MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Twenty years ago, I published a short article in the British Journal of Rheumatology. Its title was ALTERNATIVE MEDICINE, THE BABY AND THE BATH WATER. Reading it again today – especially in the light of the recent debate (with over 700 comments) on acupuncture – indicates to me that very little has since changed in the discussions about alternative medicine (AM). Does that mean we are going around in circles? Here is the (slightly abbreviated) article from 1995 for you to judge for yourself:

“Proponents of alternative medicine (AM) criticize the attempt of conducting RCTs because they view this is in analogy to ‘throwing out the baby with the bath water’. The argument usually goes as follows: the growing popularity of AM shows that individuals like it and, in some way, they benefit through using it. Therefore it is best to let them have it regardless of its objective effectiveness. Attempts to prove or disprove effectiveness may even be counterproductive. Should RCTs prove that a given intervention is not superior to a placebo, one might stop using it. This, in turn, would be to the disadvantage of the patient who, previous to rigorous research, has unquestionably been helped by the very remedy. Similar criticism merely states that AM is ‘so different, so subjective, so sensitive that it cannot be investigated in the same way as mainstream medicine’. Others see reasons to change the scientific (‘reductionist’) research paradigm into a broad ‘philosophical’ approach. Yet others reject the RCTs because they think that ‘this method assumes that every person has the same problems and there are similar causative factors’.

The example of acupuncture as a (popular) treatment for osteoarthritis, demonstrates the validity of such arguments and counter-arguments. A search of the world literature identified only two RCTs on the subject. When acupuncture was tested against no treatment, the experimental group of osteoarthritis sufferers reported a 23% decrease of pain, while the controls suffered a 12% increase. On the basis of this result, it might seem highly unethical to withhold acupuncture from pain-stricken patients—’if a patient feels better for whatever reason and there are no toxic side effects, then the patient should have the right to get help’.

But what about the placebo effect? It is notoriously difficult to find a placebo indistinguishable to acupuncture which would allow patient-blinded studies. Needling non-acupuncture points may be as close as one can get to an acceptable placebo. When patients with osteoarthritis were randomized into receiving either ‘real acupuncture or this type of sham acupuncture both sub-groups showed the same pain relief.

These findings (similar results have been published for other AMs) are compatible only with two explanations. Firstly acupuncture might be a powerful placebo. If this were true, we need to establish how safe acupuncture is (clearly it is not without potential harm); if the risk/benefit ratio is favourable and no specific, effective form of therapy exists one might still consider employing this form as a ‘placebo therapy’ for easing the pain of osteoarthritis sufferers. One would also feel motivated to research this powerful placebo and identify its characteristics or modalities with the aim of using the knowledge thus generated to help future patients.

Secondly, it could be the needling, regardless of acupuncture points and philosophy, that decreases pain. If this were true, we could henceforward use needling for pain relief—no special training in or equipment for acupuncture would be required, and costs would therefore be markedly reduced. In addition, this knowledge would lead us to further our understanding of basic mechanisms of pain reduction which, one day, might evolve into more effective analgesia. In any case the published research data, confusing as they often are, do not call for a change of paradigm; they only require more RCTs to solve the unanswered problems.

Conducting rigorous research is therefore by no means likely to ‘throw out the baby with the bath water’. The concept that such research could harm the patient is wrong and anti-scientific. To follow its implications would mean neglecting the ‘baby in the bath water’ until it suffers serious damage. To conduct proper research means attending the ‘baby’ and making sure that it is safe and well.

14 Responses to Alternative medicine, the baby and the bath water

  • Very little change indeed. The main issue I have is with the alternologists’ claim that their preferred modality cannot be tested because it is so personalised. That is clearly nonsensical. A patient either noticeably improves, or doesn’t. In a large enough trial, there are simply no valid reasons to assume that actual effects will not be detected, even when a black-box approach is followed.
     
    At he extreme end, a patient is either dead or not. It can’t be that hard for even the most uneducated alternologist to come to the same conclusion as a medical practitioner regarding the alive-or-dead status of a patient. When a patient is cremated, or a rotting corpse can be clearly seen, the patient must be dead, or does a patient really become alive when looked at by an alternologist, only to be dead when looked at by a doctor, only to become alive again when looked at by the alternologist and then dead once more when looked at by the doctor? It’s always possible, but I would need some serious convincing before I accept that.
     
    Of course, there are always the cases of Jesus and Elvis to contend with, but there must be a way around them too ^_^

    • At he extreme end, a patient is either dead or not. It can’t be that hard for even the most uneducated alternologist to come to the same conclusion as a medical practitioner regarding the alive-or-dead status of a patient.

      I expect that, with the aid of a little quantum flapdoodle, they can argue that they are both.

      • Could be ^_^ Like Kim Tinkham. I am sure she was “healed” and is “in a better place” now. Glory Alleluia.
         
        They do seem very good at disappearing those for whom their guaranteed miracles don’t work. Obviously, not keeping records has its advantages, especially for the quack.

  • ‘Real acupuncture’ v ‘sham acupuncture’… what an interesting concept. I thought real acupuncture WAS sham!

  • Conducting rigorous research is therefore by no means likely to ‘throw out the baby with the bath water’.

    If you want to avoid throwing babies out with the bathwater, the best thing to do is to check whether there actually is a baby in the bath.

    • To an alternologist, a single cell in a glass dish (or even a single electron in the case of homeopathy) _is_ their baby in the bathwater, therefore they feel justified in throwing tantrums whenever science throws their unsubstantiated baby-like ‘theories’ out with the bathwater.

      When we have a bath we are ridding ourselves of unwanted dead skin and bacteria. Alt-med is long overdue for having a bath because, currently, it really stinks!

  • The most logical explanation is that both acupuncture and sham acupuncture modulate pain in different ways, as fMRI and other neuroimaging studies suggest. The end result, however, is that both forms of acupuncture lead to pain relief of similar magnitude. This isn’t really surprising at all, given the power of the placebo effect to modulate pain perception.

    • @Critical Thinker,
      I’m not sure I understand you.
      ~
      You said, “The most logical explanation is that both acupuncture and sham acupuncture modulate pain in different ways, as fMRI and other neuroimaging studies suggest. The end result, however, is that both forms of acupuncture lead to pain relief of similar magnitude. This isn’t really surprising at all, given the power of the placebo effect to modulate pain perception.”
      How would both sham and “real” (whatever that means) acupuncture “modulate pain in different ways”? Given they are both placebos, how does one distinguish between placebo effects?

  • Placebo effect has its benefits. If you know how acupuncture works and you understand a few basic scientific principles all criticism can be proved wrong. I tried to to contact Prof. Ernst in this regard but with no success. I will be able to explain it to him.

    • pieter h j labuschagne said:

      Placebo effect has its benefits. If you know how acupuncture works and you understand a few basic scientific principles all criticism can be proved wrong. I tried to to contact Prof. Ernst in this regard but with no success. I will be able to explain it to him.

      Please explain it here so we can all benefit from your knowledge and wisdom.

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