 February 2010 07:53 AM   [ Ignore ]   [ # 48 ]
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Write4U - 20 February 2010 03:29 AM

Moreover, I don’t quite understand the insistence that ALL CAM products are either ineffective or downright harmful. If we were to enforce that notion worldwide, 80% of the world population would have no medicine whatever.

We aren’t saying that all CAM is ineffective or harmful. We’re saying that no CAM has been proven effective or safe, which is a different though similar proposition. Indeed, it’s the very definition of “alternative” in CAM that means that it hasn’t been properly tested.

(It’s also the case, of course, that some CAM has been tested and actually found ineffective and/or harmful).

What this says is that 80% of the world already has no medicine whatsoever; that is, nothing that has been proven to actually work safely, and some purported medications which have actually been demonstrated unsafe and ineffective. They’re using the equivalent of untested or quack materials and prayer healing or witchcraft.

Put another way, smoking tobacco or similar stimulants is popular among many indigenous people. I believe it is also used in some healing ceremonies. Yet we know conclusively that tobacco is extremely harmful and heals nothing. It is no argument whatever that people have done X for hundreds of years, so therefore X must be safe and effective. People practiced cupping and bleeding, cast horoscopes and flung wishes written on pottery into wells for millennia. None of them work.

Write4U - 20 February 2010 03:29 AM

I do believe in strong oversight and enforcement of dangerous products or deceptive practices, but to apply blanket prohibitions to the manufacture of minimally altered natural products seems overly aggressive.

Again, neither of us is recommending blanket prohibitions on the manufacture of herbal products. This keeps resurfacing, and we keep denying it. Let’s drop the straw man. What we are recommending is that:

(1) It be illegal to sell any product with false advertising. This means including homeopathic products, and it also means enforcing the laws already on the books in some cases.

(2) There be much greater efforts to inform the public about the lack of efficacy of products which have been tested and found ineffective, and about the lack of information on products which have not been properly tested.

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Posted: 20 February 2010 11:44 AM   [ Ignore ]   [ # 49 ]
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dougsmith - 20 February 2010 07:53 AM

(1) It be illegal to sell any product with false advertising. This means including homeopathic products, and it also means enforcing the laws already on the books in some cases.

What conditions of sale will satisfy you ?

(2) There be much greater efforts to inform the public about the lack of efficacy of products which have been tested and found ineffective, and about the lack of information on products which have not been properly tested.

What kind of information ? and which kinds of products would you campaign to have banned from sale ?

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Posted: 20 February 2010 02:01 PM   [ Ignore ]   [ # 50 ]
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scepticeye - 20 February 2010 11:44 AM
dougsmith - 20 February 2010 07:53 AM

(1) It be illegal to sell any product with false advertising. This means including homeopathic products, and it also means enforcing the laws already on the books in some cases.

What conditions of sale will satisfy you ?

I thought what you quoted from me made that pretty clear. To get clearer I’d have to do some research into the history of the practice and the law. Is there anything in particular you see as requiring clarification?

scepticeye - 20 February 2010 11:44 AM

(2) There be much greater efforts to inform the public about the lack of efficacy of products which have been tested and found ineffective, and about the lack of information on products which have not been properly tested.

What kind of information ? and which kinds of products would you campaign to have banned from sale ?

The information which is lacking is information that could be gained from competent, objective, scientific testing. That is, the sort of testing required by law before any effective medication is brought onto the market. In the US this involves three stages of FDA testing on humans. The stages are designed to provide data about appropriate dosage level, safety and efficacy. Until those tests have been properly done, no competent professional can state that a drug is safe or effective, or at what dosage it should be taken.

Re. products I’d campaign to have banned from sale, to repeat what I said, above: “neither of us is recommending blanket prohibitions on the manufacture of herbal products.” The only products I’d recommend be banned from sale are those which are known to be harmful.

There’s something of a grey area with products that could be harmful but haven’t been tested for harm. Most such products in the food chain are labeled “GRAS” for “Generally Recognized As Safe”; that should include such things as teas, herbs, spices, etc. These may not actually have been tested for safety, but they have been in the food chain so long that they are assumed to be safe. As such they can’t be banned from sale unless and until some evidence were to arise that something assumed harmless was in fact harmful.

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Posted: 20 February 2010 02:09 PM   [ Ignore ]   [ # 51 ]
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dougsmith
We aren’t saying that all CAM is ineffective or harmful. We’re saying that no CAM has been proven effective or safe, which is a different though similar proposition. Indeed, it’s the very definition of “alternative” in CAM that means that it hasn’t been properly tested. (It’s also the case, of course, that some CAM has been tested and actually found ineffective and/or harmful).

In this case the word “alternative” does not mean that all CAM have been tested and found to be ineffective. I dare say the opposite is true. Modern medicine was founded on the “quackery” of previous generations of medical practinioners. How did we discover the beneficial properties of natural products in the first place? Did we have a eureka moment and modern medicine was borne? No, in many instances there were reports of “native” medicines which seemed to be effective and were thus tested. The result speaks for itself (40%). Refining a product is not the same as invalidating.

What this says is that 80% of the world already has no medicine whatsoever; that is, nothing that has been proven to actually work safely, and some purported medications which have actually been demonstrated unsafe and ineffective. They’re using the equivalent of untested or quack materials and prayer healing or witchcraft.

At least 40% of current medicines was in use prior to modern medicine, granted with more or less effectiveness, and yes some with harmful effects. But that is the nature of the evolution and development of all things, trial and error are ultimately just as effective as chemical analysis in discovering beneficial properties. Do you accuse all indigenous medicine men as practising witchcraft, just because in addition to administering potions and salves, they prayed for their patients? Seems to me at least that part has not changed very much.
The point I am trying to make is that it is unfair and a little arrogant to dismiss the efforts of previous medical practitioners as pure quackery. I believe all inquiry, discovery, and practical application of science by serious and dedicated people is worthy of our respect. All of science is build on the shoulders of those who came before, in all disciplines, including medicine. In the battlefield, when there is no MASH, leaches and grubs are still used to clean and sterilize wounds, no one calls that quackery. 

(1) It be illegal to sell any product with false advertising. This means including homeopathic products, and it also means enforcing the laws already on the books in some cases.

(2) There be much greater efforts to inform the public about the lack of efficacy of products which have been tested and found ineffective, and about the lack of information on products which have not been properly tested.

I completely agree.

[ Edited: 20 February 2010 02:23 PM by Write4U ]
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Posted: 20 February 2010 08:12 PM   [ Ignore ]   [ # 52 ]
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One of the biggest problems I see any time CAM is discussed - including right here - is that a whole wide range of “treatments” are included in that very broad umbrella term, and each of them presents different problems, different degrees of acceptance, different responses. I don’t think it’s very helpful to discuss “CAM” altogether as though it’s one monolithic program. To get anywhere in this or any other discussion, you really have to break it down and discuss them individually. My response to, say, herbal medicines (and even that term is entirely too broad to warrant a useful single response), is entirely different from my response to Reiki, or homeopathy, or acupuncture, or ......

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Posted: 21 February 2010 09:14 AM   [ Ignore ]   [ # 53 ]
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I keep getting the idea that write4u and skepticeye are responding to someone not participating n this thread. How can you quote my post saying I do not advocate baning all CAM and then go off on a tirade about banning all products that ever do harm as if that had anything at all to do with what I’m saying. Nobody light a match or the strawmen around here will immolate us all!

As I have said over and over again, all I am suggesting is that marketing as medicines things that either clearly do not work (e.g. homeopathy) or that have no reasonable evidence that they might work and are safe (e.g. most herbal remedies) is not good for anyone and should not be allowed. People get very upset every time a pharmaceutical product turns out to have harmful side effects partly because we’re used to expecting our drugs to be helpful and not harmful, which on balance most of them are because we regulate their production and marketing. When the pharmaceutical companies cheat, I am all for punishing them appropriately, so the regulation I’m suggesting isn’t just about CAM, it’s about all medical therapies. The problem is that CAM seems to get a free ride on safety and efficacy claims because of the widespread perception that it is harmless, “natural,” and provided by small-time dedicated healers rather than large corporations motivated by profit. These are all, to a greater or lesser extent, myths that are part of the CAM marketing paradigm.

As for my saying all CAM is ineffective, did you not read my post in which I listed some forms of CAM which have shown some reasonable evidence for efficacy? Strawmen again. CAM by definition is mostly made up of therapies that haven’t gone through the usual scientific process to prove safety and efficacy but which people believe in based on faith, personal experience, word of mouth, etc. It is a heterogenous mish-mash of thinfs ranging from the completely ridiculous to the very likely beneficial. However, I repeat there is no sound, logical reason to exempt it from the same standards of evidence we rightfully apply to airplane engineering, bridge-building, mainstream medicine, or any other are in which wishful thinking that happens to be wrong has serious consequences. I cannot imagine why so many here see it as closed-minded or arrogant to expect everyone to demonstrate their claims with some reasonable objective evidence? How is that a controversial idea for self-proclaimed skeptics? Where is the “fundamentalism” here?

I understand that scepticeye has a philosophical objection to government regulation, and that that appears to carry more weight for him than the skeptical principle that claims should be backed by evidence or expect to be vigorously challenged. Regardless, if you’re going to argue with my criticism of CAM, try to argue with what I actually say, not your exaggerated notion of what I’m saying. Yes, I support regulation to prevent unsupported medical claims. Yes, I believe CAM is often ineffective and sometimes harmful. Yes I believe CAM is often fraudulently marketed. Argue with those statements if you like. But no, I don’t claim all CAM is automaticaly ineffective or harmful and I don’t claim that all CAM should be banned, so maybe it isn’t germane or useful to argue against those positions in this thread?

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Posted: 21 February 2010 09:38 AM   [ Ignore ]   [ # 54 ]
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Write4U - 20 February 2010 02:09 PM

The point I am trying to make is that it is unfair and a little arrogant to dismiss the efforts of previous medical practitioners as pure quackery. I believe all inquiry, discovery, and practical application of science by serious and dedicated people is worthy of our respect. All of science is build on the shoulders of those who came before, in all disciplines, including medicine. In the battlefield, when there is no MASH, leaches and grubs are still used to clean and sterilize wounds, no one calls that quackery. 

One small point, because I think the general thrust of this question is really OT here. Calling someone who practiced medicine before, say, the late 19th century a “quack” is something of an anachronism, akin to calling someone in the 17th century a “scientist”. “Quackery” only becomes a truly meaningful term when there is something like scientific medicine, with its complex testing regime, double-blind, placebo controlled trials, etc. Those really didn’t begin until the second half of the 20th century.

Yes, there were some people who did competent proto-medicine in the late 19th century. There were also snake-oil salesmen, in their droves, who peddled useless nostrums to people; many of which were basically high-proof alcohol, and some of which included things like morphine for babies and motor oil. For competent histories of this sort of thing, read James Harvey Young‘s books. I mean that seriously, he was a great historian and you will doubtless learn quite a lot.

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Posted: 21 February 2010 01:01 PM   [ Ignore ]   [ # 55 ]
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mckenzievmd - 21 February 2010 09:14 AM

I keep getting the idea that write4u and skepticeye are responding to someone not participating n this thread. How can you quote my post saying I do not advocate baning all CAM and then go off on a tirade about banning all products that ever do harm as if that had anything at all to do with what I’m saying. Nobody light a match or the strawmen around here will immolate us all!

I am never slow to apologise for misinterpreting someone’s position and I do so here if I was wrong.  I just reviewed all of your posts in this thread and the main problem is that a) you include all CAM in your generalisations b) you wrote “I still believe it is ethically wrong to allow the sale of harmful or useless medical remedies even with disclaimers” and c) your interpretation of what you claim is harm done by CAM is wholly unconvincing, including what happens when people chose CAM and don’t get scientific medicines; what happens when people mix CAM and scientific medicine without informing their doctor. You also make generalised claims about fraudulent advertising and patronise people about their willingness to try CAM despite the lack of scientific proof. It all creates a fundamentalist impression in my opinion.
I believe totally that any problems people have with CAm can be dealt with in a completely satisfactory way by regulation of advertising and labeling. There is no evidence for banning things like homeopathy whatsoever and without evidence I don’t support things.
An earlier poster was correct in suggesting that different kinds of CAM be discussed individually or in groups and I agree.

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Posted: 21 February 2010 03:30 PM   [ Ignore ]   [ # 56 ]
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I appreciate your rsponse, scepticeye. It is easy to overinterpret each others’ position, so I hope we can continue to disagree productively about specifics. It’s true that I often discuss the “problem with CAM,” which implies all approaches that could be considered CAM are included. I do think most of what we call CAM is, by definition, not yet proven in a reasonable, scientific way, but I try to acknowledge that each intervention must be judged on its own merits. There likely are many CAM approaches that will someday be shown to be helpful, especially the herbal products, I just object to the assumption that they are helpful and not harmful that their promoters make, and I have concens about the world-view that sees to accompany much CAM use, which includes a whole array of myths.

As for baning vs labeling regulation, I’m not sure they’re really opposing alternatives as you seem to suggest. If it is illegal to represent a product in a way not justified by evidence, then products for which there is no good evidence are effectively banned even without laws specifically intended for that purpose. I tend to favor a stronger set of controls than currently exist under DSHEA, with the goal to ultimately hold all medical therapies to the same standard. If a pharmaceutical company is required to go through the rigorous process of FDA approaval for its products, which tough and expensive as it is clearly doesn’t always work, then I don’t see why sellers of herbal medicine, homeopathic remedies, and other CAM therapies should be expected to do the same.

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Posted: 21 February 2010 03:44 PM   [ Ignore ]   [ # 57 ]
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mckenzievmd - 21 February 2010 03:30 PM

As for baning vs labeling regulation, I’m not sure they’re really opposing alternatives as you seem to suggest. If it is illegal to represent a product in a way not justified by evidence, then products for which there is no good evidence are effectively banned even without laws specifically intended for that purpose.

Careful here, Brennen. Let’s take a particular example, like garlic pills to reduce cholesterol (etc.). Now, as I argued above, the evidence is pretty conclusive that garlic does not reduce cholesterol. Let’s assume no further evidence comes out to refute that hypothesis. Then it should be illegal to label garlic pills as cholesterol fighters, or to claim or suggest in any way that they aid in cholesterol reduction, if you’re trying to sell them.

However none of that would effectively ban the sale of garlic pills. Garlic pills would still be available for sale in otherwise unlabeled packages. (Again, assuming that they aren’t found to be effective for treatment of any disease).

The same would be true for virtually all herbal remedies.

Since homeopathic remedies are simply sugar pills or water, they also would not be banned. However, sale of them would be trickier, since labeling distinguishing one homeopathic remedy from another would be illegal, if it referred to purported disease treatments.

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Posted: 21 February 2010 04:08 PM   [ Ignore ]   [ # 58 ]
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mckenzievmd - 21 February 2010 03:30 PM

I tend to favor a stronger set of controls than currently exist under DSHEA, with the goal to ultimately hold all medical therapies to the same standard. If a pharmaceutical company is required to go through the rigorous process of FDA approaval for its products, which tough and expensive as it is clearly doesn’t always work, then I don’t see why sellers of herbal medicine, homeopathic remedies, and other CAM therapies should be expected to do the same.

This is a key point where I fundamentally disagree. Alternative-style medicinal substances are part of all cultures and I believe that people should be free to use them.
I guess the essence of why i believe this is because I believe that scepticism and science, both of which I subscribe to and while important and valuable, need to be seen in perspective. What I mean is that in my opinion we need to live our lives not solely on pure rational thought, pure scientific evidence and pure scepticism. Life is too complex and too rich to do that. We need to use science and use rational thought where they are appropriate but put them aside when not.
When we interact with people, friends, lovers, colleagues etc we behave and respond instinctively and do not analyse everything to the nth degree or look for scientific evidence of every response we make or they make. When we go to movies or the theatre likewise. When we buy a lottery ticket or throw a dice for fun one night when we are out with friends we don’t stop and analyse each action based on some scientific evidence or rationalised set of deductions. If we do, then we are no more than robots.
Scientific medicine has it’s place, a place of honor in our lives and in society. It is the gold standard. We demand 100% chemical knowledge of the medicine, it’s action, it’s mechanism, it’s interaction with other substances and it’s side effects. We demand scientific proof of it’s repeatable success. Rightly. This is our ultimate medical and scientific achievement.
However just because we have this achievement does not mean we are under some kind of compulsive obligation to then wipe away all other medicinal substances because they do not match up to this gold standard. What we should do, in my opinion, is to recognise and educate ourselves about the differing standards we are applying to the different parts of our medicinal history and culture.
We apply a rigorous standard, as described above, to scientific medicine. Great. But we also have traditional medicines that do not satisfy these standards. Medicines where repeatability is not proven. 100% success is not proven. Mechanism is not proven. Evidence of a scientific standard is not there. Evidence of a cultural/traditional kind is but it is based on verbal reputation and stories handed down. But again we should not wipe it away because it does not fit the scientific standard. We should educate, label, regulate - leaving people to make choices with knowledge.
I can only speak for my part of Europe - Ireland the UK. Alternative medicine is well advertised and education is widespread and well established. Alternative medicines have no proven scientific evidence and this is known. If you use them then you accept that. Doctors always ask if you are taking any alternative medicines. 
We can live with multiple parallel standards.

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Posted: 21 February 2010 05:19 PM   [ Ignore ]   [ # 59 ]
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Interesting way of looking at it, scepticeye. I agree with the principle that not all domains lend themselves to science. I certainly believe in giving due weight to the emotional and the aesthetic. Love and at can be viewed through the lens of science, and this can be interesting and instructive, but on a day-to-day basis they are not fundamentally rational human activities and need not be strictly treated as such.

But I cannot see that medicine is such a domain. Certainly there is a psychological component for humans who are ill to dealing with disease, and not all the ways in which we confort people need to be medical. There is certainly room for emotional, even spiritual support and the comfort it offers. This is arguably less true for my patients, though of course still true for their owners. However, I see this as fundamentally different from the issue of offering treatments for disease that claim to help people or animals stay well or get better. I don’t see that it is right or truly helpful to offer ineffective or even harmful therapies as if they were truly making anything better. Even if using them offers some kind of comfort in a placebo sort of way, ultimately these therapies are lies and wishful thinking, and the small good they may do doesn’t seem to me to balance the potential harm. I can point you to a collection of literally hundreds of stories of people who sought comfort from alternative therapies at the expense of conventional medicine because, as you say, we are not strictly rational creatures, and who suffered and died needlessly for it. There may very well be plenty of people who get some psychological comfort from them with no harm done, but I see the risk differently, and as greater, than you do.

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Posted: 21 February 2010 05:26 PM   [ Ignore ]   [ # 60 ]
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Doug,

I see your point. I would hope that safety as well as efficacy rules could be strictly enforced, so even without specific label claims the manufacturers of CAM remedies would have to prove safety. If they could do so, I don’t suppose it would necessarily be such a problem if they continued to sell something like garlic pills. I realize that, as you imply, anything which could establish an efficacy claim for one indication could easily be misused for others for which there is no evidentiary support, and yet we wouldn’t be able to ban something that did have a legitimate use on this basis either. I guess I’m trying here to be realistic about the fact that irrational self-medication and outright quackery aren’t ever going to be eliminated, I’d just like to see a better job of minimizing the damage.

Of course, the distinction is largely moot since the will and resources to pass and, more importantly, effecttively enforce strict labeling regulations isn’t present and likely won’t be in the forseeable future. *sigh*

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