This post will probably work best, if you have read the previous one describing how the parallel universe of acupuncture research insists on going in circles in order to avoid admitting that their treatment might not be as effective as they pretend. The way they achieve this is fairly simple: they conduct trials that are designed in such a way that they cannot possibly produce a negative result.
A brand-new investigation which was recently vociferously touted via press releases etc. as a major advance in proving the effectiveness of acupuncture is an excellent case in point. According to its authors, the aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. This sounds alright, but wait!
755 patients with depression were randomised to one of three arms to 1)acupuncture, 2)counselling, and 3)usual care alone. The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of 10 sessions for acupuncture and 9 sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 and 12 months for acupuncture and counselling.
From this, the authors conclude that both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone.
Acupuncture for depression? Really? Our own systematic review with co-authors who are the most ardent apologists of acupuncture I have come across showed that the evidence is inconsistent on whether manual acupuncture is superior to sham… Therefore, I thought it might be a good idea to have a closer look at this new study.
One needs to search this article very closely indeed to find out that the authors did not actually evaluate acupuncture versus usual care and counselling versus usual care at all, and that comparisons were not made between acupuncture, counselling, and usual care (hints like the use of the word “alone” are all we get to guess that the authors’ text is outrageously misleading). Not even the methods section informs us what really happened in this trial. You find this hard to believe? Here is the unabbreviated part of the article that describes the interventions applied:
Patients allocated to the acupuncture and counselling groups were offered up to 12 sessions usually on a weekly basis. Participating acupuncturists were registered with the British Acupuncture Council with at least 3 years post-qualification experience. An acupuncture treatment protocol was developed and subsequently refined in consultation with participating acupuncturists. It allowed for customised treatments within a standardised theory-driven framework. Counselling was provided by members of the British Association for Counselling and Psychotherapy who were accredited or were eligible for accreditation having completed 400 supervised hours post-qualification. A manualised protocol, using a humanistic approach, was based on competences independently developed for Skills for Health. Practitioners recorded in logbooks the number and length of sessions, treatment provided, and adverse events. Further details of the two interventions are presented in Tables S2 and S3. Usual care, both NHS and private, was available according to need and monitored for all patients in all three groups for the purposes of comparison.
It is only in the results tables that we can determine what treatments were actually given; and these were:
1) Acupuncture PLUS usual care (i.e. medication)
2) Counselling PLUS usual care
3) Usual care
Its almost a ‘no-brainer’ that, if you compare A+B to B (or in this three-armed study A+B vs C+B vs B), you find that the former is more than the latter – unless A is a negative, of course. As acupuncture has significant placebo-effects, it never can be a negative, and thus this trial is an entirely foregone conclusion. As, in alternative medicine, one seems to need experimental proof even for ‘no-brainers’, we have some time ago demonstrated that this common sense theory is correct by conducting a systematic review of all acupuncture trials with such a design. We concluded that the ‘A + B versus B’ design is prone to false positive results…What makes this whole thing even worse is the fact that I once presented our review in a lecture where the lead author of the new trial was in the audience; so there can be no excuse of not being aware of the ‘no-brainer’.
Some might argue that this is a pragmatic trial, that it would have been unethical to not give anti-depressants to depressed patients and that therefore it was not possible to design this study differently. However, none of these arguments are convincing, if you analyse them closely (I might leave that to the comment section, if there is interest in such aspects). At the very minimum, the authors should have explained in full detail what interventions were given; and that means disclosing these essentials even in the abstract (and press release) – the part of the publication that is most widely read and quoted.
It is arguably unethical to ask patients’ co-operation, use research funds etc. for a study, the results of which were known even before the first patient had been recruited. And it is surely dishonest to hide the true nature of the design so very sneakily in the final report.
In my view, this trial begs at least 5 questions:
1) How on earth did it pass the peer review process of one of the most highly reputed medical journals?
2) How did the protocol get ethics approval?
3) How did it get funding?
4) Does the scientific community really allow itself to be fooled by such pseudo-research?
5) What do I do to not get depressed by studies of acupuncture for depression?
Many reader of this blog will remember the libel case of the British Chiropractic Association (BCA) against Simon Singh. Simon had disclosed in a Guardian comment that the BCA was happily promoting bogus chiropractic treatments for 6 paediatric conditions, including infant colic. The BCA not only lost the case but the affair almost destroyed this strange organisation and resulted in an enormous reputational damage of chiropractors worldwide. In an article entitled AFTER THE STORM, the then-president of the BCA later described the defeat in his own words: “in 2009, events in the UK took a turn which was to consume the British Chiropractic Association (BCA) for two years and force the wider profession to confront key issues that for decades had kept it distanced from its medical counterparts and attracting ridicule from its critics…the BCA began one of the darkest periods in its history; one that was ultimately to cost it financially, reputationally and politically…The GCC itself was in an unprecedented situation. Faced with a 1500% rise in complaints, Investigating Committees were assembled to determine whether there was a case to answer…The events of the past two years have exposed a blind adherence to outdated principles amongst a small but significant minority of the profession. Mindful of the adage that it’s the squeaky wheel that gets the grease, the vocalism of this group has ensured that chiropractic is characterised by its critics as unscientific, unsafe and slightly wacky. Claims that the vertebral subluxation complex is the cause of illness and disease have persisted despite the three UK educational establishments advising the GCC that no evidence of acceptable quality exists to support such claims.”
Only a few years AFTER THE STORM, this story seems to have changed beyond recognition. Harald Walach, who is known to readers of this blog because I reported that he was elected ‘pseudo-scientist of the year’ in 2012, recently published a comment on the proceedings of the European Congress of Integrated Medicine where we find the following intriguing version of the libel case:
Mein Freund und Kollege George Lewith aus Southampton hatte einen Hauptvortrag über seine Überblicksarbeit über chiropraktische Interventionen für kleinkindliche Koliken vorgelegt. Sie ist ausgelöst worden durch die Behauptung, die Singh und Ernst vor einigen Jahren erhoben hatten, dass Chiropraktik gefährlich ist, dass es keine Daten dafür gäbe, dass sie wirksam sei und dass sie gefährliche Nebenwirkungen habe, speziell wenn sie bei Kindern angewendet würde. Die Chiropraktiker hatten den Wissenschaftsjournalisten Singh damals wegen Verleumdung verklagt und recht erhalten. George Lewith hatte dem Gericht die Expertise geliefert und nun seine Analyse auf Kinder ausgedehnt.
Kurz gefasst: Die Intervention wirkt sogar ziemlich stark, etwa eine Standardabweichung war der Effekt groß. Die Kinder schreien kürzer und weniger. Und die Durchforstung der Literatur nach gefährlichen Nebenwirkungen hatte keinen, wortwörtlich: nicht einen, Fall zu Tage gefördert, der von Nebenwirkungen, geschweige denn gefährlichen, berichtet hätte. Die Aufregung war seinerzeit dadurch entstanden, dass eine unqualifizierte Person einer zart gebauten Frau über den Rücken gelaufen ist und ihr dabei das Genick gebrochen hat. Die Presse hatte das ganze dann zu „tödlicher Nebenwirkung chiropraktischer Intervention“ aufgebauscht.
Oh, I almost forgot, you don’t read German? Here is my translation of this revealing text:
“My friend and colleague Geoorge Lewith from Southampton gave a keynote lecture on his review of chiropractic interventions for infant colic. This was prompted by the claim, made by Singh and Ernst a few years ago, that chiropractic was dangerous, that no data existed showing its effectiveness, and that it had dangerous side-effects, particularly for children. The chiropractors had sued the science journalist Singh for libel and won the case. George Lewith had provided the expert report for the court and has now extended his analysis on children.
To put it briefly: the intervention is even very effective; the effect-size is about one standard deviation. The children cry less long and more rarely. And the search of the literature for dangerous side-effects resulted in no – literally: not one – case of side-effects, not to mention dangerous ones. The fuzz had started back then because an unqualified person had walked over the back of a thin woman and had thus broken her neck. The press had subsequently hyped the whole thing to a “deadly side-effect of a chiropractic intervention”. (I am sorry for the clumsy language but the original is even worse.)
Now, isn’t that remarkable? Not only has the truth about the libel case been turned upside down, but also the evidence on chiropractic as a treatment for infant colic seems mysteriously improved; other reviews which might just be a bit more independent and objective come to the following conclusions:
The literature concerning this topic is surprisingly scarce, of poor quality and lack of convincing conclusions. With the present day data on this topic, it is impossible to say whether this kind of treatment has a significant effect.
And what should we make of all this? I don’t know about you, but I conclude that, for some apologists of alternative medicine, the truth is a rather flexible commodity.
In 1747, James Lind conducted what may well be the first documented controlled clinical trial in the history of medicine. He treated a small group of healthy sailors with a range of different remedies to see whether one of these regimen might be effective in preventing scurvy. The results showed that lemon and lime juice – effectively vitamin C – did the trick. This trial changed the world: it saved tens of thousands of lives, gave Britain the advantage at sea needed to become a dominant empire, and set medicine on the track to eventually become evidence-based.
Of course, Lind did not know that the effective principle in his lemon/lime juice was vitamin C. The Hungarian physiologist Albert Szent-Gyorgyi discovered vitamin C only ~200 years later and received the Nobel Prize for it in 1937. Since then, research has been buoyant, and vitamin C has been advocated for almost every condition one can think of. Looking at some of the claims made for it, I get the impression that more charlatans have jumped on the vitamin C band-waggon than the old vehicle can support. In alternative medicine, high-dose IV vitamin C is a popular variation of Lind’s concept, not least for the treatment of cancer.
Researchers from the NIH in the US surveyed attendees at annual CAM Conferences in 2006 and 2008, and determined sales of intravenous vitamin C by major U.S. manufacturers/distributors. They also queried practitioners for adverse effects, compiled published cases, and analyzed FDA’s Adverse Events Database. Of 199 survey respondents (out of 550), 172 practitioners had administered IV vitamin C to 11,233 patients in 2006 and to 8876 patients in 2008. The average dose was 28 grams every 4 days, with a mean of 22 treatments per patient. Estimated yearly doses used (as 25g/50ml vials) were 318,539 in 2006 and 354,647 in 2008. Manufacturers’ yearly sales were 750,000 and 855,000 vials, respectively. Common reasons for treatment included infection, cancer, and fatigue. Of 9,328 patients for whom data was available, 101 had adverse effects, mostly minor, including lethargy/fatigue in 59 patients, change in mental status in 21 patients and vein irritation/phlebitis in 6 patients. Publications documented serious adverse events, including two deaths. The FDA Adverse Events Database was uninformative.
The authors of this paper conclude that high dose IV vitamin C is in unexpectedly wide use by CAM practitioners. Other than the known complications of IV vitamin C in those with renal impairment or glucose 6 phosphate dehydrogenase deficiency, high dose intravenous vitamin C appears to be remarkably safe. Physicians should inquire about IV vitamin C use in patients with cancer, chronic, untreatable, or intractable conditions and be observant of unexpected harm, drug interactions, or benefit.
I find these results somewhat worrying. Desperate cancer patients are constantly being told that they can fight the disease with high-dose vitamin C, for instance on the >9 million (!) websites on this subject. One site, for instance, leaves little doubt about the efficacy of vitamin C as a treatment for cancer: First shown to be a powerful anti-cancer agent in 1971, it wasn’t until 20 years later that vitamin C started to be accepted by the mainstream medical profession. Eating a vitamin C-rich diet substantially reduces the risk of cancer, and high intakes – above 5000mg a day (the equivalent of 100 oranges) – substantially increases the life expectancy of cancer patients.
Statements like this one give false hope to cancer patients which is unethical and cruel and might hasten the death of many. The reality is quite different and provides little reason for such hope. Here are just a few conclusions from recent scientific analyses on this or closely related topics:
We could not find evidence that antioxidant supplements prevent gastrointestinal cancers. On the contrary, they seem to increase overall mortality. The potential cancer preventive effect of selenium should be studied in adequately conducted randomised trial
The question whether the regular intake of high doses of vitamin C have a preventative effect for certain cancers is currently open. But there is no good reason to suggest that high dose IV vitamin C is an effective treatment for any cancer. To pretend otherwise, as so many alternative practitioners seem to do, is less than responsible – in fact, it is a hallmark for cancer quackery.
This post was inspired by a shiatsu-practitioner who recently commented on this blog. As I have not yet written a post about shiatsu, I think this might be a good occasion to do so. On one of the websites of the said practitioner – who claimed to have such amazing powers that he “would be locked up or worse“, if he made them public – explains that Shiatsu is a form of natural healing therapy that promotes health through finger pressure along energy meridians or channels – like acupuncture but with no needles and all your clothes on. Shiatsu is a combination of ancient theories of oriental medicine and ‘energy’, with modern knowledge of anatomy and physiology. Shiatsu originated in Japan where it is officially recognised and parents teach their children to treat them. Shiatsu is one of the fastest growing areas of complementary therapy in the UK. Shiatsu is safe and non-invasive. Shiatsu is a holistic therapy which means your whole body is treated. Work on your energy channels promotes well-being at the physical and emotional levels and stimulates your natural self-healing processes. The application of pressure and gentle stretching helps relieve muscle tension, joint stiffness and to realign body structures. Contact with the energy pathways helps to correct imbalance in the functioning of internal organs and to re-balance the effects of emotional disturbance. You don’t have to be ill to enjoy Shiatsu, many people enjoy it simply because it is deeply relaxing.
I also looked up another of his websites and found that he claims to treat the following conditions:
- Anger Management
- Anxiety and Stress
- Back pain
- Bipolar disorder
- Breathing/respiratory problems
- Confidence issues
- Digestive Disorders
- Eating Disorders
- Emotional Issues
- Fears and Phobias
- Irritable bowel syndrome (IBS)
- Joint Pain
- Low energy/Lethargy
- Low Self-Esteem
- ME/Chronic Fatigue Syndrome
- Muscular Tension
- Nausea and sickness
- Panic Attacks
- Sexual problems
- Sinus problems
- Skin conditions
- Sleeping problems
- Social anxiety disorder
- Spiritual Issues
- Weight problems
Impressed by this list, I looked at similar sites and found that such extravagant claims seem more the rule than the exception in the world of shiatsu. Such therapeutic claims came as a big surprise to me: the last time we reviewed the evidence, we had concluded: NO CONVINCING DATA AVAILABLE TO SUGGEST THAT SHIATSU IS EFFECTIVE FOR ANY CONDITION.
But that was 5 years ago; perhaps there have been major advances since? To find out, I did a quick Medline search and – BINGO! – found a recent systematic review entitled “The evidence for Shiatsu: a systematic review of Shiatsu and acupressure“. It was authored by proponents of this therapy and can therefore not be suspected to be riddled with ‘anti-shiatsu bias’ (I just love the give-away title THE EVIDENCE FOR SHIATSU….!). These authors found that “Shiatsu studies comprised 1 RCT, three controlled non-randomised, one within-subjects, one observational and 3 uncontrolled studies investigating mental and physical health issues. Evidence was of insufficient quantity and quality” The only RCT included in their review was not actually a study of shiatsu but of a complex mixture of treatments including shiatsu for back and neck pain. No significant effects compared to standard care were identified in this study.
So, what does that tell us about shiatsu? It clearly tells us that it is an unproven therapy. And what does that say about shiatsu-practitioners who make multiple claims about treating serious conditions? I think I can leave it to my readers to answer this question.
I regularly used to ask alternative practitioners what diseases they are good at treating. In fact, we once ran an entire research project dedicated to this question and found that their own impressions were generally based on wishful thinking rather than on evidence. The libel case of the BCA versus Simon Singh then brought this issue into the focus of the public eye, and consequently several professional organisations of alternative practitioners seem to have advised their members to be cautious about making unsubstantiated therapeutic claims. This could have been an important step into the right direction – unless, of course, a clever trick had not been devised to bypass the need for evidence. Today, when I ask alternative practitioners ‘what do you treat effectively?’ I tend to get answers like:
- Alternative practitioners, unlike conventional clinicians, do not treat diseases.
- I treat the whole person, not just the disease.
- I treat people and their specific set of signs and symptoms, rather than disease labels (this actually is a quote from the comments section of one of my recent posts).
- I focus on the totality of the symptoms; disease labels are irrelevant in the realm of my therapy.
- Chiropractors adjust subluxations which are the root cause for most diseases.
- Acupuncturists re-balance life energies which is a precondition for healing to commence irrespective of the disease.
- Homeopaths treat the totality of symptoms so that the patient’s vital force can do the healing.
- etc. etc.
All of these statements are deeply rooted in the long obsolete notions of vitalism, i.e. the assumption that a vital energy flows in all living organisms and is responsible for our health irrespective of the disease we happen to suffer from. But what do the answers to my question ‘what do you treat?’ really mean? If we analyse the above responses critically, they seem to imply that:
- Conventional clinicians do not treat patients but merely disease labels.
- Alternative practitioners can successfully treat any disease or condition.
Ad 1 In my view, it is arrogant and grossly unfair to claim that alternative practitioners work holistically, while conventional health care professionals do not. I have pointed out repeatedly that any good medicine always has been and always will be holistic. High-jacking holism as a specific characteristic for alternative medicine is misleading and an insult to all conventional clinicians who do their best to practice good medicine.
Ad 2 By claiming that they treat the whole person irrespective of her disease, alternative practitioners effectively try to give themselves a ‘carte blanche’ for treating any disease or any condition or any symptom. If a child has asthma, a chiropractor will find a subluxation, adjust it with spinal manipulation, and claim that the child’s condition will improve as a consequence of his treatment – NEVER MIND THE EVIDENCE. If a person wants to give up smoking, an acupuncturist will use acupuncture to re-balance her yin and yang claiming that this intervention will make smoking cessation more successful – NEVER MIND THE EVIDENCE. If a patient suffers from cancer, a homeopath might find a remedy that promotes her vital energy claiming that the cancer will subsequently be cured – NEVER MIND THE EVIDENCE which in all of the three cases is negative.
The claim of alternative practitioners to not treat disease labels but the whole patient is doubtlessly attractive to consumers and it is also extremely good for business. On closer inspection, however, it turns out to be a distraction from the fact that alternative practitioners treat everything and anything, usually without the slightest evidence that their interventions generates more good than harm. It allows alternative practitioners to live in a fool’s paradise of quackery where they believe themselves to be protected from any challenges and demands for evidence.
One cannot very well write a blog about alternative medicine without giving full credit to the biggest and probably most determined champion of quackery who ever hugged a tree. Prince Charles certainly has done more than anyone else I know to let unproven treatments infiltrate real medicine. To honour his unique achievements, I am here presenting a fictitious interview with him. It never did take place, of course, and the questions I put to him are pure imagination. However, the ‘answers’ are in a way quite real: they have been taken unaltered from various speeches he made and articles he wrote. To avoid being accused of using dodgy sources which might have quoted him inaccurately or sympathetically, I have exclusively used HRH’s very own official website as a source for his comments. It seems safe to assume that HRH identifies with them more fully than with the many other statements he made on this subject.
I have not changed a single word in his statements and I have tried to avoid quoting him out of context; I did, however, take the liberty of putting sentences side by side which do not always originate from the same speech or article, i.e. I have used quotes from different communications to appear as though they originally were in sequence. It will be clear from the text that the fictitious interview is dated before Charles’ Foundation folded because of money laundering and fraud.
It is, of course, hugely tempting to comment on the various statements by Charles. However, I have resisted this temptation; I wanted the reader to enjoy his wisdom in its pure and unadulterated beauty. Anyone who feels like it will have plenty of opportunity to post comments, if they so wish.
To make clear what is what, my questions appear in italics, while his ‘answers’ are in Roman typeface.
Q I believe you have no training in science or medicine; yet you have long felt yourself expert enough to champion bizarre forms of therapies which many of our readers might call quackery.
As you know by now, this is an area to which I attach the greatest importance and where I have tried to make a particular contribution. For many years, the NHS has found complementary medicine an uncomfortable bedfellow – at best regarded as ‘fringe’ and in some quarters as ‘quack’; never viewed as a substitute for conventional medicine and rarely as a genuine partner in providing therapy.
I look back to the rather “lukewarm” response I received in 1983 as President of the British Medical Association when I first spoke about integration and complementary and alternative medicine. We have clearly travelled a very long way since that time.
Q Alternative medicine is mainly used by those who can afford it; at present, little of it is available on the NHS. Why do you want to change this situation?
The very popularity of non-conventional approaches suggests that people are either dissatisfied with the kind of orthodox treatment they are receiving, or find genuine relief in such therapies. Whatever the case, it is only reasonable to try to identify the factors that are contributing to their increased use. And if advantages are found, clearly they should not be limited only to those people who can pay, but should be made more widely available on the NHS.
Q If with a capital “I”?
I believe it is because complementary and alternative approaches to healthcare bring a different emphasis to bear which often unlocks an individual’s inner resources to aid recovery or help to manage living with a serious chronic illness. It is also because complementary and alternative therapies often offer more effective and less intrusive ways of treating illness.
Q Really? Are you sure that they are more effective that conventional treatments? What is your evidence for that?
In 1997 the Foundation for Integrated Medicine, of which I am the president and founder, identified research and development based on rigorous scientific evidence as one of the keys to the medical establishment’s acceptance of non-conventional approaches. I believed then, as I do now, that the move to a more integrated provision of healthcare would ultimately benefit patients and their families.
Q But belief is hardly a good substitute for evidence. In this context, it is interesting to note that chiropractors and osteopaths received the same status as doctors and nurses in the UK. Is this another of your achievements? Was it based on belief or on evidence?
True healing is a synergy that comes not by courtesy of a medical diploma.
Q What do you mean?
As we know, the professions of Osteopathy and Chiropractice are now regulated in the same way as doctors and dentists, with their own Acts of Parliament. I’m very proud to have played a tiny role in trying to push for that Act of Parliament over the years. It has also been reassuring to see the progress being made by the other main complementary professions and I look forward to the further development of regulatory frameworks enabling high standards of training, clinical practice and professional behaviour.
Q Some might argue that statutory regulation made them not more professional but merely improved their status and thus prevented asking question about evidence. Why did they need to be regulated in that way?
The House of Lord’s Select Committee Report on Complementary and Alternative Medicine in 2000, quite sensibly recommended that only complementary professions which were statutorily regulated, or which had well-established arrangements for voluntary self-regulation, should be made available through the NHS.
Q Integrated healthcare seems to be your new buzz-word, what does it mean? Is it more than a passing fad?
Integrated Healthcare is, I believe, here to stay. The public want it and need it. It is not a takeover of the orthodox by CAM or the other way around, but is rather the bringing together of the best from both for the ultimate benefit of the patient.
Q Your lobby-group, Foundation for Integrated Medicine, what has it ever done to justify its existence?
In 1997 the steering group of The Foundation for Integrated Medicine (FIM), of which I am proud to be president, published a discussion document ‘Integrated Healthcare – A Way Forward for the Next Five Years?’
Q Sorry to interrupt, but if so many people are already using them, why do you feel compelled to promote unproven treatments even more? Why is ‘a way forward’ in promotion actually needed? Why did we need a lobby group like FIM?
Homoeopaths, osteopaths, reflexologists, acupuncturists, T’ai chi instructors, art therapists, chiropractors, herbalists and aromatherapists: these practitioners were working alongside NHS colleagues in acute hospitals, on children’s wards, in nursing homes and in particular in primary healthcare, in GP practices and health clinics up and down the country.
Q Exactly! Why then even more promotion of unproven treatments?
All well and good, perhaps, but if there are advantages in this approach, clearly they should not be limited only to those who can pay.
Q Yes, if again with a capital “I”, presumably . Anyway, do you believe these therapies should be tested like other treatments?
One of the obstacles always raised is that it is very difficult to trial complementary therapies in the rigorous randomised way that mainstream medicine deems to be the gold standard. This is ironic as there are, of course, un-evaluated orthodox practices which continue to be funded by the NHS.
Q Are you an expert on research methodology as well?
At the same time, we should be mindful that clinically controlled trials alone are not the only pre-requisites to apply a healthcare intervention. Consumer-based surveys can explore WHY people choose complementary and alternative medicine and tease out the therapeutic powers of belief and trust
These “rationalist selves” would be enormously relieved to see the effectiveness of these treatments proven through the “double-blind randomized controlled trial” – the gold-standard of medical research. However, we know that some complementary and alternative medicine disciplines (and indeed other forms of medical or surgical intervention) do not lend themselves to this research method.
Q Are you sure? This sounds like something someone who is ignorant of research methodology has told you.
… it has been suggested that we need a research method for complementary treatment that is, to use that awful expression, “fit for purpose”. Something that is entirely practical – what has been called “applied” research – which takes into account the whole person and the whole treatment as it is actually given in the surgery or the hospital. Something that might offer us a better idea of the cost-effectiveness of any given approach. It would also help to provide the right sort of evidence that health service commissioners require when they decide which services they wish to commission for their patients.
Q Hmm – anyway, would you promote unproven treatments even for serious conditions like cancer?
Two surveys have indicated that up to eighty per cent of cancer patients try alternative or complementary treatments at some stage following diagnosis and seventy-five per cent of patients would like to see complementary medicine available on the N.H.S.
Q Yes, but why the promotion?
There is a major role for complementary medicine in bowel cancer – as a support to more conventional approaches – in helping to prevent it through lifestyle changes, helping to boost our immune systems and in helping sufferers to come to terms with, and maintain, a sense of control over their own lives and wellbeing. My own Foundation For Integrated Medicine is, for example, involved in finding ways to integrate the best of complementary and alternative medicine.
Q And what do you understand by “the best”? In medicine, this term should mean “the most effective”, shouldn’t it?
Many cancer patients have turned to an integrated approach to managing their health, finding complementary therapies such as acupuncture, aromatherapy, reflexology and massage therapy extremely therapeutic. I know of one patient who turned to Gerson Therapy having been told that she was suffering from terminal cancer, and would not survive another course of chemotherapy. Happily, seven years later she is alive and well. So it is therefore vital that, rather than dismissing such experiences, we should further investigate the beneficial nature of these treatments.
Q Gerson? Is it ethical to promote an unproven starvation diet for cancer?
…many patients use and believe in Gerson Therapy, yet more evidence needs to be available as to who might benefit or what adverse effects there might be. But, surely, we need to take a wider view of the most appropriate types of research methodology – a wider view of what research will help patients.
Q You are a very wealthy man; will you put your own money into the research that you regularly demand?
Complementary medicine is gaining a toehold on the rockface of medical science.
Q I beg your pardon.
Complementary medicine’s toehold is literally that, and it’s an inescapable fact that clinical trials, of the calibre that medical science demands, cost money. Figures from the Department of Complementary Medicine at the University of Exeter show that less than 8p out of every £100 of NHS funds for medical research was spent on complementary medicine. In 1998-99 the Medical Research Council spent no money on it at all, and in 1999 only 0.05% of the total research budget of UK medical charities went to this area.
Q Hmm – Nature; you are very fond of all things natural, aren’t you?
The garden is designed to remind people of our interconnectedness with Nature and of the beneficial medicinal properties She provides through countless plants, flowers and trees. Throughout the 20th century so much ancient, accumulated, traditional wisdom has been thrown away – whether in the fields of medicine, architecture, agriculture or education. The baby was thrown out with the bathwater, so this garden is designed to bring the baby back again and to remind us of that priceless, traditional knowledge before we lose that rich store of Nature’s healing gifts for the benefit of our descendants.
When you think about it, what on earth is the point of throwing away our lifeline; of abandoning the priceless knowledge and wisdom accumulated over 1,000’s of years relating to the treatment of the human condition by natural means? It is sheer folly it seems to me to forget that we are a part of Nature and to imagine we can survive on this Earth as if we were merely a mechanical process divorced from, and in opposition to, the unity of the world around us.
Q …and herbalism?
Medical herbalists talk about ‘synergy’, the result of a complex mix of active ingredients in a plant that create a more powerful therapeutic effect together than if isolated. It’s a concept that has a wider application. As the 17th century poet John Donne famously wrote, “No man is an Island, entire of itself; every man is a piece of the Continent, a part of the main.”
Q I am not sure I understand; what does that mean?
Medical herbalists, who make up their own preparations from combinations of fresh or dried plants, believe that this mix within individual herbs as well as in traditional mixtures of plant medicines creates what is called synergy, in which all the chemical components contribute to the remedy’s specific therapeutic effects.
At a time when farmers everywhere are struggling to make ends meet, the development of a natural pharmacy of organically grown herbs offers an alternative means of earning a living. Yet without protective measures, herbs are easily adulterated or their quality compromised.
Q …and homeopathy?
I went to open the new Glasgow Homeopathic Hospital for instance a couple of years ago, I met a whole lot of students who were studying homeopathy, I think, and I’ve never forgotten when they said to me ‘Are you interested in homeopathy’ and I thought – I don’t know, why do I bother?
Q And why exactly do you bother, if I may ask?
By allowing patients treatment choice, negative emotions can, in part, be alleviated. Many complementary practitioners provide time, empathy, hope and reassurance – skills that are referred to as the “human effect” – which can improve the confidence of cancer patients, alter mindsets and produce major positive changes in the immune system. As a result the “human effect” can greatly prolong life: it has been demonstrated that in a variety of cancers, such as breast cancer, that attitude of mind can not only raise the quality of life but in some cases can even prolong life. At the same time, we need specific treatments that are designed to improve the quality of patients’ lives, and to provide relief from the unpleasant symptoms of cancer – anxiety; pain; sleeplessness; skin irritation; poor appetite; nausea and depression, to name but a few.
Q At heart you seem to be a vitalist who believes in a vital force or energy that interconnects anything with everything and determines our health.
Research in the new field of psychoneuroimmunology – or mind-body medicine as it is sometimes called – is discovering that there is a constant interplay between our emotions, thoughts and actions and our body systems. It seems that the food we eat, the air we breathe, the exercise we take, our relationships with other people, all have a direct bearing on our health and natural healing processes. Complementary medicine has always known this and I believe it is one of the reasons for its enormous popularity.
Q Clarence House made several statements assuring the British public that you never overstep your constitutional role by trying to influence health politics; they were having us on, weren’t they?
A few days ago I launched an initiative to promote the provision of more complementary medicine in the NHS. For many years I have been working towards this goal.
Q Does that mean these statements were wrong?
I am convinced there is no better moment than now to create a real integration of our healthcare, particularly when there is talk of a Patient-Centred NHS. So much ill-health and disease is due to the misery, stress and alienation we see in our community.
Homeopaths can bear criticism only when it is highly diluted. Any critique from the ‘outside’ is therefore dismissed by insisting that the author fails to understand the subtleties of homeopathy. And criticism from the ‘inside’ does not exist: by definition, a homeopath does not criticise his/her own trade. Through these mechanisms, homeopaths have more or less successfully shielded themselves from all arguments against their activities and have, for the last 200 years, managed to survive in a world of make-belief.
As I will show below, I started my professional life on the side of the homeopaths – I am not proud of this fact, but there is no use denying it. When the evidence told me more and more clearly that I had been wrong, about 10 years ago, I began expressing serious doubts about the plausibility, efficacy and safety of using homeopathic remedies to treat patients in need. Homeopaths reacted not just with anger, they were also at a loss.
Their little trick of saying ‘He does not understand homeopathy and therefore his critique is invalid’ could not possibly work in my case – I had been one of them: I had attended their meetings, chaired some of their sessions, edited a book on homeopathy, accepted an invitation to join the editorial board of the journal ‘HOMEOPATHY‘ as well as a EU-panel investigating homeopathy, conducted trials, systematic reviews and meta-analyses, published over 100 articles on the subject, accepted money from Prince Charles as well as from the ‘ueber-homeopath’ George Vithoulkas for my research, and even contributed to THE INTERNATIONAL DICTIONARY OF HOMEOPATHY. It would have not looked reasonable to suddenly deny my previously accepted expertise. Homeopaths thus found themselves in a pickle: critique from the ‘inside’ is not what they were used to or could easily cope with.
The homeopathic idyll was under threat, and a solution to the problem had to be found with some urgency. And soon enough, it was found. Homeopaths from across the world started claiming that I had been telling porkies about my training/qualifications in homeopathy: “Edzard Ernst has admitted that he has over the years lied or supported a lie about having homeopathic training. In reality he has had none at all! The leading so-called ‘expert’ and critic of homeopathy, Professor Edzard Ernst, has admitted that he has no qualifications in homeopathy. etc. etc. Diluting the truth to the extreme, they almost unanimously insisted that, contrary to my previous assertions, I had no training/qualifications in homeopathy. Thus, they began to argue, that I was an imposter and had insufficient knowledge, expertise and experience after all: Professor Edzard Ernst the leading ‘authority’ on homeopathy, and perhaps its most referenced critic, has no qualifications in homeopathy. William Alderson of HMC21 also claims that Ernst’s book Trick or Treatment? shows Ernst to be unreliable as a researcher into homeopathy. Opposition to homeopathy is based on propaganda, they stated. Others wrote that Edzard Ernst’ failure as a homeopath only proves he lacked some basic qualities essential to become a successful homeopath. He failed as a homeopath, and then turned a skeptic. His failure is only his failure- it does not disprove homeopathy by any way. Once he failed in putting a mark as a successful homeopath or CAM practitioner, he just tried the other way to become famous and respectable- he converted himself into a skeptic, which provided him with ample opportunities to appear on ‘anti-homeopathy’ platforms’ as an ‘authority’, ‘expert’ and ‘ex-homeopath’! Some went even further claiming that I had also lied about my medical qualifications.
These notions has been going around the internet for several years now and conveniently served as a reason to re-categorise me into the camp of the homeopathically unqualified pseudo-experts: ‘We believe that it is time to recognise that opposition to homeopathy is largely based on the opinions of individuals who are unqualified or unwilling to judge the evidence fairly’. I, by contrast, believe it is time that I disclose the full truth about ‘my double-life as a homeopath’. What exactly is my background in this area? Have I really been found out to be a confidence-trickster?
THE HOMEOPATHIC CLINICIAN
I graduated from medical school in Munich in the late 1970s and, looking for a job, I realised that there weren’t any. At the time, Germany had a surplus of doctors and all the posts I wanted were taken. Eventually, I found one in the only hospital that was run almost entirely homoeopathically, the KRANKENHAUS FUER NATURHEILWEISEN in Munich. Within about half a year, I learned how to think like a homeopath, diagnose like a homeopath and treat patients like a homeopath. I never attended formal courses or aspired to get a certificate; as far as I remember, none of the junior doctors working in the homeopathic hospital did that either. We were expected to learn on the job, and so we did.
Our teachers at medical school had hardly ever mentioned homeopathy, but one thing they had nevertheless made abundantly clear to us: homeopathy cannot possibly work; there is nothing in these pills and potions! To my surprise, however, my patients improved, their symptoms subsided and, in general, they were very happy with the treatment we provided. My professors had told me that homeopathy was rubbish, but they had forgotten to teach me a much more important lesson: critical thinking. Therefore, I might be forgiven for proudly assuming that my patients’ improvement was due to my skilful homeopathic prescriptions.
But then came another surprise: the boss of the homeopathic hospital, Dr Zimmermann, took me under his wings, and we had occasional discussions about this and that and, of course, about homeopathy. When I shyly mentioned what I had been told at medical school ( about homeopathy being entirely implausible), he agreed! I was speechless. Crucially, he considered that there were other explanations: “Our patients might improve because we look after them well and we discontinue all the unnecessary medication they come in with; perhaps the homeopathic remedies play only a small part”, he said.
THE INVESTIGATOR OF HOMEOPATHY
This may well have been the first time I started looking critically at homeopathy and my own clinical practice – and this is roughly where I left things as far as homeopathy is concerned until, in 1993, it became my job to research alternative therapies systematically and rigorously. Meanwhile I had done a PhD and tried my best to learn the skills of critical analysis. As I began to investigate homeopathy scientifically, I found that my former boss had been right: patients do indeed improve because of a multitude of factors: placebo-effects, natural history of the disease, regression towards the mean, to mention just three of a multitude of phenomena. At the same time, he had not been entirely correct: homeopathic remedies are pure placebos; they do not play a ‘small part’ in patients’ improvement, they play no part in this process.
As I began to state this more and more clearly, all sorts of ad hominem attacks were hauled in my direction, and recently I was even fired from the editorial board of the journal ‘HOMEOPATHY’ because allegedly I “…smeared homeopathy and other forms of complementary medicine…” I don’t mind any of that – but I do think that the truth about ‘my double-life as a homeopath’ should not be diluted like a homeopathic remedy until it suits those who think they can defame me by claiming I am a liar and do not know what I am talking about.
This rather depressing story shows, I think, that some homeopaths, rather than admitting they are in the wrong, are prepared to dilute the truth until it might be hard for third parties to tell who is right and who is wrong. But however they may deny it, the truth is still the truth: I have been trained as a homeopath.
It is time, I think, to call an end to this series of articles on ‘drowning in a sea of misinformation’. Not that I have covered every contributor to and aspect of it. On the contrary, I could have carried on for another couple of weeks writing a post every day as I did during the last 15 days. But it was getting a bit boring – at least for me. So, for the last post, I have decided to briefly discuss politicians. In my view, they are crucially important in this context, as they create the general atmosphere and framework in which all the other mis-informers can thrive.
Peter Hain (Labour) is a campaigner for homeopathy and wants to see it widely used on the NHS. He was quoted as saying: “I first came to know about homeopathy through my son who as a baby suffered from eczema. He had it a couple of years but with conventional treatment the eczema was getting progressively worse and at the age of four he also developed asthma. We turned to homeopathy out of desperation and were stunned with the positive results. Since then I have used homeopathy for a wide variety of illnesses, but I rely on arnica as it’s excellent for treating the everyday bruises and shocks to the system we face. My view is that homeopathy and conventional medicines must remain side by side under the NHS to offer the best to patients”
Politicians who put anecdote before evidence do worry me quite a bit, I have to admit; by doing this, they provide us with strong evidence that they would be wise to keep their mouth shut when it comes to matters of science and medicine. But Hain is in good company: Jeremy Hunt (conservative), the current Secretary for Health, signed the following Early Day Motion in 2007: That this House welcomes the positive contribution made to the health of the nation by the NHS homeopathic hospitals; notes that some six million people use complementary treatments each year; believes that complementary medicine has the potential to offer clinically-effective and cost-effective solutions to common health problems faced by NHS patients, including chronic difficult to treat conditions such as musculoskeletal and other chronic pain, eczema, depression, anxiety and insomnia, allergy, chronic fatigue and irritable bowel syndrome; expresses concern that NHS cuts are threatening the future of these hospitals; and calls on the Government actively to support these valuable national assets.
The wording here is remarkable, I think: “…believes that complementary medicine has the potential to offer clinically-effective and cost-effective solutions to common health problems faced by NHS patients…” What is this supposed to mean? Health politics based on believe??? What it, in fact, implies is that there is merely belief but no evidence. Bravo! This looks like an own-goal to me.
And there are many, many more politicians who seem to prefer belief over evidence – not just in the UK but in virtually every country; our US friends would probably want me to mention Senator Tom Harkin who is responsible for spending billions of tax-payers’ dollars on researching implausible concepts with flawed studies. To make things worse, it is not just individual politicians who promote woo, as far as I can see, most political parties have a group of members promoting pseudo-science.
But why? Why do so many politicians misinform their voters about the values of unproven and disproven treatments? And I do not mean those members of parliament who nobody seems to be able to take seriously, like David Tredenick; I mean otherwise respectable politicians with real influence. Should they not be the first to insist on reliable evidence? Do they not have a mandate and an ethical/moral obligation to do so?
Call me cynical, but I have come to the conclusion that the answer is actually quite simple. Politicians need to be (re-)elected, and therefore they have to run with whatever subject is popular – and, like it or not, alternative medicine is popular. Politicians rarely take a reasonably long view on health care (in fact, very few understand the first thing about science or medicine); their perspective has exactly the same length as the current legislative period. They usually do not even attach much importance to alternative medicine; after all, it only amounts to a tiny fraction of the total health care budget.
Tony Blair (Labour) is as good an example as any other politician; in relation to homeopathy, he is quoted saying: I think that most people today have a rational view about science and my advice to the scientific community would be fight the battles you need to fight. I wouldn’t bother fighting a great battle over homeopathy – there are people who use it, people who don’t use it, it is not going to determine the future of the world, frankly. What will determine the future of the world however, is the scientific community explaining for example the science of genetics and how it develops, or the issue to do with climate change and so on.
Sounds reasonable? Almost, but not quite. Firstly, if people employ homeopathy to protect themselves from infectious diseases like malaria, typhus, TB, AIDS etc., or if people believe those charlatans who promote it as an effective cure for life-threatening conditions, we do have a serious public health issue at hand. Secondly, why should the vast majority of health care professionals bend over backwards to do their very best implementing the concepts of EBM, if homeopathy is being given a free ride to continue existing in a virtual universe of belief-based medicine? Thirdly, how on earth can scientists possibly explain “the science of genetics and how it develops, or the issue to do with climate change”, if they lack the skill, courage, power or honesty to adequately respond to harmful quackery masquerading as medicine?
It is not difficult to criticise politicians but what might be the way forward and out of this mess? Because of the central role they play in all this, I think that it would be important that those politicians who take up posts in science-based areas be adequately educated and trained in science. I know this may sound naïve, but I think it would be an essential step towards avoiding politicians regularly making fools of themselves, misinforming the public and misguiding important decisions which might affect all of us.
I have said it so often that I hesitate to state it again: an uncritical researcher is a contradiction in terms. This begs the question as to how critical the researchers of alternative medicine truly are. In my experience, most tend to be uncritical in the extreme. But how would one go about providing evidence for this view? In a previous blog-post, I have suggested a fairly simple method: to calculate an index of negative conclusions drawn in the articles published by a specific researcher. This is what I wrote:
If we calculated the percentage of a researcher’s papers arriving at positive conclusions and divided this by the percentage of his papers drawing negative conclusions, we might have a useful measure. A realistic example might be the case of a clinical researcher who has published a total of 100 original articles. If 50% had positive and 50% negative conclusions about the efficacy of the therapy tested, his trustworthiness index (TI) would be 1.
Depending on what area of clinical medicine this person is working in, 1 might be a figure that is just about acceptable in terms of the trustworthiness of the author. If the TI goes beyond 1, we might get concerned; if it reaches 4 or more, we should get worried.
An example would be a researcher who has published 100 papers of which 80 are positive and 20 arrive at negative conclusions. His TI would consequently amount to 4. Most of us equipped with a healthy scepticism would consider this figure highly suspect.
So how would alternative medicine researchers do, if we applied this method for assessing their trustworthiness? Very poorly, I fear – but that is speculation! Let’s see some data. Let’s look at one prominent alternative medicine researcher and see. As an example, I have chosen Professor George Lewith (because his name is unique which avoids confusion with researchers), did a quick Medline search to identify the abstracts of his articles on alternative medicine, and extracted the crucial sentence from the conclusions of the most recent ones:
- The study design of registered TCM trials has improved in estimating sample size, use of blinding and placebos
- Real treatment was significantly different from sham demonstrating a moderate specific effect of PKP
- These findings highlight the importance of helping patients develop coherent illness representations about their LBP before trying to engage them in treatment-decisions, uptake, or adherence
- Existing theories of how context influences health outcomes could be expanded to better reflect the psychological components identified here, such as hope, desire, optimism and open-mindedness
- …mainstream science has moved on from the intellectual sterility and ad hominem attacks that characterise the sceptics’ movement
- Trustworthy and appropriate information about practitioners (e.g. from professional regulatory bodies) could empower patients to make confident choices when seeking individual complementary practitioners to consult
- Comparative effectiveness research is an emerging field and its development and impact must be reflected in future research strategies within complementary and integrative medicine
- The I-CAM-Q has low face validity and low acceptability, and is likely to produce biased estimates of CAM use if applied in England, Romania, Italy, The Netherlands or Spain
- Our main finding was of beta power decreases in primary somatosensory cortex and SFG, which opens up a line of future investigation regarding whether this contributes toward an underlying mechanism of acupuncture.
- …physiotherapy was appraised more negatively in the National Health Service than the private sector but osteopathy was appraised similarly within both health-care sectors
This is a bit tedious, I agree, so I stop after just 10 articles. But even this short list does clearly indicate the absence of negative conclusions. In fact, I see none at all – arguably a few neutral ones, but nothing negative. All is positive in the realm of alternative medicine research then? In case you don’t agree with that assumption, you might prefer to postulate that this particular alternative medicine researcher somehow avoids negative conclusions. And if you believe that, you are not far from considering that we are being misinformed.
Alternative medicine is not really a field where one might reasonably expect that rigorous research generates nothing but positive results; even to expect 50 or 40% of such findings would be quite optimistic. It follows, I think, that if researchers only find positives, something must be amiss. I have recently demonstrated that the most active research homeopathic group (Professor Witt from the Charite in Berlin) has published nothing but positive findings; even if the results were not quite positive, they managed to formulate a positive conclusion. Does anyone doubt that this amounts to misinformation?
So, I do have produced at least some tentative evidence for my suspicion that some alternative medicine researchers misinform us. But how precisely do they do it? I can think of several methods for avoiding publishing a negative result or conclusion, and I fear that all of them are popular with alternative medicine researchers:
- design the study in such a way that it cannot possibly give a negative result
- manipulate the data
- be inventive when it comes to statistics
- home in on to the one positive aspect your generally negative data might show
- do not write up your study; like this nobody will ever see your negative results
And why do they do it? My impression is that they use science not for testing their interventions but for proving them. Critical thinking is a skill that alternative medicine researchers do not seem to cultivate. Often they manage to hide this fact quite cleverly and for good reasons: no respectable funding body would give money for such an abuse of science! Nevertheless, the end-result is plain to see: no negative conclusions are being published!
There are at least two further implications of the fact that alternative medicine researchers misinform the public. The first concerns the academic centres in which these researchers are organised. If a prestigious university accommodates a research unit of alternative medicine, it gives considerable credence to alternative medicine itself. If the research that comes out of the unit is promotional pseudo-science, the result, in my view, amounts to misleading the public about the value of alternative medicine.
The second implication relates to the journals in which researchers of alternative medicine prefer to publish their articles. Today, there are several hundred journals specialised in alternative medicine. We have shown over and over again that these journals publish next to nothing in terms of negative results. In my view, this too amounts to systematic misinformation.
My conclusion from all this is depressing: the type of research that currently dominates alternative medicine is, in fact, pseudo-research aimed not at rigorously falsifying hypotheses but at promoting bogus treatments. In other words alternative medicine researchers crucially contribute to the ‘sea of misinformation’ in this area.
It almost goes without saying that alternative practitioners contribute importantly to the ‘sea of misinformation’ about alternative medicine. Again, I could write books about this subject but have to refrain myself and therefore will merely put quick spotlights on several types of practitioners, mostly drawing from my own research on these subjects.
A survey of more than 9000 patients of U.K. non-medically trained acupuncturists showed that a considerable number had received advice from their therapists about prescribed medicines. Since these acupuncturists hold no medical qualifications, they are not qualified to issue such advice. It is therefore clear to me that the advice given is likely to be misleading. In 2000, we directly asked the U.K. acupuncturists’ advice about electro-acupuncture treatment for smoking cessation, a treatment which we previously had identified to be ineffective. The advice we received was frequently not based on current best evidence and some of it also raised serious safety concerns (Schmidt, K., & Ernst, E. Internet advice by acupuncturists—a risk factor for cardiovascular patients? Perfusion,2002, 15: 44-50. Article not Medline-listed).
Many chiropractors from the UK and other countries make unsustainable therapeutic claims on their websites. In 2002, at the height of the ‘‘MMR scare’’ in Britain, we conducted a study revealing that a sizable proportion of U.K. chiropractors advised mothers against having the measles-mumps-rubella (MMR) jab for their children. A survey of the U.K. chiropractors demonstrated that an alarming percentage of the U.K. chiropractors fail to provide advice about the risks of spinal manipulation before commencing treatment. As these risks are, in fact, considerable, this behaviour amounts to misinformation and is an obvious violation of medical ethics.
With osteopaths, it is a very similar story; the main difference is that there are far less investigations than for chiropractors. This may be due to the fact that, in the US, osteopaths are not alternative but conventional clinicians with much the same training and skills as proper doctors. But in Europe, they are strictly alternative and make as many bogus claims as chiropractors. Systematic investigations are rare, but I only need to remind us of my recent blog-post where I pointed out that:
Most osteopaths treat children for a wide range of conditions and claim that their interventions are helpful. They believe that children are prone to structural problems which can be corrected by their interventions. Here is an example from just one of the numerous promotional websites on this topic:
STRUCTURAL PROBLEMS, such as those affecting the proper mobility and function of the body’s framework, can lead to a range of problems. These may include:
- Postural – such as scoliosis
- Respiratory – such as asthma
- Manifestations of brain injury – such as cerebral palsy and spasticity
- Developmental – with delayed physical or intellectual progress, perhaps triggering learning behaviour difficulties
- Infections – such as ear and throat infections or urinary disturbances, which may be recurrent.
OSTEOPATHY can assist in the prevention of health problems, helping children to make a smooth transition into normal, healthy adult life.
Encouraging evidence exists for some specific herbs in the treatment of some specific conditions. Yet, virtually no good evidence exists to suggest that the prescriptions of individualized herbal mixtures by traditional herbalists across the globe generate more good than harm. Despite this lack of evidence, herbalists do not seem to offer this information voluntarily to his or her patients. When we directly asked the UK herbalists for advice on a clinical case, we found that it was ‘‘misleading at best and dangerous at worst’’ . In other words, herbalists misinform their patients and the public about the value of their treatments.
Many non-medically trained homeopaths advise their clients against the immunization of children. Instead, these practitioners often recommend using ‘‘homeopathic vaccinations’’ for which no good evidence exists. For instance, the vice-chair of the board of directors of ‘‘The Society of Homeopaths’’ had a site with the following statements: ‘‘Homeopathic alternatives to children’s immunisation are now available.’’ ‘‘Our clinic offers alternative immunisation programmes for the whole family.’’ Such statements amounts to misinformation which puts children’s health at risk.
Other alternative practitioners
I have chosen the above-listed professions almost at random and could have selected any other type as well. Arguably, all alternative practitioners who employ unproven treatments – and that must be the vast majority – misinform their patients to some extend. The only way to avoid this is to say: ‘look, I am going to give you a therapy for which there is no good evidence – I hope you don’t mind’. If they did that, they would be out of business in a flash. It follows, I think, that being in business is tantamount to misleading patients.
And there is, of course, another way of misinforming patients which is often forgotten yet very important: withholding essential information. In all of health care, informed consent is a ‘sine qua non’. Alternative practitioners very rarely obtain informed consent from their patients. The reason seems obvious (see above). I would argue that not informing people when they should be informed is a form of misinformation.
In this context, it is worth mentioning an investigation we did in 2009: We obtained the ethical codes of the following bodies: Association of Naturopathic Practitioners, Association of Traditional Chinese Medicine (UK), Ayurvedic Practitioners Association, British Acupuncture Council, Complementary and Natural Healthcare Council, European Herbal Practitioners Association, General Chiropractic Council, General Osteopathic Council, General Regulatory Council for Complementary Therapies, National Institute of Medical Herbalists, Register of Chinese Herbal Medicine, Society of Homeopaths, UK Healers, Unified Register of Herbal Practitioners. We then extracted the statements from these codes referring to evidence-based practice (EBP). The results showed that only the General Chiropractic Council, the General Osteopathic Council and the General Regulatory Council for Complementary Therapies oblige their members to adopt EBP.
It seems that misinformation is an alternative practitioner’s daily bread. Without it, alternative therapists would need to confine their practice to the few treatments/conditions for which the evidence is positive. If they ever followed this strategy, they would hardly be able to earn a living.