Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from a consumer about the services provided by the provider, a homeopath, in June 1997.
The complaint is that:
- On a Friday in early July 1997 the consumer consulted the provider. At the consultation the consumer felt pressured by the provider into taking two Lachesis tablets. The consumer took the Lachesis without knowledge of the possible consequences of doing so and therefore without giving informed consent.
- After taking the Lachesis tablets the consumer experienced a severe and frightening reaction. On separate occasions over the following week the consumer and her sister telephoned the provider to ask about what side effects could be expected. The provider declined to answer on the basis that it would colour the consumer's reaction to the drugs. The provider expressed anger that the consumer's sister phoned her on one occasion rather than the consumer.
- The consumer has since learned that someone suffering from Myalgic Encephalomyelitis ("ME"), which she had, can experience a severe reaction to homeopathic drugs. The consumer had informed the provider of her condition and therefore considers she should have been advised that a severe reaction was possible and that she should not have been given the tablets.
- The consumer is also concerned that the provider advised her that people with ME have an under-active immune system, when the opposite is the case. The consumer feels this demonstrates a lack of knowledge on the part of the provider.
- The consumer sought a refund of the $90.00 cost of the consultation.
The complaint was received by the Commissioner on 3 November 1997 and an investigation was undertaken. Information was obtained from:
The Provider / Homeopath
The Commissioner obtained the provider's clinical notes and also obtained advice from an independent homeopath.
Outcome of Investigation
The consumer developed Myalgic Encephalomyelitis ("ME") (otherwise known as Chronic Fatigue Syndrome or Chronic Fatigue and Immune Dysfunction Syndrome or Post Viral Fatigue Syndrome) in 1996. Prior to seeing the provider the consumer had been seeing a ME specialist who had prescribed Amitriptyline at a dose of 10mg each night in order to facilitate a deep healing sleep. By May 1997 the consumer was recovering well, was managing a light workout at the gym three times a week and a 40-minute walk three times a week. At that time her symptoms were fatigue, which was adequately remedied by a half hour rest in the afternoon, slight weakness in her left leg, occasional weakness in her left arm and some transient joint pain.
The consumer developed a cold and a chest infection in May 1997. She subsequently had a slight relapse of ME and was prescribed the antibiotic Rulide for the chest infection. The Rulide caused the consumer to get colitis but when she stopped taking the Rulide the colitis abated. She subsequently recovered from the chest infection, however still suffered from the symptoms of ME.
In June 1997 the consumer read about homeopathy in a book called "Spontaneous Healing." The book said that homeopathy was harmless and that ME patients should try it. The consumer therefore thought it would be worth trying homeopathy and on a Friday in early July 1997 went to see the provider. The consumer advised the Commissioner that she did not really go to be treated by the provider, but to get more information about homeopathy. The provider is also a registered general and obstetric nurse.
Following the consultation on that day the provider gave the consumer a dose of Lachesis and advised the consumer that she could still take Amitriptyline that night. The consumer advised the Commissioner that she felt obliged to take the two Lachesis tablets immediately as the provider gave them to her on the pottle lid. The consumer said that, "if I had been given them in a container to take home, I would have had a chance to think about what I was doing and had the opportunity to make an unpressured decision as to whether I wanted to take them at all". The consumer further advised that she was given little indication of what the Lachesis would do or the effect it would have on her body.
The consumer advised that as soon as she left the provider's office she felt weakness down her left side and started to froth at the mouth. She stated "I was quite scared at the immediacy of the reaction. This continued and then the next day I developed pressure in my head. I felt pain above my left eye and pressure behind my left eye which started to go out of focus. I developed pressure in my left ear which went dull and a headache at the base of my skull, on the left side.
By Monday night I was bedridden and in the worst relapse I had ever experienced. I only had enough energy to breathe. I had pain in my chest and felt swollen in all of my glands - a feeling that went right up into my cheekbones. The left side of my brain felt blank. I developed pain in all of the joints on my left side. I constantly felt like I was going to black out. My left side now felt totally devoid of my right. It was as if someone had drawn a line from the top of my head to between my legs and separated the two sides of me."
The consumer advised that in the first week following the consultation she rang the provider twice, and her sister also rang once to ask about the side effects of the Lachesis. The consumer was concerned that she was having such a major and frightening reaction, as was her sister. The consumer advised that the provider was not willing to supply either her or her sister with the information they requested because she said it might "colour my reaction to [the Lachesis]". Further, the consumer advised that when her sister rang on her behalf, the provider was angry and said that the consumer should call and not her sister. The consumer advised that the provider said further "any homeopath would be jumping for joy" at the consumer's reaction to the Lachesis.
In September 1997 the consumer wrote to the Royal London Homeopathic Hospital describing her symptoms and asking for advice. A Director of Research replied and said that although he could not really give advice without examining the consumer personally, he considered for someone "to have such a severe reaction as you is very unusual".
The consumer told the Commissioner that following taking the Lachesis tablets her ME was far more severe than previously. Ten weeks later, in September 1997, she could only manage a three minute walk. Her left eye continued to go out of focus when she was tired, her left side was still weak and felt cut off from her right side, and she got cramps in her left leg. The consumer said that she continued to be debilitated for six months.
The provider advised the Commissioner that she saw the consumer twice on that day in July 1997, at 10:45am and again at 12:30pm. She says that at the first consultation she informed the consumer about homeopathy in some detail including the law of similars, that is, how homeopaths take the mental, emotional and physical symptoms of the patient and find a homeopathic medicine that is as similar as possible to those symptoms. The provider says that she advised the consumer that after a homeopathic prescription an aggravation is possible. As the body heals itself, old symptoms return. She says she also advised the consumer that all medicines are tested on healthy volunteers and all symptoms are recorded so the homeopath has an accurate basis on which to make a prescription.
The provider advised the Commissioner that having spoken to the consumer at 10:45am and then also seeing her son at 12:30pm, a further hour was spent going over the consumer's case and talking about homeopathic aggravation. She advised the Commissioner that she decided on a low potency of Lachesis, in order to minimise any aggravation. She said that she asked the consumer if she wanted the medicine and the consumer confirmed that she did.
The provider advised the Commissioner that she rang the consumer several times in the week following the consultation and again explained about homeopathic aggravation. She said that after a week of going over the consumer's case with her by phone there was nothing further she could tell her and time for the body to heal itself was needed. The consumer rang two days later and explained she wanted no more homeopathic treatment.
The provider informed the Commissioner that four days after the first consultation she offered the consumer an antidote and the consumer turned this down. The provider said this left her unable to assist the consumer any further in a meaningful way. The consumer confirmed Echinacea was offered as an antidote during this time but is unsure of when it was offered. There is no record of the antidote being offered in the provider's consultation notes.
The provider also advised that the consumer had been informed at her consultation that several months would be needed to adequately help her to correct the health problems that she had had in the past. She said that close care would be needed and changes of treatment as new symptoms presented themselves, and one dose of a homeopathic treatment would not be sufficient to help her achieve permanent good health. The provider stated that she was unaware of any medical studies that have been done on homeopathic medicine in the treatment of Chronic Fatigue Syndrome. However, the provider stated there is a wealth of homeopathy material regarding the treatment of ME with homeopathy.
The provider advised the Commissioner that she had not been angry when the consumer's sister telephoned but had explained about patient confidentiality. The consumer had not given her permission to talk to her sister and the telephone call from her was "right out of the blue".
Advice to the Commissioner
The Commissioner sought independent advice from a homeopath who read the provider's notes and advised:
- Lachesis is a strong remedy potentised (diluted) from snake venom. The venom itself causes decomposition of the blood, delirium, trembling, confusion, paralysis, defective vision, septic dark coloured tissue in the throat and profound prostration amongst other symptoms. It reacts strongly on the left hand side of the body.
- The provider's decision to prescribe Lachesis was made following a standard and comprehensive "repertrisation" and would be the norm of "some practitioners". (Repertrisation is a system used by homeopaths to speed up and simplify the matching of a particular remedy to patients' symptoms, to obtain the "like cured with like" remedy). ME patients usually respond well to homeopathic treatment when correctly prescribed by an experienced practitioner. "ME patients approach a homeopath usually after having failed to obtain relief from conventional medicine. Lachesis could possibly illicit a favourable response in some patients." However there are over 50 homeopathic medications available for the treatment of ME. The provider used the repertrisation process to choose the most suitable remedy by selecting a series of key or pronounced symptoms.
- The concept of homeopathic aggravation can be distinguished from side or adverse effects in the conventional sense. If normally prescribed, aggravations are considered as part of the healing process when reactivation or life returns to totally or partially malfunctioning tissue. The provider did not appear to have "assessed the situation correctly as it developed." This is because the aggravations of any homeopathic medication will vary to some degree in each patient and they should not be intolerable. The patient has to be monitored and encouraged through the crisis until stabilised. When the treatment is obviously not beneficial it should be corrected. The aggravations experienced by the consumer were new, excessive and should have been corrected.
- It is generally accepted by professionals that the healing process in chronic diseases can take up to two years to cure with treatment. The advisor questioned:
a) How well was this fact explained to [the consumer]?
b) How was it monitored?
c) How well does [the provider] understand it?"
The provider did not present any evidence showing records of lessening of symptoms in the consumer or even an awareness of the need to keep such a record. As patients are accustomed by modern conventions to expect a "quick fix", it is important that patients are adequately informed before treatment commences as to what to expect and what reactions are possible, and not to expect such "quick fixes".
- Weaker and debilitated patients respond in an entirely different way to homeopathic remedies than healthy patients do. The "provings" referred to by the provider were originally conducted on volunteers. Groups of healthy individuals submitted themselves to regular, usually daily doses of potentised remedies sometimes for up to a year. In the course of time all their reactions to the remedies were recorded by professional homeopaths to produce "drug pictures", which were compiled into various tables which are used to assist homeopaths in prescribing matching remedies to this day. Left alone, these volunteers recovered from all their symptoms in the course of time and from this has arisen the assumption that this same phenomena repeats itself with all cases which is not always the case. However the harm can be corrected quickly if recognised and the reaction reversed. Where patients react badly to homeopathy there are available courses of action which can include remedy antidotes.
- The provider appeared to have given the consumer information about the likely effects of taking Lachesis. However "her inexperience in this sphere is comparable to her inability to prescribe remedies adequately and appreciate the complexities of the case efficiently from the start." It is necessary for the practitioner to understand the conditions of success and then to make the patient understand these.
Code of Health and Disability Services Consumers' Rights
Right to services of an appropriate standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -…
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option…
In my opinion the provider breached Right 4(2) and Right 6(1)(b) of the Code of Rights as follows:
Lachesis is a recognised strong remedy potentised from snake venom. The consumer complained of many symptoms related to its use. For example, breathing difficulties, new left-sided symptoms, and excessive fear symptoms had not been a problem before.
The provider advised the consumer that her old previous symptoms would return but in addition to the old symptoms the consumer was also confronted with a new group of more severe symptoms, which she did not understand and which caused her great anguish. When the provider heard about the details of the consumer's deteriorating condition she offered an antidote which was refused by the consumer in the light of advice given to her by her ME specialist.
The provider said that after she offered the consumer a homeopathic remedy as an antidote and this was refused, there was nothing more meaningful she could do for her. However there is no record in the provider's consultation notes of an antidote or remedy being offered. In my opinion the provider failed to meet professional standards by her lack of recording of this advice given to the consumer and therefore breached Right 4(2) of the Code.
The provider says that she informed the consumer of the likely effects of the Lachesis tablets. However the information gathered during the investigation showed the consumer had little idea of what to expect. The consumer presented to the provider in recovery from a debilitating illness. The provider ought to have clearly informed her of the possible side effects of taking the Lachesis and also should have ensured the consumer understood the possible effects before taking the Lachesis.
In my opinion the provider breached Right 6(1)(b) of the Code.
I recommend the provider take the following actions:
- Apologises in writing to the consumer for breaching the Code. The apology letter should be sent to this office, and I will forward it to the consumer.
- Refunds to the consumer the $90.00 paid for the treatment. The cheque is to be sent to my office and will be forwarded to the consumer.
- Reads the Code of Health and Disability Services Consumers' Rights.
- Ensures in future that appropriate information is given to consumers and that this is appropriately documented.
A copy of this opinion will be sent to the New Zealand Charter of Health Practitioners and the Nursing Council of New Zealand. A copy with identifying features removed will also be sent for publication in an appropriate forum for education purposes.