MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

“Wer heilt hat recht”. Every German knows this saying and far too many believe it. Literally translated, it means THE ONE WHO HEALS IS RIGHT, and indicates that, in health care, the proof of efficacy of a treatment is self-evident: if a clinician administers a treatment and the patient improves, she was right in prescribing it and the treatment must have been efficacious. The only English saying which is vaguely similar (but rarely used for therapies) is THE PROOF OF THE PUDDING IS IN THE EATING, translated into a medical context: the proof of the treatment is in the clinical outcome.

The saying is German but the sentiment behind it is amazingly widespread across the world, particularly the alternative one. If I had a fiver for each time a German journalist has asked me to comment on this ‘argument’ I could probably invite all my readers for a beer in the pub. The notion seems to be irresistibly appealing and journalists, consumers, patients, politicians etc. fall for it like flies. It is popular foremost as a counter-argument against scientists’ objections to homeopathy and similar placebo-treatments. If the homeopath cured her patient, then she and her treatments are evidently fine!

It is time, I think, that I scrutinise the argument and refute it once and for all.

The very first thing to note is that placebos never cure a condition. They might alleviate symptoms, but cure? No!

The next issue relates to causality. The saying assumes that the sole reason for the clinical outcome is the treatment. Yet, if a patient’s symptoms improve, the reason might have been the prescribed treatment, but this is just one of a multitude of different options, e.g.:

  • the placebo-effect
  • the regression towards the mean
  • the natural history of the condition
  • the Hawthorne effect
  • the compassion of the clinician
  • other treatments that might have been administered in parallel

Often it is a complex mixture of these and possibly other phenomena that is responsible and, unless we run a proper clinical trial, we cannot even guess the relative importance of each factor. To claim in such a messy situation that the treatment given by the clinician was the cause of the improvement, is ridiculously simplistic and overtly wrong.

But that is precisely what the saying WER HEILT HAT RECHT does. It assumes a simple mono-causal relationship that never exists in clinical settings. And, annoyingly, it somewhat arrogantly dismisses any scientific evidence by implying that the anecdotal observation is so much more accurate and relevant.

The true monstrosity of the saying can be easily disclosed with a little thought experiment. Let’s assume the saying is correct and we adopt it as a major axiom in health care. This would have all sorts of terrible consequences. For instance, any pharmaceutical company would be allowed to produce colourful placebos and sell them for a premium; they would only need to show that some patients do experience some relief after taking it. THE ONE WHO HEALS IS RIGHT!

The saying is a dangerously misleading platitude. That it happens to be German and that the Germans remain so frightfully fond of it disturbs me. That the notion, in one way or another, is deeply ingrained in the mind of charlatans across the world is worrying but hardly surprising – after all, it is said to have been coined by Samuel Hahnemann.

33 Responses to The worst platitude of them all?

  • Surely the only one who heals is the patient themselves?

  • Edzard, if we meet in a pub, I’m buying you a beer (but thanks for the generous thought!).
    This platitude actually reveals “the formation of superstition.” It’s why some people get attached to a “lucky” piece of clothing, shake dice in a particular way, etc. B.F. Skinner even found that pigeons will associate spinning in one direction with getting food from a random food machine, just because that was what they were doing before the pellet came out.
    Yes, it’s the causation/correlation confusion, the Post Hoc Ergo Propter Hoc (“it happened after therefore because of…”) fallacy.

  • Dr. Ernst….

    As an introduction — it is very easy to argue against a method, if you have decided that it is just placebo. Since Homeopathy is a placebo then all your arguments sound rational.

    Other researchers equally notable to you — pointing out their own work state that homeopathy is not an expensive placebo
    These are some examples
    http://www.ncbi.nlm.nih.gov/pubmed/12634583 , http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2805%2967878-6/fulltext

    Are these researchers delusional and you are correct? Maybe, all their measurements are wrong and biased..who knows?

    Besides that :Your argument against the saying that “The saying assumes that the sole reason for the clinical outcome is the treatment. ” should also apply to the mainstream medicine. Following your mode of thinking there is no way to accumulate enough evidence to show that a medication really works since the therapeutic effect might be due to other reasons as you said– even if there are controlled studies—– all the effects you described would be a crucial factor.

    Now, regarding the anecdotal evidence is BY DEFINITION weaker than a control study but it has a value -especially if it attracts as large number of people who claim they feel better. All the mainstream doctors who prescribe different medications to patients are aware of that ; and we know what the pharmaceutical companies say about their products : that they work ONLY for 45 percent of the patients – even if they have obtained a license based on placebo control studies.

    Therefore – even a placebo control trial or better a meta analysis of the trials is theoretically preferable – the anecdotal evidence might be also valuable \
    ——Example :recent studies found that anti-depressants are not more effective than exercise or other approaches – almost a placebo. If placebo control trials were the golden standard then the patients should gradually stop taking them. But doctors publicly warned their patients that they should NOT stop taking their medication— based on their experience that they ….work.

    • this post is NOT about homeopathy which was used merely as an example. it is about a popular but fallacious line of reasoning; and you have not convinced me that it is not fallacious.

      • Thiis fallacious line (it really is -according to any decent logician ) is part of the mainstream medical methodology that you always praise…as my example showed.
        L

        • “mainstream medical methodology”??? is there a non-mainstream one?

          • Why dont you try to answer the question which was :

            Is this fallacious line “Wer heilt hat recht” part of the methodology in modern medicine ?

            If it is not , why doctors tried to convinced patients to keep taking their anti depressants, based on their “experience” that they work. —–despite the fact that the meta analyses showed that they are placebos —–

          • I tried to make it quite clear that the fallacy is predominantly used by apologists of alternative medicine.
            why do doctors still use anti-depressants? I am not sure; it is not my area of expertise. perhaps because the meta-analysis [I think] you refer to was not entirely negative and there are others that show positive effects. in other words, the evidence is NOT clear-cut negative, wouldn’t you say?

    • It continues to amaze me that apologists for homoeopathy cite a letter that states that its authors “agree that homoeopathy is highly implausible and that the evidence from placebo-controlled trials is not robust” as evidence that they think homoeopathy works.

    • Sorry George: Jacobs’ work on childhood diarrhea is bogus.
      Those children suffered from diarrhea and dehydration. Two therapies were applied starting at the same time: homeopathy and WHO-rehydration. The big step occurred in both groups at day 1 in similar magnitude, so could not be attributed to homeopthy. After that, verum group actually recovers at the same speed, if not just a little more slowly than placebogroup, but had a slightly better start, which well could be a consequence of the mismatch of the groups in age and size. The only point in time when the difference in groups reached significance was at day 3, not before and not after.

      See fig 1 and table 2 in the study conducted in Nicaragua.
      http://amcofh.org/sites/default/files/Acute%20Care%20Class%201%20Research%20JJacobs.pdf

      Unfortunately Jacobs decided not to give the details of the patients’ progress in her further trials nor in her meta-analysis, but what can be seen frm the data, they look pretty similar.

      • I had not seen that…. Sorry, but i don’t know what is bogus here — your explanation > maybe…

        1. WHO-rehydration does NOT reduce the total duration of the symptoms – that was they were trying to measure –accurately.

        2. They have sophisticated ways of measuring these effects – saying a little bit or slightly is OK for the layman but researchers base their results on their EXACT measurements using statistical methods usually unavailable to people who have not study the subject so your objection : “just a little more slowly than placebogroup, but had a slightly better start, which well could be a consequence of the mismatch of the groups in age and size.” is kind of naive……..By this mode of thinking -for every trial with positive or negative outcome in any filed one could have been pointed out different undetected factors ( individual response to medication, weight, alcohol , smoking let alone ….fairies….) The meaning of a control trial is to eliminate the possibilities with precision and not to say –a little bit , not too much…

        3. The fact that this paper was published in a prestigious journal says something at least about the integrity of its design–even if one would be critical .to homeopathy..

        • What does the fact that, according to the AMA, the paper Norbert was discussing has, in the same journal, “been criticized for inconsistent/incorrect data analysis; use of different diagnostic and treatment categories but combining them in the conclusions of efficacy; and lack of chemical analysis of different treatments [and] The clinical significance of the results, given the self-limiting condition being studied, has been called into question” say?

        • Sorry for being late, but here I am. And sorry again for putting it in prose what is wrong with this studies, instead of taliking figures:

          So let me give you some data first:
          In the Nicaragua trial – for the others such data are not available – the fig 1 gives the following numbers of stools at day 1, day 2 etc.:

          Verum: 7.9 / 3.4 / 2.8 / 2.1 / 2.0 / 1.6
          Placebo: 7.5 / 4.0 / 3.7 / 3.1 / 2.2 / 2.2

          If the WHO-Treatment did not work at all, then please explain, where the improvement from 7.5 to 4.0 in the placebogroup on day 1 did come from.

          Please be assured, I am somewhat familiar with maths and statistics. If you evaluate the linear regression for day 2 to day 6, the decrease for placebo is 0.51 per day, for verum 0.44 per day only. Please let me have your interpretation of this.

          All the results claimed statistically significant are significant only, if you start out with the groups being independent – what they never have been from the start on. Group #2 contains what is not in group #1. So the main criterion of two independent groups – both standing the chance of having the same properties – does not apply. This reduces the significance of the Nepal result like any other from p = 0.036 to p = 0.25.

          If you feel, that this is a wrong idea, then please explain how the age of the children was affected by the drug (p = 0.03).

          If an article like this was published in a prestigious magazine, it gets you wondering …

          • (Firstly, keep in mind that since you don’t have the data for the later study you cannot conclude it is the same with the later one. )

            Before I answer your questions

            1. how much difference of linear regression between and controls and verum is generally acceptable to denote something significant?

            2. What do you mean “Group #2 contains what is not in group #1” and how this makes the group not independent?

            3. So the main criterion of two independent groups – both standing the chance of having the same properties – does not apply – can you elaborate ?

            4.. how the age of the children was affected by the drug (p = 0.03). – I dont geet this – can you explain?

            thanks

      • This is an earlier study..

        .”Seems to be the same” ..”.might be something else” “not a lot” “a little bit” , “not so much” are not used in research — by the way..

        .in coffee shops maybe………….

        • .”Seems to be the same” ..”.might be something else” “not a lot” “a little bit” , “not so much” are not used in research — by the way..

          .in coffee shops maybe………….

          Where did you get these quotations from? Of the five, only one had appeared anywhere else in this thread, and that was in one of your own posts.

          It’s always best to address arguments that people have actually made. Making up quotations to attack makes you look dishonest.

        • This is an earlier study..

          Yes, but it is one of the three trials, by the same lead author, that form the basis the analysis you cite. Can you address what Norbert says about the later studies? He says that for this earlier study examination of the data about the patients’ progress shows flaws in the study (see also Sampson W, London W. (1995) Analysis of homeopathic treatment of childhood diarrhea. Pediatrics. 1995;96:961-964), but he also says that the later studies didn’t provide the same sort of data, so the same issues cannot be eliminated for the later studies. Can you address this?

  • Edzard, I wholeheartedly agree with your assessment that patient outcome is related to a multitude of different factors which often operate in concert. I despair at the vast number of my Chiropractic colleagues who still delude themselves and their patients regarding this important issue!

  • Dr. Ernst ,
    The latest and larger meta analysis was clear that anti depressants = placebo for mild depression. Furthermore no meta analysis is clear cut negative and very often their findings conflict- see meta analyses in homeopathy , for instance
    But the main point here is that medical community used the line you present as fallacious to defend anti depresents – they said ” look how many people take them and feel good”- so keep taking them..

    The same line is used by the vaccine industry to defend vaccines – When a study points out side effects – they say forget about the trials (which ar small and many times probematic as you know )—-look how many people they take them and they are healthy ..

    It is the same mode of thinking you say it is fallacious ….and you don’t object to it….

    • @George
      I fail to see your point. Not that evasive tactics are not applied by the pharmaceutical industry and not that they never cheat on trials or invent diseases only the can sell a cure for… And frankly, I’m not too sure that every vaccine out there is actually necessary, at least for the general public. Vaccines in general however have proven to be very effective and they have impressive data to prove that claim. Smallpox – eradicated. Polio – practically non existent, except those corners of the world where the vaccination programs didn’t reach. Measles – the number of cases significantly lower, including the number of deaths. They could be eradicated if only incredibly stupid parents gave up their ideological/religious resistance against having their children vaccinated. As small as the side effects may be, and they are negligible in comparison to the effects of a measles infection, the children a generation or two from now could be spared even that small risk for the disease would be extinct.

      • Well….
        the vaccines industry was an example – we can talk about it later but ….

        The point here is : “The one who heals is right” line which is presented as fallacious when used in alternative Medicine is actually a common mode of thinking in conventional medicine…

        As I asked before – why someone does not object to the evidence which is not supported by placebo control trials but by the “experience” of various MD – see anti depressants case..and it s/he does objects to the same mode of thinking in alternative medicine ?..This is not rational – that’s all I m asking..Read above and you will understand my objection…

        • but lots of people DO object, and that despite the evidence not being as clear-cut as you seem to think.
          that’s the thing: in conventional medicine there is plenty of criticism and constant development as a result. in alternative medicine, there is neither.

          • Then you should include to your criticism to the fallacious line and the parts of convectional medicine which follow it : vaccines, anti depressants, and many other mediations which are described based on experience of the doctors and customer satisfaction data.

            I always praised the part of your criticism to the alternative medicine when it is rational – I think it is a great service.

          • vaccines, anti-depressants etc. are based on much more than experience or customer satisfaction data.

  • The saying itself is not fallacious. The way it is generally used is.
    We should take it at face value – which would automatically turn it against those who so often use it. If someone throws this saying at me in an occasional discussion I throw it back at them by simply asking: Then prove to me any actual healing (or curing) has been done. Which to the day no one ever could – not even to me, the medical layman who would certainly be convinced more easily than a doctor.
    Or, wait, forget the last comparison. Unfortunately an ever increasing number of doctors in Austria offer alt-med-“services”, right down to the most bizarre methods and approaches like “quantum healing” compared to which even homoepathy seems somewhat rational. And there’s hardly a pharmacy that does not advertise having some alternative “remedies” in stock. However, if one asks them for scientific prove about the efficacy all one gets to hear is long stories about how bad the pharmaceutical industry is and how cold and inhumane science in general. Magical thinking seems to be the ideology of our time. How sad.
    This having been said, I really want to thank Edzard Ernst for his work in general and this blog in particular. Not only is this a very important source for critical thinkers of all sorts, including the medical layman, it is also an encouragement not to give up the fight against superstition and charlatanerie.

  • They have no evidence that they work in mild depression – and yet they advise patients to keep taking them based on what? They even say
    “It was not a randomized controlled trial (RCT) in and of itself, which is the “gold standard” for scientific research; it was, basically, a book report. ” they call a” book” report the meta analysis which showed that they are NOT superior to placebo. —– http://www.doctorslounge.com/index.php/articles/page/152

    Would you forgive the above statement to an alternative medicine therapist? let me guess –NO…

    Much to your surprise, I might say that the pro anti depressants MDs might be correct ( in terms of efficasy not of the terrible side effects ) : reviews in every medical field many times conflict – the same in the alternative medicine ( depending of course on the method and the depth that has been investigated) —it might show positive, negative, inconclusive.

    So the “Wer heilt hat recht” line includes VERY OFTEN conventional medicine practices in my opinion..and maybe even the line is fallacious in Logic —— it is the only available approach.

    • even if you were correct, that would not mean that we should not attack fallacious thinking in alternative medicine!
      I write within my area of expertise and leave it to others to deal with theirs.

  • ‘He who heals is right’ is kind of a stub. How does ‘He’ know, it was him, that healed? The sentence stops to be fallacious if it is prolonged by six words:

    ‘He who heals is right – if he can prove he heals’.

  • Proof in terms of logic equals detection of mechanisms of action , not of course of accumulation of evidence …this is a common misconception ..

    This is problem in conventional medicine and mediations as well….. And you know that the evidence for many medications approved every year – is not really supported properly even in placebo trials…

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