MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The last time I had contact with Dr Fisher was when he fired me from the editorial board of his journal ‘Homeopathy’. He did that by sending me the following letter:

Dear Professor Ernst,

This is to inform you that you have been removed from the Editorial Board of Homeopathy.  The reason for this is the statement you published on your blog on Holocaust Memorial Day 2013 in which you smeared homeopathy and other forms of complementary medicine with a ‘guilt by association’ argument, associating them with the Nazis.

I should declare a personal interest….[Fisher goes on to tell a story which is personal and which I therefore omit]…  I mention this only because it highlights the absurdity of guilt by association arguments.

Sincerely

Peter Fisher Editor-in-Chief, Homeopathy

I did not expect to have any more dealings with him after this rather unpleasant encounter. But, as it turns out, I recently did have a further encounter.

When the BMJ invited me to write a debate article about the question whether homeopathy should continue to be available on the NHS, I accepted (with some reservations, I hasten to add). At the time, I did not know who would do the ‘other side’ of this debate. It turned out to be Peter Fisher, and our two articles have just been published.

As one would expect from a good journal, the articles were both peer reviewed. One of the peer-reviewers of my piece was most scathing of it essentially claiming that it was entirely worthless. Feeling that this was a bit harsh and very impolite, I was keen to see who this reviewer had been; it was none other than Andrew Vickers. This is remarkable because Vickers had not only published several homeopathic papers with Fisher, but also had been in the employment of the ‘Royal London Homeopathic Hospital’ under Fisher. To the best of my knowledge, his conflicts of interested had not been disclosed. I did point that out to the BMJ, but they seemed to think nothing of it.

Anyway, I was pleased to eventually (the whole procedure took many months) see the articles published, but at the same time somewhat irritated by Fisher’s piece. It contained plenty of misleading information that the peer-reviewers obviously had failed to correct. Here is a small sample from Fishers piece:

… recent overviews have had more favourable conclusions, including a health technology assessment commissioned by the Swiss federal government that concluded that homeopathy is “probably” effective for upper respiratory tract infections and allergies.

Readers interested in the clinical evidence can access the CORE-HOM database of clinical research in homeopathy free of charge (www.carstens-stiftung.de/core-hom). It includes 1117 clinical trials of homeopathy, of which about 300 are randomised controlled trials.

In the podcast that accompanies the articles Fisher insists that, on this database, there are well over 300 RCT, and I had to admit that this was new to me. Keen to learn more, I registered with the database and had a look. What I found startled me. True, the database does claim that almost 500 RCTs are available, but just a very superficial scrutiny of these studies reveals that

  • some are not truly randomised,
  • some are not even clinical trials,
  • the list includes dual publications, re-analyses of already published studies as well as aborted trials,
  • many have never been peer-reviewed,
  • many are not double-blind,
  • many are not placebo controlled,
  • the majority are of poor methodological quality.

As to the other thing mentioned in the above excerpt from Fisher’s article, the famous ‘health technology assessment commissioned by the Swiss federal government’, I can refer my readers to a blog post by J W Nienhuys which probably says it all, if not, there is plenty more criticism of this report available on the Internet.

My conclusion from all this?

THE QUEEN’S HOMEOPATH USES ARGUMENTS THAT SEEM JUST AS BOGUS AS HOMEOPATHY ITSELF.

24 Responses to Debating with the Queen’s homeopath

  • The problem is that papers about homeopathy tend to be reviewed by – guess who – other homeopaths. Journal editors don’t seem to find this odd.

    • Well to be fair, medical journals are reviewed generally by doctors or scientists. It’s not like we cite the lack of engineers peer reviewing cancer journal articles as a problem. The problem requires a step backwards and admitting that the real distinction is between how homeopaths and doctors/scientists view and assess evidence; it’s about homeopaths clothing themselves in the trappings and social signals of science without actually doing science. It’s about them bringing a “pseudo” to “science” but pretending they don’t.

    • The editors don’t find it odd because they have not stopped to think how many people are submitting papers claiming that the entire system of pharmacology is indeed valid because this new study proves that giving measurable doses of pharmacologically active compounds can cause objective effects in the human body.

      If, after 200 years, you have still failed to come up with a credible reason to think that your preferred form of treatment should work, or any remotely plausible mechanism, then writing papers that assume these things as base premises is probably all you can hope to achieve.

  • I recall Dr. Fisher appearing on the Horizon special about homoeopathy back in about 2003. He struck me then as a dishonest debater. He gave as his example of homoeopathic principles the fact that cutting an onion will make your eyes and nose run, and extrapolated from that to the conclusion that homoeopathic “allium cepa” was an effective treatment for colds and hay fever.

    To those of us familiar with the farrago of nonsense that is homoeopathic provings, this is absolutely risible. However, it served to give a veneer of rationality to a lay audience who might be prepared to swallow that but who would simply laugh in his face if he actually described provings of 30C remedies.

  • Seeing as guilt by association is an inverted form of the argument from authority, it’s quite ironic that the “Homeopath to the Queen” should be accusing others of it!

  • Carstens-stiftung? As in the Karl und Veronica Carstens-Stiftung, the foundation set up to promote homeopathy and other alternatives to medicine? So, no bias there, then.

    I am astonished that Dr. Fisher chose to lead with the Swiss HTA, given that its recommendation was to cease funding of homeopathy. Perhaps he was hoping nobody would notice.

    • But, Guy, didn’t you know that the whole “X Pharma paid for the study, so it cannot be trusted!” argument, so beloved of woosters various, doesn’t apply to honest up-standing promoters of a farrago of scientifically illiterate, ethically dubious nonsense…

      Presumably, in this instance, because the less truth and reason involved the more powerful their “arguments” become.

  • I have submitted the following response to the bmj article (not yet published):

    In his defence of homeopathy, Dr Fisher stated:

    “A meta-analysis published in the Lancet in 2005 concluded that there is “weak evidence for a specific effect of homeopathic remedies,” based on the results of just eight trials. Remarkably, this meta-analysis gave no hint of the
    identity of these eight trials, making informed discussion impossible.”

    I find this a very odd statement. Although Shang admitted it was an oversight not to identify which of the cited trials he had identified as having higher methodological quality in his original paper in The Lancet (dated 27 August 2005) [1], he did list them in the 17 December 2005 issue. [2] This was in his reply that answered criticisms that Dr Fisher and others made in the very same issue, including this oversight. So it would be completely wrong to give the impression that those eight trials remained forever unidentified and that discussion of Dr Shang’s results was somehow impeded.

    Dr Fisher also states:

    “Both these reviews are out of line with the other three systematic reviews and meta-analyses of homeopathy for all conditions published in the peer reviewed literature,8 9 10 all of which have come to essentially positive
    conclusions, as have several systematic reviews and meta-analyses for specific conditions.4 5 6 11” (Original reference numbers)

    Reference 8 (Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? Lancet 2005;366:2081-2.) was simply a letter about the Shang analysis so it’s not clear why Dr Fisher seems to refer to it as if it was a sys review or meta-analysis that supported homeopathy.

    It’s always worth reading the full papers, but for brevity, the full conclusions of 9 and 10 will suffice:

    Reference 9: Kleijnen J, Knipschild P, ter [sic] Riet G. Clinical trials of homoeopathy. BMJ 1991;302:316-23.

    “CONCLUSIONS: At the moment the evidence of clinical trials is positive but not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias.
    This indicates that there is a legitimate case for further evaluation of homoeopathy, but only by means of well performed trials.”

    Reference 10: Mathie RT, Lloyd SM, Legg LA, et al. Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Syst Rev 2014;3:142

    This paper has been criticised [3], but concluded:

    “CONCLUSIONS: Medicines prescribed in individualised homeopathy may have small, specific treatment effects. Findings are consistent with sub-group data available in a previous ‘global’ systematic review. The low or unclear overall
    quality of the evidence prompts caution in interpreting the findings. New high-quality RCT research is necessary to enable more decisive interpretation.”

    I find it difficult to understand how Dr Fisher could describe these as being “essentially positive conclusions” and it does raise the question of what high quality trials of homeopathy have been conducted since Kleijnen called for them in 1991.

    Dr Fisher goes on:

    “More recent overviews have had more favourable conclusions, including a health technology assessment commissioned by the Swiss federal government that concluded that homeopathy is “probably” effective for upper respiratory tract infections and allergies.12” (Original reference number)

    Although the authors of the publication described it as a ‘Health Technology Assessment’, this description had to be corrected by Dr Felix Gurtner of the Federal Office of Public Health FOPH, Health and Accident Insurance Directorate, Bern, Switzerland:

    “This review was declared to be an HTA by the authors (the final PEK report does not classify the literature reviews as HTA reports) and published later as a book under their responsibility without any consent of the Swiss government or administration. The book by Bonhöft and Matthiessen was later translated into English and published in 2012.” [4]

    The PEK said of the original Bonhöft report submitted top the PEK:

    “For all five assessments, it is very obvious that all or some of the authors have a positive attitude towards the treatments in question or are convinced about their efficacy. Unquestionably, strict proponents of the usual hierarchy of evidence will regard the presented evaluations as scientifically untenable and unreasonably positive (except for some specific aspects of phytotherapy). Even less skeptical academic doctors will regard many interpretations as very optimistic and not scientifically convincing.” [5]

    And the Swiss Government review panel:

    “The positive interpretation of the current evidence seems understandable, as long as one does not require especially high evidence standards, given the low plausibility of homeopathy in the light of established scientific knowledge. Very skeptical people will regard the reviewed evidence as not very convincing.” [5]

    It is also not entirely clear to me whether Dr Fisher realises that the Shang et al. analysis was part of this same Swiss evaluation of homeopathy.

    However, as a direct result of their assessment, the Swiss Government concluded that the evidence for homeopathy did not meet the required criteria and removed homeopathy from their state health reimbursement scheme.

    Overall, it is therefore difficult to understand Dr Fisher’s assessment of the evidence for homeopathy – and therefore his desire to see it integrated with conventional medicine – as anything more than wishful thinking.

    Alan Henness
    Director, The Nightingale Collaboration
    Challenging misleading healthcare claims

    References:

    1. Shang, Aijing, Karin Huwiler-Müntener, Linda Nartey, Peter Jüni, Stephan Dörig, Jonathan AC Sterne, Daniel Pewsner, and Matthias Egger. “Are the Clinical Effects of Homoeopathy Placebo Effects? Comparative Study of Placebo-Controlled Trials of Homoeopathy and Allopathy.” The Lancet 366, no. 9487 (August 2005): 726–32. doi:10.1016/S0140-6736(05)67177-2.

    2. Shang, Aijing, Peter Jüni, Jonathan AC Sterne, Karin Huwiler-Müntener, and Matthias Egger. “Are the Clinical Effects of Homoeopathy Placebo Effects? – Authors’ Reply.” The Lancet 366, no. 9503 (January 6, 2006): 2083–85. doi:10.1016/S0140-6736(05)67881-6.

    3. “HOMEOPATHY: Proof of Concept or Proof of Misconduct?” Edzard Ernst, December 29, 2014. http://edzardernst.com/2014/12/homeopaty-proof-of-concept-or-proof-of-misconduct/.

    4. Gurtner, F. “The Report ‘Homeopathy in Healthcare: Effectiveness, Appropriateness, Safety, Costs’ Is Not a ‘Swiss Report.’” Swiss Medical Weekly, December 17, 2012. doi:10.4414/smw.2012.13723.

    5. Henness, Alan, and Rudloff, Sven. “That ‘neutral’ Swiss Homeopathy Report | Zeno’s Blog,” May 9, 2012. http://www.zenosblog.com/2012/05/that-neutral-swiss-homeopathy-report/. (Translations by Sven Rudloff)

    • very well done!!! thanks

      • There was, of course, a lot more criticism that could be made of Fisher’s nonsense, but I though that was enough to be getting on with…

        It really is quite staggering that he trots out the same old tropes and zombie arguments. I expect that of your common-or-garden homeopathy enthusiast, but am I wrong to expect better from someone in his position?

        No, don’t answer that.

    • Robert Mathie replied to my comment, so I have just submitted this:

      The solution to Robert Mathie’s apparent dichotomy rests in comparing the evidence Dr Fisher cited with the claims he makes.

      I highlighted the conclusions of studies Dr Fisher chose to cite. Dr Fisher concluded these had ‘essentially positive conclusions’ but it’s difficult to see that as representing a fair and balanced view. Indeed, they simply raise the question as to what has happened following, for example, the calls for “well performed trials”, “New high-quality RCT research” and “The observations found in this study need to be confirmed by randomized clinical trials.” [Dr Fisher’s references 9, 10 & 15].

      However, it is left to readers to form their own view as to whether studies that, despite their flaws, are, at best, equivocal, are adequate substantiation for the claims espoused by Fisher:

      “When integrated with standard care homeopathy is safe, popular with patients, improves clinical outcomes without increasing costs, and reduces the use of potentially hazardous drugs, including antimicrobials.”

      As far as I can see, the only assertion that is justified by the evidence cited is that homeopathy is popular with patients.

      The more critical reader may find the evidence for the rest of his plea somewhat less than compelling particularly when Dr Fisher himself admits:

      “…the fact that one homeopathic treatment for a condition is ineffective doesn’t mean that another is ineffective.”

      The corollary of this must surely be that even if there was good evidence that homeopathy was effective for one condition, it doesn’t mean it’s therefore effective for any other.

  • Thank you for informing us of the CORE-HOM database. I followed your example and registered to take a look. It is a truly amazing database, with a beautiful user interface. It allows users to search its 1117 publications with a very flexible set of options. I set up a search for trials of any homeopathic remedy in any indication with a placebo control, randomized sequence generation, double-blind design, intention-to-treat analysis and ‘high’ ‘Shang’s quality’ — in other words trials done with the type of methodology regulatory bodies like the FDA normally require for registration of any new drug, and of a quality sufficient that a referee in a decent journal would not reject the paper outright. Precisely four of the 1117 trials met these criteria!
     
    Perhaps my requirements were too tough. By relaxing the requirement for intention-to-treat analysis — an issue that often generates controversy around clinical trials — the database now came up with 21 publications. In other words, by the database’s own criteria, very few indeed of its 1117 publications are double-blind, placebo-controlled trials done with any kind of quality.
     
    I was fascinated to see the detail of the four papers with intention-to-treat analysis: presumably the best evidence of the bunch. I could access only two of them, but found the abstract for a third, and conclusions from the fourth all on the database. I’m sure Prof. Ernst is already familiar with these, but as one who has never previously looked beyond systematic reviews of homeopathy, they came to me as an eye-opener.
     
    Jacobs et al (2001) studied homeopathy in acute otitis media. Result: “There were fewer treatment failures in the group receiving homeopathy after 5 days, 2 weeks and 6 weeks … but these differences were not statistically significant. Diary scores showed a significant decrease in symptoms at 24 and 64 h after treatment in favor of homeopathy (P < 0.05). Sample size calculations indicate that 243 children in each of 2 groups would be needed for significant results, based on 5-day failure rates. My italics: they had tested groups of 36 and 39.
     
    Chapman et al (1994) studied homeopathy for premenstrual syndrome. Results: “No significant differences in the blinded phase of the study; high placebo response. Patients rated 50% relief in 2/5 homeop. patients and 3/5 placebo patients.” They did a trial with ten patients?!
     
    Schmidt et al (2002) studied homeopathy for weight reduction in fasting, overweight subjects. Conclusion: “Patients receiving Thyroidinum had less weight reduction on day 2 after treatment than those receiving placebo. Yet, since no significant differences were found in other outcomes and since adjustment for baseline differences rendered the difference for the main outcome measure non-significant, this result must be interpreted with caution.” Allow me to assist the authors with their caution: their study demonstrates with perfect clarity that their homeopathic treatment was worthless. (They go on to say that by predefining the outcome in a different way they could demonstrate an effect, thus missing the entire scientific point of predefining how you’ll measure effects before you start the study.)
     
    Jawara at al (1997): homeopathy effects on delayed onset muscle soreness. [!] From the abstract: “Though the results of the trial favoured homoeopathy, differences between groups were small and did not reach statistical significance (p>0.2). A sub-group analysis of subjects who did not take vigorous exercise and who would therefore be expected to be more responsive to treatment showed clinically but not statistically significant differences between groups (p>0.2).”
     
    Professor Ernst, I have to admire your resilience in spending years reading this sort of stuff. These best four trials from the CORE-HOM database clearly illustrate what you and others have said about homeopathy a million times before: as the quality of the trial improves, the effect becomes less and less apparent. What concerns me most is the way the authors, publishing trials that clearly show zero effect from homeopathy, dissemble in their conclusions to suggest that another trial, or a less stringent re-analysis, will prove that homeopathy really is a potent and valid medical discipline. Bovine excrement!!

  • Having first heard about this “debate” (what’s next, an ESA aeronautial engineer “debates” a purveyor of flying carpets?) on ScIence Based Medicine’s blog, I have to ask: WHY did the BMJ commission this debate? Is the headline really a matter of urgency? How many GP’s are referring patients to homeopaths anyway? Perhaps the BMJ is hoping to stop those who do so, but if that is the case, then why not simply run an editorial with top notch references and emphasize the underlying implausibility of this quaint anachronism of medicine’s earlier days?

    Also, what is the point of peer review for a medical journal if the reviewers are not qualified? Would British Air allow the flying carpet salesman to rate a plane as fit for service?

  • Let’s see if this gets published:

    I suppose the ding-dong between believers and unbelievers in homeopathy will be of little interest to many, but I would like to propose a discussion which perhaps might be less sterile.

    It is this: for the partisans in this debate, what would cause you to doubt your present conclusions?

    Let me go first.

    I will revisit my views on homeopathy when some property of matter is demonstrated which persists through homeopathic dilution as normally practiced, is transferrable via the usual intermediary medium of a sugar pill, and can be objectively shown to arrive in some distinct and specific form (as in, provably different between starting materials) in the human body.

    I will not require that this property can be shown to exist in all matter, or even in all substances used in homeopathic preparations, only that it is objectively verifiable and sufficiently common to account for at least a meaningful proportion of claimed results.

    I will not require that it becomes stronger with additional dilutions, as most homeopaths claim, only that it is verifiably present in a dilution of at least 30C, being the most common I can find.

    I will not require that it be symptomatically linked to any condition, either as a cause or as a relief or cure of those symptoms, nor to any identified disease, pathogen or disease process.

    I will not even require that the effect is shown to be available systemically, only that there is some objectively verifiable change that is provably not due to contamination of the sample by the remedy itself.

    I would also revise my opinion if there was one study using a remedy in the normal range of potencies (again 30C would seem to be the benchmark) that convincingly refuted the null hypothesis, and this could be independently replicated.

    Note that by refuted I do not mean repudiated. The result has to be objectively verified as not consistent with any known prosaic explanation, including prior or concomitant treatment and any nonspecific effect. I would imagine that a trial that delivered an objectively tested result when using remedy A but not remedy B, fully blinded of course, Perhaps a crossover design would be preferred by homeopaths since they seem to believe that remedies are dependent on the individual.

    Neither of these should be terribly hard to do if the claims of believers are accurate. I have asked homeopaths a similar question before but the answers have been unsatisfactory, amounting to: I will cease to believe in homeopathy if I had not seen this particular miracle. That may be personally compelling as a conversion narrative but it is, as I hope we can all agree, not a helpful way of exploring the approach to evidence, which is what I am addressing here.

  • There is now an excellent comment by Claudina Michal-Teitelbaum that summarises the various arguments and highlights the many flaws and holes in the arguments of the homeopathy enthusiasts.

    Well worth reading.

  • Mmm, I just love the way this man is always referred to as ‘the Queen’s homeopath’. So what? If he was the homeopath to someone we had never heard of, would anyone take so much notice of him? Of course not.

    • ‘By Royal Appointment’ is a much sought after designation. I’m told it can boost income enormously.

      • Re: The Queen’s Homeopath

        I simply take that to mean that the Queen, whom I otherwise find to be a shining example of how to live well with dignity and decorum, to be a bit daft.

  • I’ve contributed a few further comments to the article and Ian Brassington, senior lecturer in Bioethics and Medical Law, has written a post on the bmj’s Journal of Medical Ethics blog about a comment by Karyse Day: On the other hand…. Ian teases apart Day’s ‘arguments’, laying them bare.

    I particularly liked his comparison between homeopathy and a carrot…

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