MD, PhD, FMedSci, FSB, FRCP, FRCPEd

“Conflicts of interest should always be disclosed.”

This is what I wrote in the ‘RULES’ of this blog when I first started it almost 4 years ago. Sadly, very few people writing comments observe this rule. Perhaps, I just thought, I did not observe it either? So, here are my conflicts of interest: none.

Not true!!! I hear some people say. But it is!

I have no financial interest in any ‘Big Pharma’ or  ‘TINY CAM’, and I get not a penny for writing this blog.

How do I pay for my living? Mind your own business… well, on second thought, even that must not be a secret: I get a small pension and have some savings.

Still not convinced?

Perhaps it’s time to define what ‘conflicts of interests’ are. According to Wikipedia, they can be defined as  situations in which a person or organization is involved in multiple interests, financial interest, or otherwise, one of which could possibly corrupt the motivation of the individual or organization.

So, not having financial benefits from my current work does not necessarily mean that I have no conflicts of interest. The above definitions vaguely mentions ‘or otherwise’ – and that could be important. What could this mean in the context of this blog?

Well, I might have very strong beliefs, for instance (for instance, very strong beliefs that acupuncture is by definition nonsense [see below]). We all know that strong beliefs can corrupt motivation (and a lot more). And if I ask myself, do you have strong beliefs?, I have to say: Yes, absolutely!

I believe that:

  • good evidence is a prerequisite for progress in healthcare,
  • good evidence must be established by rigorous research,
  • we should not tolerate double standards in healthcare,
  • patients deserve to be treated with the best available treatments,
  • making therapeutic claims that are not supported by sound evidence is wrong.

These strong beliefs might make me biased in the eyes of many who comment on this blog. In Particular, we recently had a bunch of acupuncturists who went on the rampage attacking me personally the best they could. However, a rational analysis of my beliefs can hardly produce evidence for bias against anything other than the promotion of unproven therapies to the unsuspecting public.

The above mentioned acupuncturists seem to think that I have always been against acupuncture for the sake of being against acupuncture. However, this is not true. The proof for this statement is very simple: I have published quite a bit of articles that concluded positively – even (WOULD YOU BELIEVE IT?) about acupuncture for back pain! A prominently published meta-analysis of 2005 (with me as senior author) concluded:  “Acupuncture effectively relieves chronic low back pain.” (This of course was 11 years ago when the evidence was, in fact, positive; today, this seems to have changed – just like the NICE guidelines [probably not a coincidence!])

Conflicts of interest? No, not on my side, I think.

But what about the ‘other side’?

The unruly horde of acupuncturists (no, this is not an ad hominem attack, it’s a fact) who recently made dozens of ad hominem attacks against me, what about them?

  • They earn their money with acupuncture.
  • They have invested in acupuncture training often for long periods of time.
  • They have invested in practice equipment etc.
  • Some of them sell books on acupuncture.
  • Others run courses.
  • And all of them very clearly and demonstrably  have strong beliefs about acupuncture.

I think the latter point constitutes by far the most important conflict of interest in this context.

And this is where the somewhat trivial story has an unexpected twist and gets truly bizarre:

I have just leant that the same group of conflicted acupuncturists are now planning to publicly attack the panel of experts responsible for drafting the NICE guidelines. The reason? They feel that this panel had significant conflicts of interest that led them to come out against acupuncture.

Perhaps I should mention that I was not a member of this group, but I suspect that some of its members might have links to the pharmaceutical industry. It is almost impossible to find top experts in any area of medicine who do not have such links. You either gather experts with potential conflicts of interest, or you get non-experts without them. Would that bias them against acupuncture or any other alternative therapy? I very much doubt it.

What I do not doubt for a minute is that conflicts of interest are of major importance in these discussions. And by that I mean the more than obvious (but nevertheless undeclared) conflicts of interest of the acupuncturists. It seems that those with the strongest conflicts of interest shout the loudest about the non-existent or irrelevant conflict of interest of those who do not happen to share their quasi-religious belief in acupuncture.

21 Responses to Conflicts of interest?…the recent example of UK acupuncturists

  • If there is not a conflict, why do you not assess the publications on the website

    http://www.palmer.academia.edu/JensAndersKjersem

    The are based on research of chiropractic physician with 47 years of clinnical experience.

    These publications hit both right and left, but are honest.

    • the short answer is: precisely because I am not biased!
      I do not search sites of interest groups [chiros, pharma, acupuncture etc.] but I go on medline, if I look for newly published articles. and there I make a selection according to what I find interesting [if I don’t find something interesting, I see no point in writing about it]

    • @ Jens Anders Kjersem on Wednesday 25 May 2016 at 09:36

      It seems you are a graduate of Palmer College of Nonsense, where subluxations are still taught as the cause of human ails, ” Improper function of the spine due to slight misalignments-called subluxations-can cause poor health or function, even in areas far removed from the spine and spinal cord itself.” http://www.palmer.edu/about-us/what-is-chiropractic/

      Why would anyone consider you credible when many chiro bodies have discarded subluxation nonsense. Alternatively, why would anyone consider papers from Palmer as having a shred of credibility?

    • I’ve pointed this same problem out to homeopathists, but it applies to chiropractors too – the Palmer folks have an inherent conflict.

      A researcher in the field of medicine does not normally rely for their income on promoting the idea that surgery, pharmaceuticals and so on can have objectively testable effects on human physiology. There is no realistic dispute about these things. Nobody has to publish studies asserting that maybe medicines work because of some implausible conjecture – we know that giving someone a measurable dose of a substance with testable pharmacological properties, will do *something*, even if we’re not always clear exactly what.

      Chiropractors and other promoters of treatments based on arm-waving references to “energy” of various types, do have an inherent conflict of interest, in that they must, for the sake of their livelihood, promote the idea that such energies exist. No chiropractor can write a study claiming to validate the chiropractic subluxation without an inherent conflict of interest. A pharmacoloist would also have a conflict if promoting the idea that drugs can affect the body, but nobody is doing that because it is accepted fact which is demonstrable by people outside the field of pharmacology.

    • @Jens Anders Kjersem
      Interesting.
      Where have you published your research findings? I cannot find anything neither in the main databases of research publications e.g. Pubmed or Researchgate nor in Linkedin or via Google etc.
      The link you give only lists essays and books which at a somewhat superficial glance do not contain any research, only lengthy, speculative passages of what seem to be your personal observations and conjectures. In effect anecdotes from which you seem to draw conclusions that often fly in the face of established knowledge without trying to substantiate them.
      The only thing I stumbled upon that in some way might (to the layman that is) resemble a study report is in one of your books with the grand title: “Proving Chiropractic” where you describe the results of a survey that you seem to believe demonstrates evidence of how chiropractic works. Alas the document I could procure is only a scanned fascimile (image) so I cannot copy and paste it here but it can be taken part of here. The pertinent passage is a bulleted item listing on page 47.
      A survey is not a useful or valid research instrument for hypothesis testing and reporting it in the approximative way you do there precludes any evaluation of the results. For example it starts with these words: ” About 100 percent of all patients leaving the clinic after a chiropractic manipulative treatment session did so with a perfectly horizontal TICL”
      (TICL = Transverse Iliac Crest Line)
      This stands in stark contrast to the millimetric thoroughness you apply to the measurment of limb lengths.

      Another item that struck my interest is on page 55 in the same book. There you go on at length about “TICL” what seems to be your favourite measure of postural imbalance as I believe you call it, right?
      On page 55 you say in a bulleted paragraph: “The TICL keeps the same divergence after the ‘short’ leg has been increased in length by 5 millimetres”
      I have two questions in this regard:
      The first is how do you go about lengthening a leg by 5mm?
      In my formative years as a surgeon I helped an orthopedic surgeon with several leg lengthening procedures. It was a tedious, difficult process involving special osteotomy operations and slowly over weeks pulling apart the separated bones which were secured in a special frame named after Ilisarov, a Russian surgeon – an undertaking not free of problems and side effects. The slow pace is necessary so the soft tissues, especially the nerves had a chance to elongate.
      If you have a simpler method of lengthening bone by such any significant extent then you should share it with the world. Many would be thankful if it proves effective and safe. Might even bring you fame and fortune.
      The other question is how you measure leg length with such exactness? Do you perfrom standardised x-ray studies or do you rely on your spirit level instrument that you seem to use extensively. What is the margin of error in such measurements. One would think it was more than half a centimetre?

  • Edzard said:

    Perhaps I should mention that I was not a member of this group, but I suspect that some of its members might have links to the pharmaceutical industry. It is almost impossible to find top experts in any area of medicine who do not have such links. You either gather experts with potential conflicts of interest, or you get non-experts without them. Would that bias them against acupuncture or any other alternative therapy? I very much doubt it

    The problem is that acupuncturists will only want fellow acupuncturists on the NICE group so they can ‘properly’ evaluate the evidence… Their cognitive dissonance is total.

  • Professor Ernst,

    When the NICE Guidelines Draft was published, you gave an expert opinion to the Guardian and published a blog post publicising the removal of acupuncture, agreeing with the conclusions. When it was pointed out to you that there were serious data errors in the forest plots that led to erroneous conclusions and that there were fundamental flaws in the methods of the development of the guidelines, you essentially said that you did not want to look into it but would rather wait until the new guidelines came out in September.

    When repeatedly asked to justify your agreement with the analysis and conclusions of these seriously flawed guidelines, you have repeated your fervent desire to refrain from comment until September and insisted that you have “the right to remain silent.”

    Even you must see how ludicrous this post is. You have the option of commenting on the actual substance of the guidelines and the analysis, which you have repeatedly expressed no desire to do. Yay science!!

    You could remain silent, as you said mere hours ago that you wished to do, and yet here you are. Why you are now writing a yet another post with more uninformed commentary on the NICE guidelines development process is truly puzzling to consider.

    There is nothing bizarre about anyone pointing out that the chair of the GDG is in direct violation of NICEs published conflict of interest policy. He is. That doesn’t mean that acupuncture works or that it doesn’t work. It just means that he doesn’t meet the criteria to be chair of the committee. Do you agree? Or do you need to wait until September to comment?

    • “When it was pointed out to you that there were serious data errors in the forest plots that led to erroneous conclusions and that there were fundamental flaws in the methods of the development of the guidelines…” This is all IN THE OPINION OF ACUPUNCTURISTS and has not been confirmed by NICE. do you not think it is fair to wait for their response? I do! and you can do very little about it. so you might as well stop wingeing.

      • Dear Professor Ernst,

        Following your lesson in ad hominem attacks, saying that the data errors are the “opinion of acupuncturists,” which is pointing to motivation rather than the argument itself is again, classic ad hominem and hypocritical when the document is sitting on servers freely downloadable as we speak for you and your “systematic review superpowers” to dig into. It certainly is the opinion of acupuncturists, as well as professors, doctors, and researchers of any type who have read the guidelines and are blessed with the dual gifts of literacy and numeracy that there are data errors that when corrected, change the outcomes of the forest plots. Thanks for bringing it up again.

        “do you not think it is fair to wait for their response? I do! and you can do very little about it. so you might as well stop winging.”

        No, you misunderstand, I’m not “winging” at all. I’m grateful to you! You continue to publicly and authoritatively discuss a document that by your own admission are completely unfamiliar with and have no desire to familiarise yourself with while simultaneously lecturing on bias, conflict of interest, research methods and the document itself. It’s marvelous, bless you! Keep up the stellar work!

        • I think there is reason for being cautious here:
          if you interpret my statement of “opinion of acupuncturists” as an ‘ad hominem’, how much misinterpretation would you be capable of when it comes to the data in the NICE guideline, I wonder. [unless wondering about such things is also an ‘ad hominem’, of course]

          • “unless wondering about such things is also an ‘ad hominem’, of course.” Oh no, not at all. Wondering about that just means that you don’t understand what ad hominem means. And yet you just wrote an entire post about it . . . Looks like you found your niche.

            You wrote “This is all IN THE OPINION OF ACUPUNCTURISTS” in direct to response to my point that the guidelines contain data errors, a comment that is easily refutable if incorrect. Your counter argument had nothing to do with refuting the substance of the comment, but rather questioned the motivations of the commenters. That is textbook ad hominem.

          • not quite!
            I stated: “This is all IN THE OPINION OF ACUPUNCTURISTS and has not been confirmed by NICE. do you not think it is fair to wait for their response? I do! and you can do very little about it. so you might as well stop winging.”
            I still think it is fair to wait what NICE say, don’t you?
            and I think quoting people out of context is not quite right, don’t you?

      • I guess that kind of response is the reason that your Professorship was in Complementary Medicine, rather than in a real subject. Do real Professors look down on you at parties?

  • Dear Dr. Ernst:

    Your work, and your blog is very much appreciated! May I take the liberty of suggesting a small language change that I humbly suggest might have educational value:

    My suggestion is to drop the word “beliefs” (as in “I have strong beliefs…”) and substitute the word “principles.”

    “Beliefs” has connotations of faith in dogmas — while “principles” is more indicative of links to logic, reason, and ethics.

    Best regards,

    Jim Whitehead.

    • Technically even science is predicated on a human belief: the belief that the universe does not lie. (Though as Einstein and others do note it certainly does a tricky sleight of hand.)

      So I’m happy with Dr Ernst’s choice of words: it reminds us that we’re all Human, and not some of us Vulcans; thus there is both hope and caution for all too, Altie and Skeptic alike.

  • So, not having financial benefits from my current work does not necessarily mean that I have no conflicts of interest. The above definitions vaguely mentions ‘or otherwise’ – and that could be important. What could this mean in the context of this blog?

    Well, I might have very strong beliefs, for instance (for instance, very strong beliefs that acupuncture is by definition nonsense [see below]). We all know that strong beliefs can corrupt motivation (and a lot more). And if I ask myself, do you have strong beliefs?, I have to say: Yes, absolutely! I believe that:

    * good evidence is a prerequisite for progress in healthcare,
    * good evidence must be established by rigorous research,
    * we should not tolerate double standards in healthcare,
    * patients deserve to be treated with the best available treatments,
    * making therapeutic claims that are not supported by sound evidence is wrong.

    Hey, everyone’s biased. The first step towards neutralizing that bias is accepting and acknowledging that you have it, and exactly why that is.

    Show me a sCAMmer who can enumerate her own personal motivations in a way that isn’t flat-out religious protelyzation and outrageous sales pitch, and I strong suspect she already won’t be a sCAMmer for much longer, as such a pitch change would mean she’s already caught the personal introspection and self-questioning that ultimately drives her toward the same unflinching self-criticism and unceasing self-correction that Dr Ernst, Britt Hermes, and other despised, blasted apostates of CAM religion have painfully but admirably undertaken before her.

    It is incredibly easy never to be wrong: either by astonishing good fortune or, far more commonly, simply denying point-blank that you ever are. Far, far harder to look deep into your soul and accept and admit that you are wrong – not just to others but you yourself most of all. (Heck, even religion itself occasionally gets this.) And an even more laudable undertaking to work towards correcting those mistakes, not only for your own personal wellbeing but the betterment of others as well.

    I suspect most of us skeptics have trudged at least some part of that road ourselves, so come on CAMsters, if you really are so certain you hold All The Right Answers: why so utterly unwilling even to set a toe on it yourselves?

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