MD, PhD, FMedSci, FSB, FRCP, FRCPEd

The most common pronouncement regarding alternative medicine that I have heard over the years from consumers, health care professionals or decision makers with a liking of alternative medicine goes as follows: “I don’t care how it works, as long as it helps.”

At first glance, this argument seems reasonable, logic and correct; it would be foolish, perhaps even unethical, to reject an effective treatment simply because we fail to understand how its effectiveness comes about – this would not be pragmatic and it is not what we do in medicine: aspirin, for instance, was used and helped many patients long before we understood how it worked. However, once we consider the way this notion is regularly used to defend the use of unproven therapies, we see that, in this context, it is fallacious – in fact, if we dissect it carefully, we find that it  crams three large fallacies in one tiny sentence.

The first thing we notice is that the argument combines two fundamentally different issues which really should be separate  1) the mechanism of action of a therapy and 2) its clinical effectiveness. The matter gets clearer, if we discuss it not in the abstract, but in relation to a concrete example: BACH FLOWER REMEDIES (BFRs). I could have selected many other alternative therapies but BFRs seem fine, particularly as they have so far received no mention on this blog.

Similar to homeopathic preparations, BFRs are so dilute that they do not contain any active ingredients to speak of (they differ from homeopathic preparations, however, in that they do not follow the ‘like cures like’ principle). Several clinical trials of BFRs have been published; collectively, their results show very clearly that the clinical effects of BFRs do not differ from those of placebo. (This does not stop manufacturers selling and consumers buying them; in fact, BFRs are a thriving business.)

The principles backing up BFRs are scientifically implausible, and even BFR-practitioners would probably admit that they have no scientifically defensible idea how their remedies work. Scientists might add that a mechanism of action of such highly dilute remedies is not just unknown but unknowable; there is no way to explain how they work without re-writing several laws of nature.

The overall situation is thus quite clear: BFRs are not effective and there is no plausible mechanism of action.Yet it is hard to deny that many patients feel better after having consulted a BFR-practitioner (or after self-medicating BFRs), and those satisfied customers often insist: “I don’t care how BFRs work, as long as they help me.”

As previously discussed, symptoms can improve for a range of reasons which are related to any specific therapeutic effect: the natural history of the condition, regression towards the mean, placebo-effects etc. Only rigorously controlled trials can tell us whether the therapy or other factors caused the clinical outcome; our perception alone cannot identify cause and effect.

The fact that thousands of patients swear by BFRs, does therefore not constitute proof for their efficacy. The explanation of the apparently different impressions from experience and the results of clinical trials is therefore simple: the empathetic encounter with a therapist and/or a placebo-effect and/or the natural history of the condition are perceived as helpful, while the BFRs are pure placebos.

Back to the notion “I don’t care how this therapy works, as long as it helps” – it turns out to be based on at least three misunderstandings all tightly woven together.

Firstly, it was not the treatment itself that helped, but something else (see above). To imply that the treatment worked is therefore a fallacy.

Secondly, the reference to an unknown mechanism of action is aimed at misleading the opponent: it distracts  from the first fallacy (“the treatment is effective”) by super-imposing a second fallacy (that there might be a mechanism of action). Crucially it attempts to wrong-foot the opponent by implying: “you reject something useful simply because you cannot explain it; this is poor logic and even worse ethics – shame on you!”.

BFR-enthusiasts are bound to see all this quite differently. They will probably claim that a placebo-effect is also a plausible mechanism. “Surely” they might say “this means that BFRs are useful and should be widely employed”.

In proclaiming this, they turn the double-fallacy into a triple fallacy. What they forget is that we do not need a placebo to generate placebo-effects. An effective treatment administered with time, compassion and empathy will, of course, also generate a placebo-effect – what is more, it would generate a specific therapeutic effect on top of it. Thus the BFR are quite useless in comparison. There is rarely a good justification for using placebos in clinical routine.

In conclusion, the often-used and seemingly reasonable sentence “I don’t care how it works, as long as it is helpful  turns out to be a package of fallacies when used to support the use of unproven treatments.

23 Responses to Three fallacies for the price of one!

  • I read this just this morning, which seems relevant…. about personal care budgets for the chronically ill. The paper seems to conclude that it doesn’t matter whether the treatment works or not, so long as the patients like it, and it is cheap…

    From the conclusion –

    “In recent years the increasing popularity of CAM interventions
    has been countered with a backlash from a movement which
    characterises CAM as lacking in credible evidence and which
    argues as a consequence that public monies should not be given to
    any interventions of this kind. This paper has argued for a different
    perspective on evidence.”

    http://www.personalhealthbudgets.dh.gov.uk/Topics/latest/Resource/?cid=8167&excludepageid=2289

    http://www.personalhealthbudgets.dh.gov.uk/_library/Resources/Personalhealthbudgets/2011/PHBs_a_new_way_of_accessing_complementary_therapies_Dec_10.pdf

    I found the phrase “a different perspective on evidence” rather scary.

    Ann

    • Ann

      Very scary indeed.

      I hope you noticed that paper’s argument for ‘choice’, ie allowing patients to choose whatever nonsense they want, at the taxpayer’s expense, of course? It’s worth repeating here in all its fallacious glory:

      There is a strong body of evidence, for example, that demonstrates that giving patients choice and control leads to better health outcomes and even greater longevity. In one study people living in care homes who were simply given a plant to look after lived significantly longer. A study of women undergoing surgery for breast cancer noted that those women given a choice of treatment, with the agreement of the surgeon, had less post operative depression than those whose surgeon insisted on either mastectomy or lumpectomy. In a large RCT, the effect of giving a choice of formats for a programme of heart disease management improved physical and psychosocial functioning.

      This, in a section titled The evidence debate.

      • Yes, the “choice” argument is often ideological nonsense, but here its use is especially maddening. One reason we rely on doctors is because we really aren’t qualified to make the choice.

        Of course the reasoning behind the idea is also back to front. It seems to go like this. Chronically ill patients use a lot of alternative therapies. Real treatment for them costs money and is not effective. Why not let them choose treatment that we know isn’t effective but is cheaper, because it’s always good for people to feel they are in control.

        The truth is chronically ill people are already spending money on these treatments that don’t do any good. To spend NHS money on it too…would actually reinforce the fallacious idea that the therapies are beneficial.

        • Indeed. It’s the false dichotomy it sets up by calling it the ‘effectiveness gap’ as if it’s a simple choice between treatments that might not appear to be working and a whole pile of unproven and disproven treatments. There may well be a point where treatments that have some good evidence behind them are not helping a particular patient and that might be called a dead end, but to imply it isn’t and it’s simply a gap that one has to step across to reach a wealth of alternative treatments, proven simply by looking at the evidence in a ‘different way’ that is mendacious. And it is this that leads inevitably to patients being misled.

          In using this phrase, I note the author cites a paper by one P Fisher:

          Fisher P, Van Haselen R. Effectiveness gaps in general practice: the potential of complementary medicine. Focus on Alternative and Complementary Therapies 2003;8.

          That’ll be Peter Fisher, Clinical Director and Director of Research at the Royal London Hospital for Integrated Medicine, of course.

        • People feeling a sense of control, getting a nice bit of ‘care’ – this seems to be the primary reason for the NHS’s provision of a range of psychosocial interventions for those with chronic conditions. Maybe we should cut back on all of this, but I’m not sure that I see patient vouchers for CAM as any less worthwhile than some of what is already being provided. Ideally patients would be well informed enough to spend any vouchers on a good book, or some quality head-phones, that might do more to improve their quality of life, but it’s hard to pretend that the NHS only provides treatments which are known to be effective at improving a patient’s health condition.

          “I don’t care how this therapy works, as long as it helps”

          This is a common refrain for psychosocial interventions. Combined with the difficulty of developing controls which will fully account for the placebo affect in behavioural RCTs, and a tendency to rely upon subjective outcome measures, it doesn’t inspire much faith.

          • Thank you Randal. Indeed – this fallacy is the rationale for the aggressive pushing of CBT/GET on patients to ‘cure’ or lead to ‘recovery’ of Myalgic Encephalomyelitis – also known as ‘Chronic Fatigue Syndrome’. Away from all the problems of the discrepancies in reporting so-called ‘cure’, ‘improvement’ or ‘recovery’, or the fact that psychogenic explanations themselves are often full of fallacious reasoning, this rationale of ‘it doesn’t matter how it works, it just does’ mirrors the CAM approach, and yet does not cause horror, even when patients report adverse effects of the ‘treatment’. And I say this NOT as a CAM advocate at all. It is a glaring inconsistency in those that wish to debunk CAM, but refuse to use their rational critical faculties on allopathic medicine (yes I use the term allopathic to conceptually separate it from CAM. I know to some people that makes me a tin-hat wearer, but those people are not thinking rationally). I wish Professor Ernst would practise his critical faculties on interrogating fallacies underlying psycho-social interventions. The obsession with debunking CAM while ignoring the glaring problems in institutionalised psycho-social therapies seems inappropriate.

          • CBT works, there’s a decent evidence base for it. Some people hate the fact that it works because it suggests that their condition might be mental not physical, as a sufferer of both depression and PTSD I think that is nonsense. PTSD is no less physically debilitating for having a primarily psychological cause.

            The problem with most alternatives to medicine is that they deliver the caring element in an amateur and deceitful way. Brien et. al. found that the effects of homeopathy on rheumatoid arthritis were due to the consultation, not the remedies, which is entirely consistent with the consensus view that the remedies are inert. They still seek to claim this as some sort of vindication of homeopathy, but any dispassionate observer will conclude that it would be better to send patients to a properly qualified counsellor rather than an amateur counsellor who pretends that magic sugar pills will cure you.

            There is nothing inherently wrong with helping patients to manage chronic symptoms through psychological coping strategies, and some parts of these chronic symptoms may indeed be psychological in nature and none the less real for it. As a very simple example, one of the chief symptoms of PTSD is insomnia, which is often not manageable even with medication. Getting that under control can have a profound effect on overall wellbeing.

  • What they forget is that we do not need a placebo to generate placebo-effects.

    Another thing that people forget (or perhaps simply don’t realise) is that the fact that a patient improved after being given a placebo (or a treatment that is no more effective than placebo) doesn’t actually mean that the improvement was caused by the placebo effect. It could have been spontaneous recovery, regression to the mean, the normal progress of the disease, or any of the other factors, other than the placebo effect, that are controlled for by a placebo control. Saying (as people often do) something along the lines of “even if [a particular form of CAM] has been found to work only as well as placebo, that still shows it works” is missing this point.

    • Thank you Mojo for this. You are right of course. The notion of a placebo effect is actually full of problems, yet is taken for granted. The failure to address these by those claiming authority to ‘debunk’ is another one of those inconsistencies and discrepancies in logic that is very frustrating, and impedes scientific progress in medicine.

  • in this context, it is relevant to mention what someone just sent me:”We recommend that if personal health budgets proceed beyond the pilot stage the Government should not allow patients to buy non-evidence-based treatments such as homeopathy with public money. (Paragraph 104)”…it comes from this document: http://www.homeowatch.org/policy/evidence_check_response.pdf

  • ANGELA: i am not debunking but advocating critical assessment of alt med. i focus on alt med because this is my area of expertise and was my job for 20 years. i do not believe in talking about things i do not fully understand. yes, critical thinking MUST be applied to all healthcare but this must be done by experts who are competent in their specific areas, don’t you think?

    • Edward,

      I am concerned that you may be making an appeal to privileging “insiders over outsiders” and possibly an irrational appeal to authority and ‘expertise in this comment. By your logic, if you are not an ‘expert’ in homeopathy (i.e. you haven’t trained in it), you should not be critically analysing homeopathy. Critical analysis of anything does not have to be limited to ‘experts’ only, and that’s before we get ourselves in a muddle trying to define ‘expertise’ in any one subject. Surely critical thinking is something you should be encouraging in as many people as possible?

  • I use to use BFR back in the day when I believed in such nonsense. I know why they made me feel better. The solution the supposed ingredient is in is grape alcohol. Gives a lovely buzz. However whisky is more honest and cheaper.

  • What about the role of individual faith? Suppose that for some reason, somebody has a deep unshakable faith in the efficacy of BFR:s. How much will this increase the placebo effect? Is it possible that for somebody and some condition, BFR might actually be the preferred treatment because of this effect?

    It sounds like this could be easily tested, e.g. by recruiting a group of “true believers” and a group who are more neutral about the treatment.

    • yes, expectation [orfaith, as you put it] seems to impact of the outcome. in fact, this is part of the placebo-effect. plenty of research on that.

  • In my experience, there is a widespread practice, particularly in the southern united states, of treating upper respiratory infections with antibiotics, often IM ceftriaxone or PO azithromycin and IM steroids. By my standards, and those of the American Academy of Otolaryngology-Head and Neck Surgery this practice is bad medicine. As a practitioner in the south I encountered many patients who would insist on this treatment for mild upper respiratory infections (colds). They had received such treatments before and their colds GOT BETTER! I had the literature on hand and would explain to patients that there was no need for such treatment and that it, in fact, would expose them to risks that were not necessary. Many patients left disappointed. In their eyes I was the quack because I was unwilling to prescribe the medicines that they had grown to depend upon, medicines that had worked so well for them in the past. In some ways, I can’t blame them, they had paid to receive my counsel and I was not giving them what they wanted. On the other hand, I was following the best recommendations based on the best available scientific evidence and practicing my craft in a way that would do my teachers proud. Many of my colleagues found it to hard to do what was right from a medical standpoint and loose their patients to the doc down the street. They would give the “sinus cocktail” knowing that it was unlikely to do anything useful but at least the patient would leave happy. Isn’t that perverted?!

    • It’s part of the bizarre and inconsistent thinking we see in medicine these days. People rail against “toxic chemicals” in carefully measured purified doses but happily consume equal toxic chemicals in unknown doses with undocumented impurities as long as they have a “natural” label; others insist on antibiotics to treat a virus. The problem is that health communication these days is so polluted with self-serving bullshit that there is little chance of sane and rational voices being heard.

  • I’m addressing Guy Chapman’s comments on CBT, in answer to my comments on ME/CFS and CBT (as for some reason I cannot respond directly under his comment):

    “CBT works, there’s a decent evidence base for it. Some people hate the fact that it works because it suggests that their condition might be mental not physical, as a sufferer of both depression and PTSD I think that is nonsense. PTSD is no less physically debilitating for having a primarily psychological cause.”

    Unfortunately, CBT’s evidence base for treating ME/CFS is poor. One recent trial – the PACE study, showed extremely poor results. There is also the problems of claiming ME/CFS is caused by psychological problems, which you are basically claiming in the above comment. ME/CFS is classified as a neurological disease by the World Health Organisation, NOT a psychological disorder similar to PTSD. In addition, PTSD does not have the physical impairment documented in ME/CFS, so to liken the two is incorrect. That is before we start considering the fallacies in reasoning inherent in psychogenic explanations for physical impairments, and their potential for iatrogenic harm.

    “There is nothing inherently wrong with helping patients to manage chronic symptoms through psychological coping strategies, and some parts of these chronic symptoms may indeed be psychological in nature and none the less real for it. As a very simple example, one of the chief symptoms of PTSD is insomnia, which is often not manageable even with medication. Getting that under control can have a profound effect on overall wellbeing.”

    CBT for ME/CFS is often NOT about psychological coping strategies, but about exhorting the patient to ‘reattribute’ their illness to psychological causes rather than physical causes. This is acknowledged even by its proponents, and has been rightly criticised by doctors knowledgeable about the disease, for example, Carruthers et al (2003).

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