The refusal of the doctors of the Jiménez Díaz Foundation in Madrid to give a homeopathic treatment at the request of the family to a young man in a coma -a decision sanctioned after judicially– does not close a debate that comes out of the scientific.
From a medical point of view there are no doubts: the doctor is responsible for deciding what the patient will receive. But there is an argument that leaves a crack open: they could have acceded for humanitarian reasons. "If the medical team had approached the family with compassion and humanity, the matter would have been resolved," says Jacinto Bátiz, palliative physician and a reference in deontology of the College Medical Organization (WTO). "Beyond the fact that you want to give a homeopathic treatment, an ethical debate is opened between the right of the family to try to give the best to the young person and the professionals who must ensure that the best is given within what is proven, "says Gonzalo Fernández Quiroga, doctor and president of the Homeopathy National Assembly. But the appeal to humanity does not figure in the laws that regulate the medical profession.
The Constitution. Article 43 "recognizes the right to health protection". It does not mention the freedom of therapeutic choice or go into details.
General Law of Health. Affirms that everyone has the right "to be assigned a doctor, whose name will be announced, who will be your main interlocutor with the health care team" and "to obtain the medicines and health products deemed necessary to promote, conserve or restore your health. "
College Medical Organization (OMC). "The treatment is prescribed by the doctor to the patient, and the latter must not self-medicate (…). This treatment must be proposed, after a duly informed consent, so that the patient has the possibility of rejecting or accepting it. "
WTO Code of Ethics. He points out that "if the patient demands from the doctor a procedure that, for scientific or ethical reasons, he deems inappropriate or unacceptable, the doctor, after duly informing him, will be excused from acting". He adds: "when legal representatives make a decision that, in the opinion of the doctor, is contrary to the interests of the represented, the doctor will request judicial intervention."
Pubmed. This web reference on medical research has a single entry on the use of homeopathy in a patient in a coma. It is not one of the compounds proposed by the family.
Fernández Quiroga states that in "those circumstances you can not impose any type of therapy because you think about it". With this he rejects what happened. According to the story of the parents, the family was very affected because what was supposed to be an almost procedural operation, an appendicitis, ended in a very serious situation: a coma. With this burden of stress, a relative of the young man entered the ICU with the bottles of the products – three homeopathic preparations and one vitamin C – to be injected into the patient. The doctors refused because they did not know what it was and did not consider it appropriate, and ended up calling the police to take the family members. The father went to the courts of the Plaza de Castilla in Madrid to ask them to let them apply the treatment they considered appropriate.
"It's a dramatic situation," says Fernández Quiroga. And he proposes that, "given that traditional medicine no longer has alternatives for the young person, experts in homeopathy could have been called to agree on an adequate treatment that had a scientific justification and could have been administered as a compassionate use." This is applied with the scientific medicines and consists in supplying to a patient without other alternative other products of which there are indications that work, although they have not finished the tests or have been approved with other indications.
Federico de Montalvo, president of the Bioethics Committee of Spain and professor of Constitutional Law at ICADE, is the most emphatic: the administration of homeopathy should have been admitted "out of compassion towards parents who, although possibly mistaken, only seek to save their child without harming him". Of course, in that case, even if the judge had agreed with the family, "the doctors are not obliged to give it if they believe that it does not contribute anything to the child". "Doctors have the professional freedom to refuse to give a treatment in which they do not believe and that also does not cover the public system. Another thing is that parents ask for discharge, that this does not affect the health of the child and that they transfer it without risk to where someone is willing to give them said treatment, "adds Montalvo. Something similar to what has happened. The young man arrived on Thursday night to Albacete, where he is still in critical condition and doctors are trying to reduce brain swelling, according to relatives, reports Francisco José Barroso.
The debate reaches the top of the WTO. Jerónimo Fernández Llorente, treasurer of that institution and in charge of the observatory for the pseudosciences of the collegiate entity, affirms that he does not believe that he should have given in to the demands of the family. "From a scientific point of view, it would be a fraud to use these three compounds without any evidence," he says. And "from an ethical point of view, the Code of Ethics is clear, and professionals have acted as required," he adds.
The Cordovan doctor Maimónides wrote 900 years ago a prayer that shows that problems such as those that just happened in the Jiménez Díaz Foundation in Madrid were already frequent in his practice. One of his paragraphs reads: "Make my patients trust me and my art and follow my advice and prescriptions, take away from my patients' bed the charlatans, the army of relatives who give a thousand tips and those who know always everything, because it is a dangerous interference that, by vanity, causes the best intentions to spoil and often leads to death ".
Fernandez Llorente admits that there are other plans, such as the legal, which does not enter because it is not his field, and the human, "where of course you have to be with the pain of the patient and their families and it is understandable that everything is tried" . But he believes that if the doctors had yielded to their claims they would have caused added damage by generating false hopes, since the family would interpret that the doctors saw an open door to hope with these products.
In what there is agreement between the specialists asked and between the Spanish societies of Palliative Care (SECPAL) and of Medical Oncology (SEOM) is that the dialogue has failed. "Communication with patients and their families is the best tool, and when a good relationship of trust is established and doubts are adequately explained, problems do not usually occur," they say from SECPAL.
María Cruz Martín Delgado, president of the association that brings together the intensivists (SEMICYUC), summarizes: "These are unusual cases and are often solved with information and communication. Physicians are not required to administer any type of treatment or do any procedure that will not benefit the patient. In the situation that explains the means in which the patient finds himself, he would not benefit from the treatment. It is understandable that in the face of the situation, the family will look for any option that it considers may help the patient, but this does not require professionals to contemplate alternative treatments not considered in the clinical practice guidelines. Sometimes, these situations can end up in demands for professionals. "
Because situations of disagreement occur daily, but are resolved without reaching the judge. Patients who ask for more painkillers, for example, or something to sleep on. "The patient can claim the right to treatments whenever they are indicated," says Bátiz. "For example, you may require antibiotic treatment if you have an infection for what is indicated. But he can not demand it to fill the kit for when he goes on vacation, "Bátiz explains. The doctor tells how once in the hospital of San Juan de Dios in Santurtzi (Bizkaia), where he works, a lady wanted to put his son in a coma to a wheelchair and give him a spin to see if he woke up. They had to convince her that there was no evidence that it worked and it was an added risk.
Part of that, mostly, agreements are reached, it is because the regulation is clear. "If the patient demands from the doctor a procedure that, for scientific or ethical reasons, he deems inappropriate or unacceptable, the doctor, after duly informing him, will be excused from acting," says the WTO Code of Ethics. The patient has the right "to obtain the medicines and health products considered necessary to promote, conserve or restore their health, under the terms established by the Administration in the regulations", states the General Health Law (1986). The idea that comes from afar. The Hippocratic oath, which has been maintained for 2,500 years, expresses it this way: "I will serve, according to my ability and my criteria, the regime that tends to the benefit of the sick, but I will abstain from everything that leads to injury or desire to harm" .
In fact, the most well-known cases of disagreement that have ended up in the courts have happened when relatives or the patient have requested that they be removed from treatment, a right recognized in the General Health Law, the Autonomy of the Patient (2002) and the future law of dignified death. And the relatives had judicial support. It was the case of Inmaculada Echevarría, the woman who had to take to court her petition to have her ventilator removed that kept her alive in 2007, and more recently, in 2015, that of Andrea, the 12-year-old girl affected by a degenerative and irreversible disease whose parents had to go to court to be disconnected by doctors. Bátiz and Fernández Llorente coincide in recalling in this regard the cases of doctors who ordered transfusions of minors against their parents, who were Jehovah's Witnesses.
In summary: the patient has the right to reject what they propose. The rest, you must negotiate.
The State Platform of Users Associations of Homeopathy has addressed a letter to the Patient Care service of the Jiménez Díaz Foundation in which it claims the "freedom of therapeutic choice" and considers it "a constitutional right". Miquel Peralta, its president, insists that there is "evidence for whoever wants to look for it" that supports the use of homeopathy in people in a coma. And the letter insists on that idea and cites a case, the only one collected in the scientific literature for a patient in a coma, but it does not clarify whether it was improved by the use of the preparation or by the natural evolution of the process.
"The discussion about the efficacy of homeopathy in medicine is being treated in an unequal and authoritarian way and, in cases like this, in which the life of a person is at stake, the will of the relatives in charge of the affected person must be respected. "says the letter.