Marcia Angell

An essential ethical condition for a randomized clinical trial comparing two treatments for a disease is that there be no good reason for thinking one is better than the other.1,2 Usually, investigators hope and even expect that the new treatment will be better, but there should not be solid evidence one way or the other. If there is, not only would the trial be scientifically redundant, but the investigators would be guilty of knowingly giving inferior treatment to some participants in the trial. The necessity for investigators to be in this state of equipoise2 applies to placebo-controlled trials, as . . .

What is there about alternative medicine that sets it apart from ordinary medicine? The term refers to a remarkably heterogeneous group of theories and practices — as disparate as homeopathy, therapeutic touch, imagery, and herbal medicine. What unites them? Eisenberg et al. defined alternative medicine (now often called complementary medicine) as “medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals.”1 That is not a very satisfactory definition, especially since many alternative remedies have recently found their way into the medical mainstream. Medical schools teach alternative medicine, hospitals and health maintenance organizations offer it,2 and . . .

In 1984 the Journal became the first of the major medical journals to require authors of original research articles to disclose any financial ties with companies that make products discussed in papers submitted to us.1 We were aware that such ties were becoming fairly common, and we thought it reasonable to disclose them to readers. Although we came to this issue early, no one could have foreseen at the time just how ubiquitous and manifold such financial associations would become. The article by Keller et al.2 in this issue of the Journal provides a striking example. The authors' ties with . . .

1 am delighted to have been asked to deliver the Hogan & Hartson Jurimetrics Lecture in honor of Lee Loevinger. I had many conversations with him about the interface between science and the law, a no-man's-land rife with misconceptions and hard feelings, as we both agreed, and I greatly admired his efforts through Jurimetrics to bring some clarity and civility to the area. His death last year is a loss to both science and the law, and 1 am particularly honored to be giving the lecture this year.

Few things a doctor does are more important than relieving pain. Yet the treatment of severe pain in hospitalized patients is regularly and systematically inadequate.1 2 3 4 5 One study showed that 73 per cent of patients undergoing treatment for pain continued to experience moderate to severe discomfort.2 This is not for want of tools. It is generally agreed that most pain, no matter how severe, can be effectively relieved by narcotic analgesics.4 , 6 , 7 Why this inconsistency between what is practiced and what is possible?One consideration that limits the use of narcotics is the possibility of a variety of side effects, including drowsiness, . . .