Arthur Caplan on Hyperbaric Oxygen Therapy

Art Caplan has a new piece on hyperbaric oxygen therapy over at NBC News:

Hyperbaric oxygen therapy. Have you ever heard of it? The Internet sure has.

Centers and clinics tout the benefits of sitting in a tank breathing 100 percent oxygen at higher than atmospheric pressure for treating autism, infant brain trauma, multiple sclerosis, chronic fatigue, cerebral palsy and many other conditions.

There’s just one problem: There is no solid evidence that hyperbaric oxygen therapy does anything for any of these disorders.

Read the full article here.

One thought to “Arthur Caplan on Hyperbaric Oxygen Therapy”

  1. Dr Caplan,

    Thank you for your highly critical article on Hyperbaric Oxygen Therapy (HBOT) for PTSD published by NBC News at .

    Since your headline mentions “Bioethicists,” but you’re the only one authoring the article, I’ve “cc:’d” this email to all the other bioethicists in your department with the hope that someone ethical will help you take an honest and objective look at Hyperbaric Oxygen Therapy (HBOT).

    The key to the non-ethics in Hyperbaric Medicine is found in your 4th paragraph, and I can’t encourage you enough to unpack this further:

    “It does have a proven role in helping decompression sickness and carbon monoxide poisoning. But at $2,000 for a 90-minute run, a fairly easy to deliver treatment has a lot of believers and proponents.”

    Decompression Sickness (DCS) and CO Poisoning are both hypoxic-ischemic brain-injuries, just like PTSD, multiple sclerosis, cerebral palsy, stroke, and every other brain-injury is also hypoxic-ischemic.

    If HBOT is ever approved for brain-injury it will result in a near-immediate reduction in this $2000 fee by probably 90%. The standard fee would be closer to $200 instead of $2000. For hyperbaric practitioners, they would have to do more work for less money, and so they produce “studies” like the one you cite so as to protect their turf.

    Your fee is actually low. In NY state, HBOT cost is documented to be as high as $5500/treatment. Please see the last paragraph on page 8 at .

    However, the $2000 fee you cite is not what people are paying out-of-pocket for off-label HBOT for PTSD, cerebral palsy, multiple sclerosis, etc.

    The off-label fee is usually just $150 to $250/treatment–generally less, rarely more.

    The high fees you cite are what’s paid for the “approved” uses of HBOT, most of which have a minimum number of just 10 treatments or less. For DCS and CO, it’s just one or two treatments.

    For brain-injury, it’s typically 100 treatments, minimum.

    (I know because my wife and I are parents of a brain-injured child. Jimmy Freels was diagnosed with spastic quadriplegia cerebral palsy just before his first birthday. He was the first such kid to get in a hyperbaric chamber in Georgia, and to my knowledge, we were the first to prove it worked in a court of law. Under the EPSDT statute (Medicaid for children), HBOT is mandated, and we spent 12 years in multiple court hearings repeatedly proving efficacy while the state perpetually appealed until they could appeal no more.)

    (I’ve put everything we learned and experienced on the web at MedicaidforHBOT.com, and have voluntarily helped hundreds of families across the US access HBOT for their children.)

    Please look at the biology of hyperbarics. The JAMA article you cited had no control, no placebo. What they claimed was a control was 1.2 ATA of compressed air, but even this protocol produces a therapeutic benefit.

    Pressure is measured by “atmospheres absolute” (ATA). Breathing at sea level pressure is 1 ATA. Breathing compressed air at 1.1 ATA, 1.2 ATA, and 1.3 ATA (and above) always produces a therapeutic benefit, and this is a well-known fact within the universe of hyperbaric practitioners.

    1.3 ATA of hyperbaric air increases the partial pressure of arterial oxygen to about 30% from the normal level of 20.9% found in atmosphere. This is nearly a 50% increase in oxygen and is obviously bound to have a therapeutic benefit.

    Reducing oxygen levels under pressure also produces a neurological effect. For example, when you fly on a commercial airliner, they typically cut the oxygen level to just under 20.9%, which creates just enough hypoxia to make passengers slightly drowsy–so they’ll stay in their seats.

    This means the JAMA article you referenced had no control, i.e., no placebo, not only for the reason I’ve just given, but also because, by definition, a placebo cannot be comprised of the same substance that’s tested.

    What’s tested here is oxygen, and therefore it’s placebo cannot contain oxygen. Ambient air pressurized to 1.2 ATA contains more than 20.9% oxygen. I’m not trying to be flippant, just factual.

    Let’s get back to the economics of this.

    Look at the treatment protocols for the covered uses of Decompression Sickness (DCS) and CO poisoning that you cite. Go to the US Navy Manual found on page 20-18 at .

    For DCS, it’s just 1 treatment, maybe two. For CO poisoning, it’s a minimum of 1 and a maximum of 5.

    The JAMA template for claiming a placebo effect is not new but started with Collet’s 2001 “Hyperbaric oxygen for children with cerebral palsy: a randomised multicentre trial. HBO-CP Research Group” . Here, they treated a “control” group of kids with 1.3 ATA air. From the abstract: “FINDINGS: For all outcomes, both groups improved over the course of the study, but without any difference between the two treatments.”

    From the abstract of your JAMA study at :

    “Compared with the no intervention group (mean change score, 0.5; 95% CI, −4.8 to 5.8; P = .91), both groups undergoing supplemental chamber procedures showed improvement,” and “No difference between the HBO group and the sham group was observed”.

    Sound familiar? It’s Collet all over again.

    Lindell Weaver, one of the co-authors in the JAMA paper you cited also published a NEJM article titled “Carbon Monoxide Poisoning” in their Clinical Practice section. See . In the NEJM article Weaver discussed a CO victim who only discovered her poisoning years later, but Weaver refused to treat her, and now she’s chronically poisoned. Weaver claims it’s too late to help her, but this is not true.

    Weaver refused because the woman would require more than 5 treatments. Most likely she’d require at least 100 treatments by now because she’s suffering from a chronic–instead of acute–hypoxic-ischemic brain-injury.

    The other reason why Weaver refused to treat her? The most effective treatment protocol for her is below 2 Atmospheres Absolute (ATA) of pressure, and HBOT protocols for what’s covered are all 2 ATA or above. On page 2 of the article “Hyperbaric oxygen therapy: types of injury and number of sessions–a review of 1506 cases” is this very revealing paragraph:

    “HBO2 effects depend on the O2 pressure employed, as well as on session duration, frequency, and the number of sessions applied. The O2 pressure recommended by the Undersea and Hyperbaric Medical Society (UHMS) and used in most protocols is at least 2.5 ATA (150 KPa) (14,15). Pressures of 2.1 to 2.4 ATA (110 to 140 KPa) may be employed in special cases, e.g. in children, but pressure less than 2 ATA (100 KPa) should never be used. The duration of each session is usually 90 min (13).”

    You can find this paper at .

    Please note they are recommending to never use less than 2 ATA of pressure. Why?

    Here’s the story of patient Dan Greenhouse who recovered from DCS years after his injury–via 1.5 ATA and 100% oxygen. He even wrote a book about his experience. See .

    Mr Greenhouse required more than 10 treatments to make his recovery.

    A couple of things you need to see/explore.

    HBOT is proven to improve function after brain-injury. Our son’s case may have been the first to prove this in a court of law, which has a higher standard of actual proof than what gets published in peer reviewed medical journals.

    Here’s the latest documentation. “Hyperbaric oxygen therapy applied research in traumatic brain injury: from mechanisms to clinical investigation,” at . From the abstract, “The
    effectiveness and feasibility of HBOT has been confirmed by several studies.”

    Notice this statement directly contradicts the “findings” of the JAMA “study” you referenced. As well as Collet. And any hyperbaric paper co-authored by Cifu. Somebody is not telling the truth. Somebody is lying.

    That’s unethical.

    You’re an ethicist.

    Please be ethical.

    Please look deeper at the biology and the economics of what’s going on here.

    Then do a rewrite. I’ll be glad to help you with it.

    Thank you,


    David Freels, Copywriter.
    Compelling ideas. Persuasive words.
    404-725-4520
    https://DavidFreels.com
    David@DavidFreels.com

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