MD, PhD, FMedSci, FSB, FRCP, FRCPEd

education

Medical ethics are central to any type of healthcare – and this includes, of course, alternative medicine. The American Medical Association (AMA) have just published their newly revised code of ethics, AMA Principles of Medical Ethics.

It has long been my impression that, in alternative medicine, ethics receive no or far too little attention. Some alternative practitioners thrive to be able to call themselves ‘physicians’. Therefore, it seems interesting to ask whether they would also be able to comply with the ethical duties of a physician as outlined by the AMA.

The following 9 points are taken without change from the new AMA code; in brackets I have put my own, very brief comments pertaining to alternative practitioners. There is much more to be said about each of these points, of course, and I encourage my readers to do so in the comments section.

  1. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. [Most alternative practitioners use unproven treatments; I doubt whether this can be called ‘competent medical care’.]
  2. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. [Treating patients with unproven therapies in the absence of fully informed consent is arguably unprofessional, dishonest and deceptive. Crucially, alternative practitioners never object to even the worst excesses of quackery that occur in their realm.]
  3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. [Treatment with unproven therapies can hardly be in the best interest of the patient.]
  4. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. [The right of patients includes full informed consent which is, according to my impression, rare in alternative medicine.]
  5. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. [Alternative medicine is frequently out of line with or even opposed to medical knowledge.]
  6. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
  7. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. [Some activities of some alternative practitioners are directly opposed to public health, for instance when they advise against immunising children.]
  8. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. [Arguably this is not possible when using unproven therapies.]
  9. A physician shall support access to medical care for all people. [Some alternative practitioners advise their patients against accessing conventional healthcare.]

As I stated above, medical ethics are neglected in alternative medicine. The 9 points of the AMA together with my comments go some way towards explaining why this is so. If ethical principles were applied to alternative medicine, much of it would have to stop instantly.

Ad hominem attacks, I have previously pointed out, are victories of reason over unreason. And they are used frequently by supporters of alternative medicine!

If you doubt it, see for yourself.

I recently posted a comment on new Nice guidelines. It generated lots of comments, and mostly they were rational discussions of the issues involved. This changed abruptly when, on 16 May, Mel’s comment started a new, concerted wave of discussion at a time when the usual debate had already subsided. In the course of this new and heated debate, I was repeatedly accused of being rude.

As I have stated repeatedly on this blog, I try to keep rudeness out of the comments as much as I can. Therefore, the claim surprised me and today I reviewed the entire comment section selecting all potential ad hominem attacks. Here are the results:

ACTUAL OR POTENTIAL AD HOMINEM ATTACKS AGAINST ME

Peter Deadman on Tuesday 17 May 2016 at 12:55 Edward Ernst, I always thought you were a bully and a fraud. You’re very macho when it comes to slapping down people who may have experiential reasons for supporting acupuncture and other therapies but don’t have the skill to challenge you on the clinical evidence. Now as soon as somebody does, you back off, cry ‘enough’, say you can’t possibly comment till some undetermined future date and generally act like a wuss. I say put up or shut up. I’d prefer the former because it would be good to see you eat crow but I lean towards the latter because of the substantial harm you are causing and the beautiful silence that would ensue if you did indeed go quiet.

tonto on Tuesday 17 May 2016 at 13:19 You appear as weak in your arguments, as some pendulum swinging, new age dowser, who vainly holds sticks to their guns, not because they can back their position up with scientific evidence, but because it is what they “believe”.

Jill Onyett on Tuesday 17 May 2016 at 14:29 …an unfortunate creature too keen on the sound of his own voice.

Tracey Phillips on Tuesday 17 May 2016 at 13:16 …to date you have been fairly opinionated …

Peter Deadman on Tuesday 17 May 2016 at 16:34  I made an ad hominem response because your blog is all about you as a person. You are constantly rude to others and bypass or ignore responses that you don’t like. It’s you who makes it hominem.

Peter Deadman on Tuesday 17 May 2016 at 16:52 You are hyper-emotional, extremely biased, hostile and contemptuous of anyone you think ‘beneath you’. You gloat over people’s real or imagined inconsistencies and generally come across as a nasty piece of work.

Peter Deadman on Tuesday 17 May 2016 at 19:30 How can such a childish provocateur remain in his post. It demeans the University and it’s time they let him go.

Kylee Junghans on Wednesday 18 May 2016 at 08:42 …you, kind Sir, with your rhetoric and tantrums, are exhibiting a prime example of confirmation bias.

Peter Deadman on Wednesday 18 May 2016 at 08:48 [Ernst] professes a scholarly detachment, a commitment to evidence and an open mind, but in fact is deeply biased… He clearly loves his childish provocative stance and is as far from a disinterested observer as it’s possible to be. I wouldn’t waste my time or breath on him if he didn’t have an influence that far exceeds his worth.

Carol Cooke on Wednesday 18 May 2016 at 09:27 I have followed this discussion with interest. Some of the rudest and most discourteous posts I can see are from Mr Ernst himself. But I get that, I imagine you seek to maintain a bold and authoritative tone simply by dismissing others. Being a bit controversial in your discourse has obviously served you well in that you have built a media profile on it.

ACTUAL OR POTENTIAL AD HOMINEM ATTACKS BY MYSELF

Edzard on Wednesday 18 May 2016 at 09:18 “it is also difficult to get a man to read something, when he is foaming from his mouth”.

I know, this is not really ‘ad hominem’ but I could not find anything more dramatic. Surely, some will disagree this me here, and I do invite them to cite my rudeness from this threat, if they spot it. You are more than welcome!

CONCLUSION

You may think this is a bit trivial, but I disagree. The main reason I did this little exercise is to demonstrate a point which I think is important and carries a relevant lesson for future comments and discussions:

  • WHEN I OR ANYONE ELSE DEFENDING RATIONALITY GET AGGRESSED, WE NATURALLY TEND TO RESPOND SLIGHTLY MORE FORCEFULLY.
  • SUBSEQUENTLY, THE OTHER SIDE OFTEN REACTS BY ATTACKING US PERSONALLY.
  • THIS OFTEN LEADS TO AN ESCALATION OF TONE.
  • EVENTUALLY THE OTHER SIDE CLAIMS WITH INDIGNATION THAT WE ARE THE ONES DOING THE PERSONAL ATTACKS.
  • IT IS A TACTIC THAT IS EFFECTIVE BUT DISHONEST, IN MY VIEW.
  • THE LESSON IS SIMPLE: DO NOT LET YOURSELF GET PROVOKED INTO ISSUING AD HOMINEM ATTACKS, BE POLITE AND PATIENT.

I know this sounds simpler than it is, and I am far from being immune to the problem, but we owe it to reason to give it a try.

 

In a previous post, I asked this important question: how can research into alternative medicine ever save a single life?

The answer I suggested was as follows:

Since about 20 years, I am regularly pointing out that the most important research questions in my field relate to the risks of alternative medicine. I have continually published articles about these issues in the medical literature and, more recently, I have also made a conscious effort to step out of the ivory towers of academia and started writing for a much wider lay-audience (hence also this blog). Important landmarks on this journey include:

– pointing out that some forms of alternative medicine can cause serious complications, including deaths,

– disclosing that alternative diagnostic methods are unreliable and can cause serious problems,

– demonstrating that much of the advice given by alternative practitioners can cause serious harm to the patients who follow it,

– that the advice provided in books or on the Internet can be equally dangerous,

– and that even the most innocent yet ineffective therapy becomes life-threatening, once it is used to replace effective treatments for serious conditions.

Alternative medicine is cleverly, heavily and incessantly promoted as being natural and hence harmless. Several of my previous posts and the ensuing discussions on this blog strongly suggest that some chiropractors deny that their neck manipulations can cause a stroke. Similarly, some homeopaths are convinced that they can do no harm; some acupuncturists insist that their needles are entirely safe; some herbalists think that their medicines are risk-free, etc. All of them tend to agree that the risks are non-existent or so small that they are dwarfed by those of conventional medicine, thus ignoring that the potential risks of any treatment must be seen in relation to their proven benefit.

For 20 years, I have tried my best to dispel these dangerous myths and fallacies. In doing so, I had to fight many tough battles  (sometimes even with the people who should have protected me, e.g. my peers at Exeter university), and I have the scars to prove it. If, however, I did save just one life by conducting my research into the risks of alternative medicine and by writing about it, the effort was well worth it.

END OF QUOTE FROM MY PREVIOUS POST

Just now, I received an email from someone who clearly and vehemently disagrees with any of the above. As this blog is a forum where all sorts of opinions can and should be voiced, I thought I share this communication with you. Here it is:

Having been out of chiropractic practice for a while, I was thrilled to hear that you have been forced into early retirement on today’s Radio 4 programme. You have caused so many good people anguish and pain and your tunnel-visioned arrogance is staggering and detrimental to humanity. You REALLY think modern science has all the answers? Wow.

The question I ask myself is who is correct, the (ex-)chiropractor or I?

Specifically:

  1. Have I caused anguish and pain to many?
  2. Do I suffer from tunnel-vision?
  3. Am I arrogant?
  4. Is my work detrimental to humanity?
  5. Do I believe that modern science has all the answers?

Here is what I think about these specific questions:

  1. I have probably caused anguish (but no pain, as far as I am aware). This sadly is unavoidable if one seeks the truth in an area as alternative medicine.
  2. I am not the best person to judge this.
  3. Possibly; again I cannot judge.
  4. I truly don’t see this at all.
  5. No, not for one second.

In case you wonder what programme the author of the above email had been listening to, you can find it here.

Is there a bottom line? I am not sure. Perhaps this: whenever strong believes clash with scientific facts, some people are going to be unhappy. If we want to make progress, this seems to be almost unavoidable; all we can try to do is to minimize the anguish by being humble and by showing human decency.

The current ‘Acupuncture Awareness Week’ is perhaps a good occasion to look beyond acupuncture for humans. The ‘Chi Institute’ is an organisation that teaches TCM for animals. There you can specialise in all sorts of intriguing things that a critical mind would have never thought about. Take acupuncture for horses, for instance; on their website, the Institute informs us that:

The Equine Acupuncture Program…certifies students in veterinary acupuncture with an emphasis on horses. The program begins with an overview of fundamental aspects of Chinese Medicine, including Ying-Yang and Five Elements theory, which serve as a foundation for case diagnosis and treatment presented later in the class. A variety of acupuncture techniques are taught, including electro-acupuncture and moxibustion, in addition to conventional “dry” needling. Students of the program learn acupuncture points on large animals only, and horses are used for practice in the wet labs.

The program is presented in five sessions (two online and three on-site) over a period of six months. Online sessions are composed of lectures that students can stream at their own convenience. Afternoon wet-labs of on-site sessions give students the opportunity to learn acupuncture points on live animals in small lab groups of five to six students per instructor. A spring class and a fall class are held each year. Equine Acupuncture is offered to licensed veterinarians and veterinary school junior/senior students only.

Major Topics: 

  • Traditional Chinese Veterinary Medicine (TCVM) Principles: Five Elements, Yin-Yang, Eight Principles, Zang-Fu Physiology and Pathology, Meridians and Channels
  • Scientific Basis of Acupuncture
  • 200 Transpositional Equine Acupuncture Points (hands-on, wet-lab demos)
  • 70 Classical Equine Acupuncture Points (hands-on, wet-lab demos)
  • How to needle acupuncture points in horses
  • TCVM Diagnostic Systems, including Tongue and Pulse Diagnosis
  • How to integrate acupuncture into your practice
  • How to use veterinary acupuncture to diagnose and treat:
      1. Musculoskeletal conditions, lameness and neurological disorders
      2. Cardiovascular diseases and respiratory disorders
      3. Gastrointestinal disorders and behavioral problems
      4. Dermatological problems and immune-mediated diseases
      5. Renal & urinary disorders and reproductive disorders
  • Veterinary acupuncture techniques:
      1. Dry needle (conventional needling)
      2. Aqua-acupuncture (point injection)
      3. Electro-acupuncture
      4. Hemo-acupuncture
      5. Moxibustion

But is there not something missing, I asked myself when I read this. What about the evidence? What about the question whether there is any proof that any of this works?
As it happens, some time ago, we looked into this by conducting a systematic review. Here is our abstract ( I should mention that the first author of this paper was a vet who was very fond of acupuncture):

Acupuncture is a popular complementary treatment option in human medicine. Increasingly, owners also seek acupuncture for their animals. The aim of the systematic review reported here was to summarize and assess the clinical evidence for or against the effectiveness of acupuncture in veterinary medicine. Systematic searches were conducted on Medline, Embase, Amed, Cinahl, Japana Centra Revuo Medicina and Chikusan Bunken Kensaku. Hand-searches included conference proceedings, bibliographies, and contact with experts and veterinary acupuncture associations. There were no restrictions regarding the language of publication. All controlled clinical trials testing acupuncture in any condition of domestic animals were included. Studies using laboratory animals were excluded. Titles and abstracts of identified articles were read, and hard copies were obtained. Inclusion and exclusion of studies, data extraction, and validation were performed independently by two reviewers. Methodologic quality was evaluated by means of the Jadad score. Fourteen randomized controlled trials and 17 nonrandomized controlled trials met our criteria and were, therefore, included. The methodologic quality of these trials was variable but, on average, was low. For cutaneous pain and diarrhea, encouraging evidence exists that warrants further investigation in rigorous trials. Single studies reported some positive intergroup differences for spinal cord injury, Cushing’s syndrome, lung function, hepatitis, and rumen acidosis. These trials require independent replication. On the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.

What a pity that the pupils of the above course are not being told that THERE IS NO COMPELLING EVIDENCE that any of the tings they are about to learn has any value…but that would be bad for business, wouldn’t it? And we cannot have a bit of evidence jeopardize a nice little earner, can we?

THE LOCAL, SPAIN’S NEWS IN ENGLISH just reported that a master’s degree in homeopathic medicine at one of Spain’s top universities has been scrapped, because of its “lack of scientific basis”. A university spokesman confirmed the course was being scrapped and gave three main reasons:

  • “Firstly, the university’s Faculty of Medicine recommended scrapping the master’s because of the doubt that exists in the scientific community.
  • Secondly, a lot of people within the university – professors and students across different faculties – had shown their opposition to the course.
  • Thirdly, the postgraduate degree in homeopathic medicine is no longer approved by Spain’s Health Ministry.”

“All of these reasons taken together convinced the university to stop the course,” he added. The news has been praised by doctors and scientists throughout Spain, not least by Adrián Gómez, a chemistry student at the university, who five months ago launched a petition on the website change.org calling for the homeopathy master’s to be scrapped.

The university had started its Homeopathic Medicine Masters in 2004. Since then opposition to the course seems to have grown. Even Spain’s own Health Ministry stated in a 2011 report that “homeopathy has not proved its effectiveness in any specific clinical situation”.

The current student intake (n=20), which is due to finish the course in October 2016 will continue to the end, but there will be no new courses in homeopathy. THE LOCAL also reported that the homeopathic industry in Spain is worth around €60 million annually.

Vis a vis the now overwhelming evidence that homeopathy is a placebo therapy, more closures of homeopathy courses can be expected worldwide. Indeed, one has to ask why this particular course was started in 2004 when the evidence had been quite clear for some time. In my view, it is unethical of universities to set youngsters on a path of quackery and thus contribute to an obstacle to evidence-based health care.

 

Germany is, as we all know, the home of homeopathy. Here it has an unbroken popularity, plenty of high level support and embarrassingly little opposition. The argument that homeopathy has repeatedly been shown to merely rely on placebo effects seems to count for nothing in Germany.

Perhaps this is going to change now. On January 30, a group of experts from all walks of life have met in Freiburg to discuss ways of informing the public responsibly and countering the plethora of misinformation that Germans are regularly exposed to on the subject of homeopathy. They founded the ‘Information Network Homeopathy’ and decided on a range of actions.

No doubt, some will ask where does their financial support come from? And no doubt, some will claim that we are on the payroll of ‘Big Pharma’. The truth is that we have no funding; everyone gives his/her own time free of charge and pays for his/her own expenses etc. And why? Because we believe in progress and feel strongly that it is time to improve healthcare by relegating homeopathy to the history books.

One of the first fruits of the network’s endeavours is the Freiburger Erklärung zur Homöopathie’, the ‘Freiburg Declaration on Homeopathy’. I have the permission to reproduce the document here in full (the translation is mine):

HOMEOPATHY IS NEITHER NATUROPATHY NOR MEDICINE

Despite the support of politicians and the silence of those who should know better, homeopathy has remained a method which is in clear opposition to the proven basics of science. The members and supporter of the ‘Information Network Homeopathy’ view homeopathy as a stubbornly surviving belief system, which cannot be accepted as part of naturopathy nor medicine. The information network is an association of physicians, pharmacists, veterinarians, biologists, scientists and other critics of homeopathy who are united in their aim to disclose this fact more openly and make the public more aware of it.

NO SPECIAL STATUS FOR HOMEOPATHY

During the more than 200 years of its existence, homeopathy has not managed to demonstrate its specific effectiveness. Homeopathy only survives because it has been granted special status in the German healthcare system which is, in the opinion of the experts of the network, unjustified. Drugs have to prove their effectiveness according to objective criteria, but homeopathics are exempt from this obligation. We oppose such double standards in medicine.

Homeopathy has also not managed to demonstrate a plausible mode of action. Instead its proponents pretend that there are uncertainties which need to be clarified. We oppose such notions vehemently. Homeopathy is not an unconventional method that requires further scientific study. Its basis consists of long disproven theories such as the ‘law of similars’, ‘vital force’ or ‘potentisation by dilution’.

SELF-DECEPTION OF PATIENT AND THERAPIST

We do not dispute the therapeutic effects of a homeopathic treatment. But they are unrelated to the specific homeopathic remedy. The perceived effectiveness of homeopathics is due to suggestion and auto-suggestion of the patient and the therapist. The mechanisms of such (self-) deceit are multi-fold but well-known and researched. Symptomatic improvements caused by context-effects must not be causally associated with the homeopathic remedy. We assume that many physicians and alternative practitioners using homeopathy are unaware of the existence and multitude of such mechanisms and are acting in good faith. This, however, does not alter the fact that their conclusions are wrong and thus potentially harmful.

MEDICINE AND SCIENCE

We do not claim that the scientific method which we uphold can currently research and explain everything. However, it enables us to explain that homeopathy cannot explain itself. The scientific method shows the best way we have for differentiating effective from ineffective treatments. A popular belief in therapeutic claims nourished by politicians and journalists can never be a guide for medical activities.

AIM OF THIS DECLARATION

Our criticism is not aimed at needy patients or practising homeopathic clinicians; it is aimed at the school of homeopathy and the healthcare institutions which could have long recognised the nonsensical nature of homeopathy, but have chosen not to interfere. We ask the players within our science-based healthcare system to finally reject homeopathy and other pseudoscientific methods and to return to what should be self-evident: scientifically validated, fair and generally reproducible rules promoting top-quality medicine for he benefit of the patient.

Authors:

Dr.-Ing. Norbert Aust, Initiator Informationsnetzwerk Homöopathie

Dr. med. Natalie Grams, Leiterin Informationsnetzwerk Homöopathie

Amardeo Sarma, GWUP Vorsitzender und Fellow von CSI (Committee for Skeptical Inquiry)

Signatories:

Edzard Ernst, Emeritus Professor, Universität Exeter, UK

Prof. Dr. Rudolf Happle, Verfasser der Marburger Erklärung zur Homöopathie

Prof. Dr. Wolfgang Hell, Vorsitzender des Wissenschaftsrates der GWUP

Prof. Norbert Schmacke, Institut für Public Health und Pflegeforschung, Universität Bremen

Dr. rer. nat. Christian Weymayr, freier Medizinjournalist

A 2016 article set out to define the minimum core competencies expected from a certified paediatric doctor of chiropractic using a Delphi consensus process. The initial set of seed statements and sub-statements was modelled on competency documents used by organizations that oversee chiropractic and medical education. The statements were then distributed to the Delphi panel, reaching consensus when 80% of the panelists approved each segment. The panel consisted of 23 specialists in chiropractic paediatrics from across the spectrum of the chiropractic profession. Sixty-one percent of panellists had postgraduate paediatric certifications or degrees, 39% had additional graduate degrees, and 74% were faculty at a chiropractic institution and/or in a postgraduate paediatrics program. The panel was initially given 10 statements with related sub-statements formulated by the study’s steering committee. On all 3 rounds of the Delphi process the panelists reached consensus; however, multiple rounds occurred to incorporate the valuable qualitative feedback received.

The results of this process reveal that the Certified Paediatric Doctor of Chiropractic requires 8 sets of skills. (S)he will …

1) Possess a working knowledge and understanding of the anatomy, physiology, neurology, psychology, and developmental stages of a child. a) Recognize known effects of the prenatal environment, length of the pregnancy, and birth process on the child’s health. b) Identify and evaluate the stages of growth and evolution of systems from birth to adulthood. c) Appraise the clinical implications of developmental stages in health and disease, including gross and fine motor, language/communication, and cognitive, social, and emotional skills. d) Recognize normal from abnormal in these areas. e) Possess an understanding of the nutritional needs of various stages of childhood.

2) Recognize common and unusual health conditions of childhood. a) Identify and differentiate clinical features of common physical and mental paediatric conditions. b) Identify and differentiate evidence-based health care options for these conditions. c) Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population.

3) Be able to perform an age-appropriate evaluation of the paediatric patient. a) Take a comprehensive history, using appropriate communication skills to address both child and parent/ guardian. b) Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. c) When indicated, utilize age-appropriate laboratory, imaging, and other diagnostic studies and consultations, according to best practice guidelines. d) Appropriately apply and adapt these skills to the paediatric special needs population. e) Be able to obtain and comprehend all relevant external health records.

4) Formulate differential diagnoses based on the history, examination, and diagnostic studies.

5) Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. a) Use the scientific literature to inform the management plan. b) Adequately document the patient encounter and management plan. c) Communicate management plan clearly (written, oral, and nonverbal cues) with both the child and the child’s parent/guardian. d) Communicate appropriately and clearly with other professionals in the referral and co-management of patients.

6) Deliver skilful, competent, and safe chiropractic care, modified for the paediatric population, including but not limited to: a) Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. b) Physical therapy modalities. c) Postural and rehabilitative exercises. d) Nutrition advice and supplementation. e) Lifestyle and public health advice. f) Adapt the delivery of chiropractic care for the paediatric special needs population.

7) Integrate and collaborate with other health care providers in the care of the paediatric patient. a) Recognize the role of various health care providers in paediatric care. b) Utilize professional inter-referral protocols. c) Interact clearly and professionally as needed with health care professionals and others involved in the care of each patient. d) Clearly explain the role of chiropractic care to professionals, parents, and children.

8) Function as a primary contact, portal of entry practitioner who will. a) Be proficient in paediatric first aid and basic emergency procedures. b) Identify and report suspected child abuse.

9) Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients and professional practice. a) Monitor and properly reports of effects/adverse events. b) Recognize cultural individuality and respect the child’s and family’s wishes regarding health care decisions. c) Engage in lifelong learning to maintain and improve professional knowledge and skills. d) Contribute when possible to the knowledge base of the profession by participating in research. e) Represent and support the specialty of paediatrics within the profession and to the broader healthcare and lay communities.

I find this remarkable in many ways. Let us just consider a few items from the above list of competencies:

Identify and differentiate evidence-based health care options… such options would clearly not include chiropractic manipulations.

Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population… as above. Why is there no mention of immunisations anywhere?

Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. If that is a competency requirement, patients should really see the appropriate medical specialists rather than a chiropractor.

Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. The treatment plan is either evidence-based or it includes chiropractic manipulations.

Deliver skilful, competent, and safe chiropractic care… Aren’t there contradictions in terms here?

Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. Where is the evidence that these treatments are effective for paediatric conditions, and which conditions would these be?

Clearly explain the role of chiropractic care to professionals, parents, and children. As chiropractic is not evidence-based in paediatrics, the role is extremely limited or nil.

Function as a primary contact, portal of entry practitioner… This seems to me as a recipe for disaster.

Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients… This would include obtaining informed consent which, in turn, needs to include telling the parents that chiropractic is neither safe nor effective and that better therapeutic options are available. Moreover, would it not be ethical to make clear that a paediatric ‘doctor’ of chiropractic is a very far cry from a real paediatrician?

So, what should the competencies of a chiropractor really be when it comes to treating paediatric conditions? In my view, they are much simpler than outlined by the authors of this new article: I SEE NO REASON WHATSOEVER WHY CHIROPRACTORS SHOULD TREAT CHILDREN!

The BMJ is my favourite medical journal by far; I think it is full of good science as well as entertaining to read, and I look forward to finding it in my letter box every Friday. It is thus hard for me to criticise the BMJ, and this is not made easier by the fact that I am the author of one of the two pieces in question. However, the current ‘HEAD TO HEAD’ entitled ‘SHOULD DOCTORS RECOMMEND HOMEOPATHY’ does, in my view, not mark the finest hour of this journal. Let me explain why.

The first question that arises is whether homeopathy is a good subject for such a debate. As several commentators have pointed out, it is not – the debate has long been closed; to serious scientists and many doctors, homeopathy tends to be a subject that is nothing more than an odd, obsolete triviality that does not even deserve a mention in the BMJ or any other serious publication. In a way, this notion has almost been proven wrong by the high level of interest the subject quickly generated. So, I will not dwell on this point any longer.

The second issue that arises just from nothing more than merely reading the title of the debate is that the question posed is imprecise. ‘Homeopathy’ is too broad a term for a focussed discussion; it includes amongst other phenomena empathetic encounters, remedies with material doses of highly active ingredients (e.g. Arsenic D1) and remedies that contain absolutely nothing at all (any ‘potency’ beyond C12). In my piece, I tried to make it clear that I speak mostly about ultra-molecular dilutions. This is less obvious in Peter Fisher’s article, and there is doubtlessly a lot of confusion in the debate as well as the comments that follow.

The two articles had to be written without either author knowing the text of the other. Consequently the issues raised by one author were not necessarily addressed by the other. This is somewhat frustrating, as it fails to clarify issues that could easily have been dealt with. In a previous post, I have already explained that the peer-review process of the two articles was seriously flawed. It failed to correct the many misleading statements in Fisher’s piece, as Alan Henness has pointed out in his response both in the BMJ and on this blog. In fact, reading Fisher’s article, I fail to find a single passage that is not factually wrong or highly misleading (the accompanying podcast is even worse, in my view). To me it is obvious that the debate about homeopathy cannot advance, if one side continues to behave in this fashion.

Homeopaths are very adept at recruiting ‘grass roots’ for public relation activities. We know this from various previous experiences. It was therefore predictable that this would swiftly get organised also in this instance. I happen to know from more than one source that there was a highly active campaign by homeopaths trying to persuade their supporters to post responses on the BMJ site and to vote on the BMJ straw poll (scientists, by contrast, know that such polls are silly gadgets and tend to view homeopathy as a triviality that is not worth the effort). In this way, they try to generate the impression that the majority of the public stands firmly behind homeopathy and want doctors to recommend it. It does not need too much to realise that popularity is not a measure of efficacy. Homeopaths, however, tend to relish logical fallacies and therefore will rejoice at such nonsense and celebrate it as their very own victory.

So, was this ‘HEAD TO HEAD’ a mistake? Should I have refused to participate? With hindsight, perhaps. My main reason for accepting was that, had I declined the offer, someone else would have written the piece (there are plenty of excellent scientists who could do an excellent job at this). As sure as hell, that person would subsequently gotten attacked for not ever having researched and/or practiced homeopathy (in the podcast, Fisher even tried to undermine my authority by pointing out that 1) I have not worked as a clinician for decades and 2) I have no NHS contract). I think I may be one of the few critics of homeopathy who cannot possibly be accused of not knowing enough about homeopathy to discuss the subject.

My hope is that, because the BMJ is such an excellent journal, the two articles will survive the current hoo-hah and some people will read them carefully, look up and study the references, analyse all this critically and weigh the arguments responsibly. Then they must be able to discern the fiction from the facts. And in this case, perhaps it was worth it after all.

I just came across a website that promised to”cover 5 common misconceptions about alternative medicine that many people have”. As much of this blog is about this very issue, I was fascinated. Here are Dr Cohen’s 5 points in full:

5 Misconceptions about Alternative Medicine Today

1. Alternative Medicine Is Only an Alternative

In fact, many alternative practitioners are also medical doctors, chiropractors, or other trained medical professionals. Others work closely with MDs to coordinate care. Patients should always let all of their health care providers know about treatments that they receive from all the others.

2. Holistic Medicine Isn’t Mainstream

In fact, scientists and doctors do perform studies on all sorts of alternative therapies to determine their effectiveness. These therapies, like acupuncture and an improved diet, pass the test of science and then get integrated into standard medical practices.

3. Natural Doctors Don’t Use Conventional Medicine

No credible natural doctor will ever tell a patient to replace prescribed medication without consulting with his or her original doctor. In many cases, the MD and natural practitioner are the same person. If not, they will coordinate treatment to benefit the health of the patient.

4. Alternative Medicine Doesn’t Work

Actual licensed health providers won’t just suggest natural therapies on a whim. They will consider scientific studies and their own experience to suggest therapies that do work. Countless studies have, for example, confirmed that acupuncture is an effective treatment for many medical conditions. Also, the right dietary changes are known to help improve health and even minimize or cure some diseases. Numerous other alternative therapies have been proven effective using scientific studies.

5. Big Medical Institutions are Against Alternative Medicine

According to a recent survey, about half of big insurers pay for tested alternative therapies like acupuncture. Also, hospitals and doctors do recognize that lifestyle changes, some herbal remedies, and other kinds of alternative medicine may reduce side effects, allow patients to reduce prescription medicine, and even lower medical bills.

This is not to say that every insurer, doctor, or hospital will support a particular treatment. However, patients are beginning to take more control of their health care. If their own providers won’t suggest natural remedies, it might be a good idea to find one who does.

The Best Medicine Combines Conventional and Alternative Medicine

Everyone needs to find the right health care providers to enjoy the safest and most natural care possible. Good natural health providers will have a solid education in their field. Nobody should just abandon their medical treatment to pursue alternative cures. However, seeking alternative therapies may help many people reduce their reliance on harsh medications by following the advice of alternative providers and coordinating their care with all of their health care providers.

END OF COHEN’S TEXT

COMMENT BY MYSELF

Who the Dickens is Dr Cohen and what is his background? I asked myself after reading this. From his website, it seems that he is a chiropractor from North Carolina – not just any old chiro, but one of the best!!! – who also uses several other dubious therapies. He sums up his ‘philosophy’ as follows:

There is an energy or life force that created us (all 70 trillion cells that we are made of) from two cells (sperm and egg cells). This energy or innate intelligence continues to support you throughout life and allows you to grow, develop, heal, and express your every potential. This life force coordinates all cells, tissues, muscles and organs by sending specific, moment by moment communication via the nervous system. If the nervous system is over-stressed or interfered with in any way, then your life force messages will not be properly expressed.

Here he is on the cover of some magazine and here is also his ‘PAIN CLINIC’

naturopathic-doctor-greenville-nc

Fascinating stuff, I am sure you agree.

As I do not want to risk a libel case, I will abstain from commenting on Dr Cohen and his methods or beliefs. Instead I will try to clear up a few misconceptions that are pertinent to him and the many other practitioners who are promoting pure BS via the Internet.

  • Not everyone who uses the title ‘Dr’ is a doctor in the sense of having studied medicine.
  • Chiropractors are not ‘trained medical professionals’.
  • The concepts of ‘vitalism’, ‘life force’ etc. have been abandoned in real heath care a long time ago, and medicine has improved hugely because of this.
  • Hardly any alternative therapy has ‘passed the test of science’.
  • Therefore, it is very doubtful whether alternative practitioners actually will ‘consider scientific studies’.
  • True, some trials did suggest that acupuncture is an effective treatment for many medical conditions; but their methodological quality is often far too low to draw firm conclusions and many other, often better studies have shown the contrary.
  • Numerous other alternative therapies have been proven ineffective using scientific studies.
  • Therefore it might be a good idea to find a health care provider who does not offer unproven treatments simply to make a fast buck.
  • Seeking alternative therapies may harm many people.

If you talk to advocates of homeopathy, you are bound to hear claims that are false or misleading; in fact, you hear them so regularly that you might begin to doubt the truth. For those who have such doubts or are in need of some correct counter-arguments, I have listed here those 12 bogus claims which, in my experience, are most common together with short, suitable, and factual rebuttals.

1) THERE IS NOTHING MYSTERIOUS ABOUT HOMEOPATHY’S MODE OF ACTION, IT WORKS LIKE VACCINATIONS

This argument is used by enthusiasts in response the fact that most homeopathic remedies are too highly diluted to have pharmacological effects. Vaccines are also highly diluted and they are, of course, very effective; therefore, so the bogus notion, there is nothing odd about homeopathy.

The argument is wrong on several levels; the easiest way to refute, I think, it is to point out that vaccines contain measurable amounts of material and lead to measurable changes in the immune system. By contrast, the typical homeopathic remedy (beyond the C12 potency) contains not a single molecule of an active substance and leads to no measurable changes in any system.

2) SIGNIFICANTLY MORE CONTROLLED CLINICAL TRIALS OF HOMEOPATHY ARE POSITIVE THAN NEGATIVE

Several websites of homeopathic organisations make this claim and even provide simple statistics to back it up. Consequently, many homeopathy fans have adopted it.

The statistics they present show that x % of studies are positive, y % are negative and z % are neutral; the whole point is that x is larger than y. The percentage figures may even be correct but they rely on the spurious definitions used: positive = superior to placebo, negative = placebo superior to homeopathy, neutral = no difference between homeopathy and placebo. The latter category was created so that homeopathy comes out trumps.

For all intents and purposes, a study where the experimental treatment is no better than placebo is not a study neutral but a negative result. Thus the negative category in such statistics must be y + z which is, of course, larger than x. In other words, the majority of trials is, in truth, negative.

3) HOMEOPATHY IS SUPPORTED BY NOBEL PRIZE WINNERS

I don’t know of a single Nobel Prize winner who has stated or implied that homeopathy works better than a placebo. Some have tried to find a mechanism of action for homeopathy by doing some basic research and have published theories about it. None of those has been accepted by science.

And if there ever should be a Nobel Prize winner or similarly brilliant person who supports homeopathy, this would merely show that even bright individuals can make mistakes!

4) HOMEOPATHY IS SAFE

Tell that to the child that has just been reported to have died because her parents used homeopathy for an ear infection which (could have been easily treated with antibiotics but) degenerated into a brain abscess with homeopathic therapy. There are many more such tragic cases than I care to remember.

The risks of homeopathy are, of course, minor compared to many conventional treatments, but the risk/benefit balance of homeopathy can never be positive because, unlike those high risk conventional treatments, it has no benefit.

5) HOMEOPATHY DOES NOT LEND ITSELF TO BEING TESTED IN CLINICAL TRIALS

The best way to disprove this argument is to point out that ~ 250 controlled clinical trials are currently available. Every homeopath on the planet boasts about clinical trials – provided they are positive.

6) HOMEOPATHY WORKS VIA QUANTUM ENTANGLEMENT

I do not understand quantum mechanics and, I suspect, neither do the homeopaths who use this argument. But physicists who do understand this subject well are keen to stress that homeopathy cannot be explained in this way.

7) THERE IS NO PROOF THAT HOMEOPATHY DOES NOT WORK

The absence of evidence is not the same as evidence of absence, homeopaths like to exclaim. And they are, of course, correct! However, they forget that, science cannot prove a negative and that, in routine health care, we do not even look for a proof of ineffectiveness. We use those treatments that have a positive proof of effectiveness – everything else is irresponsible.

8) EVEN IF HOMEOPATHY WERE JUST A PLACEBO, IT STILL HELPS PATIENTS AND IS THEREFORE A USEFUL TREATMENT

It is true, of course, that placebo effects can help patients. But it is not true that, for generating a placebo response, we need a placebo. If a clinician administers an effective treatment with compassion, the patient will benefit from a placebo response plus from the specific effects of the treatment. Only giving placebos is therefore tantamount to cheating the patient.

9) THERE IS A WORLDWIDE CONSPIRACY AGAINST HOMEOPATHY

In a way, this argument merely suggests that homeopathic remedies are ineffective in treating paranoia. I have not ever seen a jot of evidence for it – and neither can anyone who uses this claim produce any.

10) YOU NEED TO BE A HOMEOPATH TO BE ABLE TO UNDERSTAND AND ADEQUATELY JUDGE THE VALUE OF HOMEOPATHY

With this notion, homeopaths want to claim that the critics of homeopathy are incompetent. It is like saying that only people who believe in god are allowed to criticise religion. By definition, homeopaths are believers, and therefore they are unlikely to be free of bias when judging the value of homeopathy. Homeopathy is a health technology that must be evaluated like all other health technologies: by independent scientists who know their job.

11) HOMEOPATHY HAS BEEN PROVEN TO WORK FOR LITTLE CHILDREN AND ANIMALS

The argument here is that animals and children cannot possibly respond to placebo. Therefore homeopathy must be more than a placebo.

This notion is twice wrong. Firstly, both animals and children can respond to placebo, if only ‘by proxy’, i.e. via their carers. Secondly, if we consider the totality of the reliable data, we find that neither for children nor for animals is the evidence convincingly positive.

12) HOMEOPATHY HAS BEEN USED VERY SUCCESSFULLY IN MAJOR EPIDEMICS, AND THAT FACT IS PROOF ENOUGH FOR ITS EFFICACY

Yes, there are some rather fascinating historical accounts which homeopaths interpret in this fashion. But if we look a little closer, we invariably find explanations which are much more plausible than the assumption of homeopathy’s effectiveness. Epidemiological observations of this nature can almost never establish cause and effect, and the clinical outcome could have been due to a myriad of confounders unrelated to homeopathy.

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