Medical ethicist wades in on Vitamin C debate

The Vitamin C Debate

Medical ethics professor Grant Gillett wades into the Vitamin C debate

First, I must say I am not an authority on Vitamin C but I take from the documents I have viewed the following conclusions.

1. Disputed and anecdotal claims have been made for the dramatic efficacy of hi-dose (>1g per day) (even mega dose >25 gram per day) Vitamin C in life threatening disorders.
2. There is no clear evidence for that claim despite European publications on oxidative stress and endothelial dysfunction.
3. There is evidence that in a patient with a serious risk of developing renal insufficiency Vitamin C may precipitate terminal renal failure due to oxalosis.
4. The families of Douglas Pinny (Waikato DHB) have taken to subterfuge to try and help their family member get better with supplements that they cannot afford to mention to the medical team for fear of reprisals or adverse effects on their relative’s care. I also understand a family in North Shore has repeatedly requested vitamin C and have been refused, and that their daughter is not doing at all well.

I find it incredible that things have deteriorated to the extent that they have between these families wanting to do the best for their sick family members and the teams of health care professionals who, according to the existing codes of ethics in NZ, should be working cooperatively and collaboratively with them.

I understand that where there is objective evidence of harm from some suggested intervention (on the basis of reputable scientific evidence), a medical team might refuse to comply with a family’s request for a certain treatment.

I also understand that where there is inordinate expense to the care provider, a family’s request might not be able to be complied with.

I appreciate that where a patient or the authorised decision maker refuses to consent to a regimen of care, the provider needs to be very sure that it can be proven to be in the best interests of the patient according to a reasonable medical consensus in order to proceed with that regimen of care. Things are otherwise with requests for a particular intervention, where the decision rests with the health care team who are charged with acting in the best interests of the patient.

I would observe that in disputed cases a reasonable body of medical opinion may lie outside the normal bounds of those opinions readily available in NZ health care and that an article such as the European consensus statement on endothelial dysfunction and oxidative stress must be taken seriously such that good reasons should be given as to why its claims should not be factored into crafting a regimen of care for an apparently suitable patient.

Whereas the anecdotal evidence given by the family should be considered with due care and diligence in the light of a professional duty of care, counter-evidence that the doctors wish to be taken into account should be based on sound scientific evidence and ought to be carefully weighed and collated with the realities of the case before them. The way that a case unfolds, especially where prognostic predictions based in orthodox views seem to be unconfirmed, may represent a signal that some factors affecting the course of the patient’s disease are not fully understood within the bounds of conventional medical wisdom.

These general considerations seem to me to recommend an overall humility and readiness to listen by medical staff unless they have sound evidence that what a family or patient is proposing is likely to be prejudicial to the course of the patient’s illness.

Where the predicted course of disease is terminal, there is little to be said for medical closed-mindedness about anecdotal treatments and where factors appear to be having an effect which cannot be accounted for by the regimen of treatment and its evidentially supported credentials, the medical staff ought to be especially attentive to alternative suggestions and not to allow theoretical considerations to outweigh apparently inconsistent clinical developments. It is worth noting that some of the relevant changes and their causes may be more readily observable by those less convinced of the rightness of their convictions or committed to a particular paradigm of health care.

It seems to me that the hospitals concerned in these cases (at least in the events that have been communicated to me) have followed what they consider to be the ethical requirements for patient consultation but the sense I get from the families concerned is that the spirit of those consultations has not always been congenial or open-minded. I would like to think that that is a mistaken impression in that I incline to the view that the profession usually conducts itself with good will and a genuine sense of partnership in its clinical activity (in so far as resource constraints permit). I do hope that proves to be so in each of these cases.

Grant Gillett, FRSNZ, FRACS, D Phil (Oxon), MBChB, MSc,
Professor of Medical Ethics, Otago Bioethics Centre,
University of Otago Medical School