MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

experience

‘The use of a harmless alternative therapy is not necessarily wrong. Even if the treatment itself is just a placebo, it can help many patients. Some patients feel better with it, and it would be arrogant, high-handed and less than compassionate to reject such therapies simply because they are not supported by sufficient scientific evidence’.

How often have I heard this notion in one or another form?

I hear such words almost every day.

Arguments along these lines are difficult to counter. Any attempt to do so is likely to make us look blinkered, high-handed and less than compassionate.

Yet we all – well almost all – know that the notion is wrong. Not only that, it can be dangerous.

I will try to explain this with a concrete example of a patient employing a harmless alternative remedy with great success… until… well, you’ll see.

The patient is a married women with two kids. She is well known to her doctor because she has suffered from a range of symptoms for years, and the doctor – despite extensive tests – could never find anything really wrong with her. He knows about his patient’s significant psychological problems and has, on occasion, been tempted to prescribe tranquilizers or anti-depressants. Before he does so, however, he tells her to try Rescue Remedies@ (homeopathically diluted placebos from the range of Bach Flower Remedies). The patient is generally ‘alternatively inclined’, seems delighted with this suggestion and only too keen to give it a try.

After a couple of weeks, she reports that the Rescue Remedies (RR) are helping her. She says she can cope much better with stressful situations and has less severe and less frequent headaches or other symptoms. As she embarks on a long period of taking RR more or less regularly, she becomes convinced that the RR are highly effective and uses them whenever needed with apparent success. This goes on for months, and everyone is happy: the patient feels she has finally found a ‘medication that works’, and the doctor (who knows only too well that RR are placebos) is pleased that his patient is suffering less without needing real medication.

Then, a few months later, the patient notices that the RR are becoming less and less effective. Not only that, she also thinks that her headaches have changed and are becoming more intense. As she has been conditioned to believe that the RR are highly effective, she continues to take them. Her doctor too agrees and encourages her to carry on as before. But the pain gets worse and worse. When she develops other symptoms, her doctor initially tries to trivialise them, until they cannot be trivialised any longer. He eventually sends her to a specialist.

The patient has to wait a couple of weeks until an appointment can be arranged. The specialist orders a few tests which take a further two weeks. Finally, he diagnoses a malignant, possibly fast growing brain tumour. The patient has a poor prognosis but nevertheless agrees to an operation. Thereafter, she is paralysed on one side, needs 24-hour care, and dies 4 weeks post-operatively.

The surgeon is certain that, had he seen the patient several months earlier, the prognosis would have been incomparably better and her life could have been saved.

I suspect that most seasoned physicians have encountered stories which are not dissimilar. Fortunately they often do not end as tragically as this one. We tend to put them aside, and the next time the situation arises where a patient reports benefit from a bogus treatment we think: ‘Even if the treatment itself is just a placebo, it might help. Some patients feel better with it, and it would be arrogant, high-handed and less than compassionate to reject this ‘feel-good factor’.

I hope my story might persuade you that this notion is not necessarily correct.

If you are unable to make your patient feel better without resorting to quackery, my advice is to become a pathologist!!!

Wellness?

Yes, it’s a new buzz-word in the realm of alternative medicine – actually, not so new; it’s been around for years and seems to attract charlatans of all imaginable types.

But what precisely is it?

The authors of this paper explain: “While the concept of wellness is still evolving, it is generally recognized that wellness is a holistic concept best represented as a continuum, with sickness, premature death, disability, and reactive approaches to health on one side and high-level wellness, enhanced health, and proactive approaches to health and well-being on the other. It is further acknowledged that wellness is multidimensional and includes physiologic, psychological, social, ecologic, and economic dimensions. These multiple dimensions make wellness difficult to accurately assess as multiple subjective and objective measures are required to account for the different dimensions. Thus, the assessment of wellness in individuals may include a variety of factors, including assessment of physiologic functioning, anthropometry, happiness, depression, anxiety, mood, sleep, health symptoms, toxic load, neurocognitive function, socioeconomic status, social connectivity, and perceived self-efficacy.”

Sounds a bit woolly?

I agree! It sounds like a gimmick for getting at the cash of the gullible public.

Is there money to be made with ‘wellness’?

Sure! Lots!

For instance, with so-called ‘wellness retreats’.

Wellness retreats are all the rage. They use all sorts of bogus therapies within luxurious holiday settings for the ‘well to do’ end of our societies.

But is there any science behind this approach?

Few studies have evaluated the effect of retreat experiences, and no published studies have reported health outcomes. The objective of this new study therefore was to assess the effect of a week-long wellness-retreat experience in wellness tourists. The study was designed as a longitudinal observational study without a control group. Outcomes were assessed upon arrival and departure and 6 weeks after the retreat. The intervention was a ‘holistic, 1-week, residential, retreat experience that included many educational, therapeutic, and leisure activities and an organic, mostly plant-based diet’.

The outcome measures included anthropometric measures, urinary pesticide metabolites, a food and health symptom questionnaire, the Five Factor Wellness Inventory, the General Self Efficacy questionnaire, the Pittsburgh Insomnia Rating Scale, the Depression Anxiety Stress Scale, the Profile of Mood States, and the Cogstate cognitive function test battery.

Statistically significant improvements were seen in almost all measures after 1 week. Many of these improvements were also sustained at 6 weeks. There were statistically significant improvements in all anthropometric measures after 1 week, with reductions in abdominal girth, weight, and average systolic and diastolic pressure. Statistically significant improvements were also noted in psychological and health symptom measures. Urinary pesticide metabolites were detected in pooled urine samples before the retreat and were undetectable after the retreat.

The authors concluded that “the retreat experiences can lead to substantial improvements in multiple dimensions of health and well-being that are maintained for 6 weeks. Further research that includes objective biomarkers and economic measures in different populations is required to determine the mechanisms of these effects and assess the value and relevance of retreat experiences to clinicians and health insurers.”

IS THIS GOOD OR BAD RESEARCH?

Let’s apply my checklist from the previous post:

  • published in one of the many dodgy CAM journals? YES
  • single author? NO
  • authors are known to be proponents of the treatment tested? YES
  • author has previously published only positive studies of the therapy in question? YES
  • lack of plausible rationale for the study? YES
  • lack of plausible rationale for the therapy that is being tested? YES
  • stated aim of the study is ‘to demonstrate the effectiveness of…’ ? NO
  • stated aim ‘to establish the effectiveness AND SAFETY of…’? NO
  • text full of mistakes, e. g. spelling, grammar, etc.? NO
  • sample size is tiny? YES
  • pilot study reporting anything other than the feasibility of a definitive trial? NO
  • methods not described in sufficient detail? YES
  • mismatch between aim, method, and conclusions of the study? YES
  • results presented only as a graph? NO
  • statistical approach inadequate or not sufficiently detailed? NO
  • discussion without critical input? NO
  • lack of disclosures of ethics, funding or conflicts of interest? NO
  • conclusions which are not based on the results? YES

To me, this rough and ready assessment indicates that there are too many warning signals for characterising this as a rigorous study. It looks a lot like pseudo-science, I fear.

But these are at best formal markers. More important is the fact that the whole idea of measuring the effects of a ‘wellness retreat’ makes little sense, particularly in the absence of a control group. If we take a few people out of their usual, stressful work-environment and put them into a nice and luxurious holiday atmosphere where they get papered, eat better food, exercise more, sleep better and relax a lot – what would we expect after one week?

Yes, precisely! We would expect that almost anything measurable has changed for the better!

In fact, this result is so predictable that it is hardly worth documenting. Crucially, the outcome has very little to do with wellness, holism, or alternative medicine.

My conclusion: wellness not only attracts charlatans, entrepreneurs and windbags, it also is firmly steeped in pseudoscience.

 

 

 

One of the questions I hear frequently is ‘HOW CAN I BE SURE THIS STUDY IS SOUND’? Even though I have spent much of my professional life on this issue, I am invariably struggling to provide an answer. Firstly, because a comprehensive reply must inevitably have the size of a book, perhaps even several books. And secondly, to most lay people, the reply would be intensely boring, I am afraid.

Yet many readers of this blog evidently search for some guidance – so, let me try to provide a few indicators – indicators, not more!!! – as to what might signify a good and a poor clinical trial (other types of research would need different criteria).

INDICATORS SUGGESTIVE OF A GOOD CLINICAL TRIAL

  • Author from a respected institution.
  • Article published in a respected journal.
  • A clear research question.
  • Full description of the methods used such that an independent researcher could repeat the study.
  • Randomisation of study participants into experimental and control groups.
  • Use of a placebo in the control group where possible.
  • Blinding of patients.
  • Blinding of investigators, including clinicians administering the treatments.
  • Clear definition of a primary outcome measure.
  • Sufficiently large sample size demonstrated with a power calculation.
  • Adequate statistical analyses.
  • Clear presentation of the data such that an independent assessor can check them.
  • Understandable write-up of the entire study.
  • A discussion that puts the study into the context of all the important previous work in this area.
  • Self-critical analysis of the study design, conduct and interpretation of the results.
  • Cautious conclusion which are strictly based on the data presented.
  • Full disclosure of ethics approval and informed consent,
  • Full disclosure of funding sources.
  • Full disclosure of conflicts of interest.
  • List of references is up-to-date and includes also studies that contradict the authors’ findings.

I told you this would be boring! Not only that, but each bullet point is far too short to make real sense, and any full explanation would be even more boring to a lay person, I am sure.

What might be a little more fun is to list features of a clinical trial that might signify a poor study. So, let’s try that.

WARNIG SIGNALS INDICATING A POOR CLINICAL TRIAL

  • published in one of the many dodgy CAM journals (or in a book, blog or similar),
  • single author,
  • authors are known to be proponents of the treatment tested,
  • author has previously published only positive studies of the therapy in question (or member of my ‘ALT MED HALL OF FAME’),
  • lack of plausible rationale for the study,
  • lack of plausible rationale for the therapy that is being tested,
  • stated aim of the study is ‘to demonstrate the effectiveness of…’ (clinical trials are for testing, not demonstrating effectiveness or efficacy),
  • stated aim ‘to establish the effectiveness AND SAFETY of…’ (even large trials are usually far too small for establishing the safety of an intervention),
  • text full of mistakes, e. g. spelling, grammar, etc.
  • sample size is tiny,
  • pilot study reporting anything other than the feasibility of a definitive trial,
  • methods not described in sufficient detail,
  • mismatch between aim, method, and conclusions of the study,
  • results presented only as a graph (rather than figures which others can re-calculate),
  • statistical approach inadequate or not sufficiently detailed,
  • discussion without critical input,
  • lack of disclosures of ethics, funding or conflicts of interest,
  • conclusions which are not based on the results.

The problem here (as above) is that one would need to write at least an entire chapter on each point to render it comprehensible. Without further detailed explanations, the issues raised remain rather abstract or nebulous. Another problem is that both of the above lists are, of course, far from complete; they are merely an expression of my own experience in assessing clinical trials.

Despite these caveats, I hope that those readers who are not complete novices to the critical evaluation of clinical trials might be able to use my ‘warning signals’ as a form of check list that helps them to tell the chaff from the wheat.

Whenever a level-headed person discloses that a specific alternative therapy is not based on good evidence, you can bet your last shirt that a proponent of the said treatment responds by claiming that conventional medicine is not much better.

There are several variations to this theme. Today I want to focus on just one of them, namely the counter-claim that, only a short while ago, conventional medicine was not much better than the said alternative therapy (the implication is that it must be unfair to demand evidence from alternative medicine, while accepting a similar state of affairs in conventional medicine). The argument has recently been formulated by one commentator on this blog as follows:

“Trepanation, leeches for UTI’s, and bloodletting are all historical treatments of medical doctors…It’s hypocritical… to impute mainstream chiropractice to the profession’s beginnings and yet not admit that medicine’s founding and evolution was inbued with consistently scientific rigor.”

Sadly, some people seem to be convinced by such words, and this is why they are being repeated ad nauseam by interested parties. Yet the argument is fallacious for a range of reasons.

  • Firstly, it is based on the classical ‘tu quoque’ fallacy (appeal to hypocrisy).
  • Secondly – unless we happen to be historians – it is not the healthcare of the past that is relevant to our discussions. The question cannot be what this or that group of clinicians used to do; the question is HOW DO THEY TREAT THEIR PATIENTS TODAY?

As soon as we focus on this issue, it is impossible to deny that conventional medicine has made lots of progress and moved light years away from treatments such as trepanation, leeches, bloodletting and many others.

Why?

Why did we make such huge progress?

Because research showed that many of the traditional treatments were ineffective, unsafe and/or implausible (thus demonstrating that hundreds of years of experience – which alternative therapists rate so very highly – is of more than dubious value), and because we consequently developed and tested new therapies and subsequently used those treatments that passed these tests and were proven to do more good than harm.

By contrast, in the last decades, centuries and millennia, homeopathy, chiropractic, acupuncture, paranormal healing etc. did make no (or very little) progress. So much so that Hahnemann, for instance, would pass any exam for  homeopathy today. (If you disagree with this statement, please post a list of those treatments that have been given up by alternative therapists in the last 100 years or so.) Come to think of it, it is a hallmark of alternative medicine that it does not progress in the way conventional medicine does. It is almost completely static, a fact, that renders it akin to a dogma or a cult.

But why? Why is there no real progress in alternative medicine?

Don’t tell me that there is no research, research funding, etc. There are now hundreds of studies of homeopathy or chiropractic, thousands of acupuncture, and dozens of paranormal healing, for instance. The trouble is not the paucity of such research but its findings! The totality of the evidence in each of these areas fails to show that the therapy in question is efficacious.

And there we have, I think, another hallmark of alternative medicine: it is an area where research is only acted upon, if its findings are in line with the preconceptions and aspirations of its proponents.

I find this interesting!

It means, amongst other things, that research into alternative medicine tends not to be used for finding the truth or establishing new knowledge; it is mainly employed for the promotion of the therapy in question, regardless of what the truth about it might be (this would disqualify this exercise from being research and qualify it as PSEUDO-RESEARCH). If the research findings are such that they cannot be used for promotion, they are simply ignored or defamed as inadequate.

You probably remember: the US Federal Trade Commission’s (FTC) has issued a statement announcing that unsupported claims for homeopathic remedies will be no longer allowed. Specifically, they said that, in future, homeopathic remedies have to be held to the same standard as other medicinal products. In other words, American companies must now have reliable scientific evidence for health-related claims that their products can treat specific conditions and illnesses.

Now the AMERICAN INSTITUTE OF HOMEOPATHY (AIH) has published a rebuttal. It is hilarious and embarrassing in equal measure. Here it is in full (I have only omitted their references – they can be seen in the linked original –  and added footnotes in bold square brackets with my very short comments):

START OF QUOTE

November 30, 2016

The American Institute of Homeopathy applauds the Federal Trade Commission’s (FTC) goal of protecting the American public from false advertising claims, but in a recent circumstance we believe the FTC has overstepped its jurisdictional bounds and promulgated false information in what appears to be a bid to restrict health care choices [1] available to the American public.

In Response to the recent Enforcement Policy Statement1 and a Consumer Information Blog,2 both issued by the FTC on November 15, 2016, the American Institute of Homeopathy registers our strong concern regarding the content of the following inaccurate statements:

  1. “Homeopathy… is based on the view that disease symptoms can be treated by minute doses of substances that produce similar symptoms…”

Homeopathy is not based on a “view” or an opinion. It is based on reliable, reproducible, clinically acquired, empiric evidence [2] gathered through two centuries of corroborated data, assisted by thousands of practitioners worldwide [3], demonstrating the actions of different medicinal substances in living systems, aka: the science of homeopathy. In fact, the homeopathic scientific community were pioneers of the modern scientific method including the widespread adoption of blinded and placebo controlled studies in 1885 [4], decades before conventional medicine.3

Homeopathy is not based on a theory or on conjecture, but on principles that have been confirmed by long-studied clinical data, meticulously gathered and analyzed over many years [5].

  1. “Many homeopathic products are diluted to such an extent that they no longer contain detectable levels of the initial substance.”

While the dilution and succussion process of formulating homeopathic medicines does reduce the concentration (and the toxicity) of the original substances, detectable amounts of these materials remain quantifiable in the form of nanoparticles [6] dispersed throughout.4 Multiple independent laboratories, worldwide have confirmed that these nanoparticles persist,5 and that they are biologically active.6 Many other homeopathic products (particularly those sold OTC and described as “low potency”) have dilute amounts of the original substance [7] that remain chemically detectable by straightforward titration.

  1. “…homeopathic product claims are not based on modern scientific methods…”

This statement is false and misleading. The active ingredients within most OTC homeopathic products have hundreds or thousands of case reports from physicians who have used these medicines [8]. These reports of direct clinical experiences establish a collective, real-world dataset that demonstrates which conditions have been observed to respond to treatment. Such historical data is similar to the types of information used to demonstrate effectiveness for many conventional OTC medicines on the market today [9].

The Homeopathic Pharmacopeia Convention of the United States (HPCUS) maintains a formulary describing the appropriate manufacturing standards for homeopathic medicines [10]. Every homeopathic manufacturer member of the American Association of Homeopathic Pharmacists in good ethical standing complies with both manufacturing and labeling standards set by the HPCUS. Consumers should be cautious when using any products that are not distinguished by conformance with “HPUS” on the label.

  1. “…the case for efficacy is based solely on traditional homeopathic theories…”

This statement is false. Neither homeopathy nor homeopathic efficacy is based on any theories. Efficacy for various homeopathic medicines has been established by scientifically reproducible clinical empiric research evidence [11] and cured patient cases followed over many years [12]. Homeopathy is an evidence-based medical subspecialty rooted in patient care.

  1. “…there are no valid studies using current scientific methods showing the product’s efficacy.”

While this statement may have limited accuracy with respect to some OTC products, it is false and misleading with respect to most homeopathic medicines listed in the Homeopathic Pharmacopeia of the United States. Hundreds of state-of-the-art double-blinded, randomized, placebo-controlled studies, many in peer-reviewed journals, demonstrate the superior efficacy of homeopathic medicines in a wide range of conditions, including asthma,7 depression and anxiety,8 chronic illness,9 allergic rhinitis,10 hypertension,11 headaches/migraines,12 sepsis,13 mild traumatic brain injury,14 otitis media,15 cancer,16 and many other conditions [13]. The American Institute of Homeopathy maintains and continually updates an extensive database, available free to the public, with over 6,000 research articles [14].17

Multiple meta-analyses published in peer reviewed medical journals that conclude that homeopathic medicine effects are superior to placebo [15] and that additional study of this therapeutic system is warranted.18,19,20,21,22,23  To that end, we encourage the National Institutes of Health to reverse their current position of blocking funding for homeopathic trials.24

  1. “…marketing claims that such homeopathic products have a therapeutic effect lack a reasonable basis and are likely misleading…”

The conclusion of whether a product has a “reasonable basis” is entirely irrelevant if that product has demonstrable clinical effectiveness. The important question, when it comes to homeopathy, is whether it is effective in clinical settings, not whether it has a “reasonable basis” for how it works. The mechanism by which homeopathy works differs from conventional medicines [16], but this fact does not make these products “misleading”.

Several recent class-action lawsuits brought against homeopathic manufacturers confirm that marketing practices were neither deceptive nor misleading [17].25

The FTC’s inability to formulate a reasonable basis for why homeopathic medicines work should not enter into any governmental enforcement policy statement. The FTC is not a medical organization, lacks expertise in interpreting scientific research [18], and is not qualified to make any comment on the validity of any field of medicine. To be less misleading, the FTC should exclude opinions from its policy statements.

  1. “Homeopathy: Not backed by modern science”

Homeopathy, as a system of medicine, does not fall under the purview of the FTC. Therefore, the FTC has been reckless in expressing an opinion of this magnitude. In this situation, the FTC’s comments can only be construed as being prejudicially biased and intentionally discriminatory against homeopathy. Such statements cause unwarranted harm to public trust and damage to a respected traditional system of medicine in the United States [19].

The American Institute of Homeopathy strongly objects to the FTC’s characterization of the entire field of homeopathic medicine as being without scientific evidence of efficacy. These comments are unqualified and wholly lacking in merit. The release of this Enforcement Policy Statement serves only to align the FTC with several recently released scientifically fraudulent [20] reports by a variety of pseudoscientists [21] and lowers the credibility of this valued consumer protection agency.

This type of misinformation should be embarrassing to a government organization striving to be nonpartisan and objective. The FTC owes an apology to the American Institute of Homeopathy as well as the many consumer groups that look toward this agency for fair and accurate information.

END OF QUOTE

My comments:

1 In healthcare, choice must be restricted to treatments which demonstrably generate more good than harm.

2 The AIH seems to be unaware of the difference between the nature of evidence, anecdote and experience.

3 Fallacy – appeal to popularity.

4 The first randomized, placebo-controlled study of homeopathy was, in fact, published in 1835 – its results were negative.

5 Fallacy – appeal to tradition.

6 The nano-particle explanation of homeopathy is but a theory (at best).

7 Fallacy – appeal to tradition.

8 Fallacy – appeal to authority.

9 Really? Which ones? Examples would help, but I doubt they exist.

10 The proper manufacturing of nonsense must still result in nonsense.

11 See footnote number 2

12 Fallacy – appeal to tradition.

13 For all of these conditions, the totality of the reliable evidence fails to demonstrate efficacy.

14 In this context, only clinical trials are relevant, and their number is nowhere near 6,000.

15 Most of the independent systematic reviews fail to be positive.

16 The mechanism is well-known and is called ‘placebo-effect’.

17 Many class actions also went against the manufacturers of homeopathic preparations.

18 I assume they ‘bought in’ the necessary expertise.

19 Surely, the damage is only to the cash-flow of firms selling bogus products.

20 Really? Name the report you libel here or be quiet!

21 Name the individuals you attack in this way or be quiet!

I must say, I had fun reading this. In fact, I cannot remember having seen a document by an organisation of healthcare professionals which was so embarrassingly nonsensical that it becomes comedy gold. If one of my PhD students, for instance, had submitted such drivel, I would have had no choice but to fail him or her.

Having said that, I need to stress to the AIH:

FULL MARKS FOR AMUSEMENT!!!

 

During the last two decades, I have had ample occasion to study the pseudo-arguments of charlatans when trying to defend the indefensible. Here I will try to disclose some of them in the hope that this might help others to identify charlatans more easily and to react accordingly.

Let’s say someone publishes a document showing evidence that homeopathy is a useless therapy. Naturally, this will annoy the many believers in homeopathy, and they will counter by attempting to make a range of points:

  1. THEY WILL STATE THAT THERE IS EVIDENCE TO THE CONTRARY. For instance, proponents of homeopathy can produce studies that seem to ‘prove’ homeopathy’s efficacy. The facts that these are flawed or irreproducible, and that the totality of the evidence is not positive does hardly ever bother them. Charlatans are born cherry-pickers.
  2. THEY WILL SUGGEST THAT THE EXISTING EVIDENCE HAS BEEN MIS-QUOTED. Often they will cite out of context from original studies one or two sentences which seem to indicate that they are correct. Any reminders that these quotes are meaningless fall on deaf ears.
  3. THEY WILL SAY THAT THE PUBLISHED EVIDENCE WAS MISINTERPRETED. Often the evidence is complex and can therefore be open to interpretation. Charlatans use this fact and spin the evidence such that it suits their needs. Charlatans are spin-doctors.
  4. THEY WILL SAY THAT SCIENTIFIC EVIDENCE IS OVER-RULED BY CENTURIES OF EXPERIENCE. The notion that millions of satisfied customers cannot be wrong is used frequently to distract from negative evidence. The fact that such experience can be due to a host of non-specific effects, the natural history of the condition or regression to the mean will not convince the charlatan.
  5. THEY WILL SUGGEST THAT THE AUTHOR IS PAID BY BIG PHARMA TO TRASH HOMEOPATHY. Whenever seemingly reasonable arguments have been exhausted, overtly irrational notions or blatant lies will come into play. The allegation that anyone criticising homeopathy is corrupt is one of the most popular such notion. The truth does not have a high value in charlatanry.
  6. THEY WILL SAY THAT THE CRITIC HAS NO TRAINING IN HOMEOPATHY AND IS THUS NOT COMPETENT. Equally popular is the claim that only trained and experienced homeopaths are able to judge over homeopathy. This pseudo-argument is most handy: experienced homeopaths are invariably believers, and the notion essentially claims that only those who believe in it can judge homeopathy. In other words, criticism of homeopathy is by definition invalid.
  7. THEY WILL SAY THAT THE CRITIC HAS PREVIOUSLY BEEN CRITICISED FOR HIS POOR RESEARCH. Similarly, homeopaths might claim that the critic is someone who is being criticised for being a very bad scientist; therefore, it would be a mistake to trust anything he or she says. Ad hominem is the name of the game!
  8. THEY WILL TRY TO RIDICULE THE CRITIC. Readers of this blog will have noticed how some commentators belittle their opponents by giving them laughable nicknames thus undermining their authority. The obvious aim is to make them look less than credible. Charlatans are like little children.
  9. THEY WILL CLAIM THAT IN OTHER AREAS OF HEALTHCARE THE EVIDENCE IS ALSO NOT CONVINCING. The ‘tu quoque’ fallacy is popular for distracting from the embarrassingly negative evidence in quackery – never mind that problems in the aviation industry are no argument for using flying carpets.
  10. THEY WILL POINT OUT HOW SAFE HOMEOPATHY IS COMPARED TO OTHER DRUGS. This is another form of the ‘tu quoque’ fallacy; it works very well for distracting from the problems with homeopathy and regularly convinces lay people.
  11. THEY WILL SAY THAT MEDICAL RESEARCH IS GENERALLY SO FLAWED THAT IT CANNOT BE TRUSTED. The fact that some medical research is less than rigorous is used here to claim that evidence in general is unreliable. The best solution is therefore to go by experience – a big step into the dark ages, but charlatans don’t seem to mind.
  12. THEY WILL REVERSE THE BURDEN OF PROOF. Homeopathy (or any other alternative therapy) may not have been proven to be effective, they claim, but it has not been proven to be ineffective. Therefore, they say, we must give it the benefit of the doubt. The facts that a) science cannot prove a negative and that b) we therefore should use those treatments that are supported by positive evidence is being ignored by charlatans.

These 12 pseudo-arguments are in my experience the most common defences of charlatanry. I am sure there are others – and I would be delighted if you did elaborate on them in the comments section below. Thanks!

In a recent PJ article, Michael Marshall from the ‘Good Thinking Society’ asked “WHY ON EARTH IS THE NHS SPENDING EVEN A SINGLE PENNY ON HOMEOPATHY?”. A jolly good question, given the overwhelmingly negative evidence, I thought  – but one that must be uncomfortable to homeopaths. Sure enough, a proponent of homeopathy, Jeanette Lindsay from Glasgow, has objected to Marshall’s arguments in a short comment which is a fairly typical defence of homeopathy; I therefore take the liberty of reproducing it here (the 12 references in her text were added by me and refer to my footnotes below):

I wonder if people such as Michael Marshall (The Pharmaceutical Journal 2016;297:101), who would refuse [1] patients the option of NHS homeopathic treatment, have considered the plight of people failed by evidence-based medicine ? [2] Where are those with chronic, disabling conditions to turn when the medicines available on the NHS do not work, or worse, are positively harmful? [3]

Take the instance of a woman with multiple drug allergies who has no means of treating her severe inflammatory arthritis and no suitable analgesia. [4] It has been demonstrated that disease states with immune system involvement are particularly susceptible to the placebo effect but how does one induce this? Current thinking precludes treatment with placebo medicines but it so happens that homeopathic remedies would appear, from the results of clinical trials [5], to be a good substitute. [6] Used properly, there is a good chance that in this case homeopathic treatment may achieve a real therapeutic effect. [7]

Patients who cannot tolerate allopathic [8] treatment do not just go away because they cannot take the prescribed medicine. [9] They suffer and surely deserve a better range of options [10] than those provided by the current obsession with evidence-based medicine. [11] The availability of homeopathic treatment is important and should not be denied until better alternatives become commonplace. [12]

[1] Michael Marshall does not ‘refuse’ homeopathy on the NHS; that is not in his power. He merely questions whether NHS funds should not be spent on treatments that demonstrably do more good than harm.

[2] I am sure he as carefully considered such patients.

[3] Depending on the exact circumstances, such patients have many options: for instance, they could change their physician, have their diagnosis re-considered, or try a non-drug treatment.

[4] An allergy to one drug is rarely (I would even say never) associated with allergies to all drugs for any given condition. Even if this were the case, there are several non-drug treatments for arthritis or other diseases.

[5] I think this is fantasy; there is no good evidence from clinical trials to show that homeopathy is efficacious for either inflammatory or degenerative arthritis.

[6] Is this an admission that homeopathic remedies are placebos?

[7] I am not aware of sound evidence to support this statement.

[8] ‘Allopathic’ is a derogatory term introduced by Hahnemann to defame conventional medicine.

[9] I have never seen a patient who could not tolerate any prescription medicine. I suspect this is fantasy again.

[10] Patients deserve the optimal therapy available for their conditions – that is a therapy that demonstrably generates more good than harm. Homeopathy is clearly not in this category.

[11] An obsession? Yes, perhaps it is an obsession for some dedicated healthcare professionals to provide the best possible treatments for their patients. But the way it is put here, it sounds as though this was something despicable. I would argue that such an ‘obsession’ would be most commendable.

[12] For practically all conditions, symptoms, illesses and diseases that afflict mankind, better alternatives than homeopathy have been available since about 150 years.

It seems to me that Jeanette Lindsay has been harshly disappointed by conventional medicine. Perhaps this is why, one day, she consulted a homeopath and received the empathy, understanding and compassion that she needed to get better. Many homeopaths excel at these qualities; and this is the main reason why their patients swear by them, even though their remedies are pure placebos.

My advice to such patients is: find a physician who has time, empathy and compassion. They do exist! Once you have found such a doctor, you can benefit from the compassion and empathy just as you may have benefitted from the homeopath’s compassion and empathy. But in addition to these benefits (and contrary to what you got from your homeopath), you will also be able to profit from the efficacy of the treatments prescribed.

To put it simply: homeopaths can help patients via non-specific therapeutic effects; responsible physicians can help patients via non-specific therapeutic effects plus the specific effects of the treatments they prescribe.

 

We have become used to bogus claims made by homeopaths – far too much so, I would argue. Therefore, we let the vast majority of their bogus claims pass without serious objections. Yet exposing bogus claims would be an important task, particularly when they relate to serious conditions. Doing this might even save lives!

According to the website of the ‘HOMEOPATHIC DOCTOR’, homeopathy is mild in nature and tends to modify the body’s natural immunity. It is the responsibility of the immune system of the body to protect it from all sorts of damage, whether from bacteria or viruses or from any other disease. It also helps in repairing any damage that may occur at any time. Homeopathic medicines help strengthen the natural immunity of the body so that it can perform its natural functions in a more efficient manner.

5 Best Homeopathic remedies for Ulcerative Colitis

In my experience, homeopathic medicines like Merc Sol, Baptisia, Nux Vomica, Arsenic Album and Phosphorus have been found to be quite effective in the treatment of Ulcerative Colitis…

Merc Sol- One of the best homeopathic medicines for ulcerative colitis with blood and tenesmus

When there is too much bleeding with tenesmus and other symptoms, Merc Sol is one of the best homeopathic medicines for ulcerative colitis. There are frequent stools with blood being discharged almost every time. The patient is a sweaty sort of patient who keeps on sweating most of the time. Creeping sort of chilliness may be felt in the back.

Nux Vomica- One of the best homeopathic remedies for ulcerative colitis due to high life

When the problem has occurred from living a high life, Nux Vomica is one of the best homeopathic remedies for ulcerative colitis. Excess of alcohol, stimulants like tea and coffee, late night partying and other habits incident to modern lifestyle can contribute to such a problem. The patient is usually a chilly sort of patient who cannot tolerate cold. He is unusually angry and that too at trifles.

Arsenic Album – One of the best homeopathic medicines for ulcerative colitis with anxiety and restlesness

When the predominant symptoms are the mental symptoms of anxiety and restlessness, Arsenic Album is one of the best homeopathic medicines for ulcerative colitis. The patient gets anxious, worried and restless for no rhyme or reason. There may be weakness which may be disproportionately more than the problem. There is increased thirst for water, though the patient takes a small quantity or a sip at a time.

Baptisia – One of the best homeopathic remedy for ulcerative colitis with low grade fever

When there is low grade fever present along with other symptoms, Baptisia is one of the best homeopathic remedy for ulcerative colitis. The patient has great muscular soreness all over the body as if bruised and beaten. Appetite is reduced or next to nil. At the same time, there is constant desire for water. Stools are very offensive, thin and watery.

Phosphorus – One of the best homeopathic medicine for ulcerative colitis with increased thirst for cold water

When there is intense thirst for cold water, Phosphorus is one of the best homeopathic medicine for ulcerative colitis. The patient is usually tall and thin. The diarrhoea is copious. Stool is watery and profuse bleeding may be present. Patient feels too weak and more so after passing a stool.

The ‘HOMEOPATHIC DOCTOR’s first statement was ‘in my experience…’? Unfortunately most patients will not understand what this expression truly means when written by a homeopath. It means THERE IS NOT A JOT OF EVIDENCE FOR ANY OF THIS. Had he stated this clearly, it would probably have been the only correct sentence in the whole article.

People who understand medicine a bit might laugh at such deluded clinicians and their weird, unethical recommendations. However, patients who are chronically ill and therefore desperate might take them seriously and follow their advice. Patients who suffer from potentially life-threatening diseases like ulcerative colitis might then cause serious damage to themselves or even die.

And this is precisely the reason why I will continue to expose these charlatans for what they are: irresponsible, unethical, uninformed, dangerous quacks

On a good day, I get several emails from complete strangers; some are complimentary, others are critical, and others again are just strange. Few are stranger than the exchange I am about to disclose.

The author asked me twice to treat his/her emails with ‘trust and confidence’; after the second email, I nevertheless felt that I should not respect this wish but needed to share this brief exchange with my readers. I have, however, erased all the details that would allow an identification of the author.

 

INITIAL EMAIL of 18/7/2016

I am responding to you latest post regarding “Informed Consent”. I have decided to do so because my instincts suggest that we may in fact have an empathy in our individual objective to establish an evidence base for complementary medicine. However, I do not have any empathy with many of the contributors to your blog and especially with those that have a desire to “grind homeopathic vets and feed them to the pigs” Given that you moderate the site, I am surprised that you allowed such a post.

As you are aware, I obtained a copy of your book “A Scientist in Wonderland” which I have read with considerable interest and as you know, I have posted extracts on your blog. In this respect I make the following observations:

1. Your early experiences of homeopathy were positive and on this basis I find great difficulty in accepting that you are as anti-homeopathy as you publically state. From my own experience, this is not logical.

2. I am of the opinion that the sad loss of your Hungarian friend and colleague is an influencing factor, particularly as you avoided any mention of him receiving any form of alternative medicine.

3. I can empathise with your frustration at the lack of support from the alternative medicine community, as I have experienced this in my own efforts.

4. I am inclined to accept the possibility that you are using the blog to deliberately provoke the homeopathic community into action from a long standing but understandable state of complacency. (If you know that something works, then why is there a need to prove it).

5. I find difficulty to believe that you are at home surrounded by such closed minded individuals, because, historically, you have always moved on from such situations. However, I am not sure that you know how you can escape from the trap that you now find yourself in. Is this what you want for the rest of your life?

For a variety of reasons, I embarked on this … venture as a means of finding evidence that these therapies do work and have found that the homeopathy community is somewhat less than supportive in my efforts, so I do understand your potential frustration.

I appreciate that my observations are assumption based and may be wishful thinking on my part; however, if my assumptions have validity, please contact me, otherwise ignore this message.

If you do choose to pursue this conversation, then it must take place under the strict condition of TRUST & CONFIDENCE.

 

MY REPLY of 18/7/2016

thank you for your email. you say you read my memoir; may I suggest you read it again – because the answers to your questions seem to be all in there. your assumptions about me are quite wrong, and I think my book explains why.

best regards
e ernst

 

THE RESPONSE of 21/7/2016

In Britain we have a saying “Don’t mention the war when speaking to a German”, so out of respect I refrained from mentioning the Nazi regime in my last message; however, as you have made an implied reference to it, I will now comment.

I have some six years of close working experience with a large German organisation … so that I am fully aware of the significant differences between the German and British mentality and approach to life. I am therefore able to appreciate many of the difficulties that you will have encountered when arriving in this country to take up the Exeter post, which by definition was designed to advise the UK alternative therapy community how to do things properly!

The Anglo/Germanic axis is a significant challenge under normal circumstances but for you to arrive in this country and make direct comparisons between alternative medicine and the Third Reich in a country that spearheaded the fight against the Nazi’s at a cost of nearly half a million British lives was a fatal mistake on your part.

Having spent some forty years in and around the alternative health world here in Britain, India and the USA I don’t think your view point can be further from the truth. What amazes me is that you do not moderate Nazi type comments such as “grinding homeopaths and feeding them to pigs” from your blog which is a complete contradiction to your reasoning.

Your blog purports to provide cautionary advice to would be patients choosing alternative health options but your band of followers seem to have no understanding whatsoever as to the importance of respect for others. They seem to believe that from the offset, respect has to be earned, which implies judgement. Any doctor or therapist that starts from this view point when dealing with a patient, should not be treating patients at all. Empathy and respect are key factors in the healing process and those that automatically practice this naturally operate under and accept a moral code of ethics which forms part of all training within the main alternative treatments. The fundamental ethic behind all medicine is “first do no harm”. How can this be achieved if you do not respect the patient, regardless of his views?

At a personal level, I am concerned that your early experiences have distorted your views and unfortunately you have managed to alienate yourself from the very form of healthcare that would best resolve these issues without the need for suppressive drugs.

I suggest that you re-read your book and honestly ask yourself if the “peaceful vantage point” referred to on page 170, in any way measures up to the “peaceful, happy time” you mention on page 36.

I again extend my offer of an exploratory conversation in an atmosphere of “trust and confidence”.

END OF QUOTE

I do not feel like adding any comments just now… perhaps just a few questions:

How is it possible that someone who has obviously read quite a bit of what I have published misunderstands so much of it? Deluded? Demented? Or worse?

Informed consent is a basic ethical principle and a precondition for any medical or surgical procedure (e. g. a therapeutic intervention or a diagnostic test). Essentially, there are 4 facets of informed consent:

  1. the patient must have decision-making capacity,
  2. the patient’s decision must be free from coercion or manipulation,
  3. all relevant information must be disclosed to the patient,
  4. the patient must not merely be told but must understand what he/she has been told.

It seems to me that points 1, 2 and 4 are more or less the same in alternative as in conventional medicine. Point 3, however, has fundamentally different implications in the two types of healthcare.

What is meant by ‘all relevant information’? There seems to be general agreement that this should include the following elements:

  1. the indication,
  2. the nature of the procedure,
  3. its potential benefits,
  4. its risks,
  5. other options for the proposed procedure, including the option of doing nothing at all.

If we carefully consider these 5 elements of ‘all relevant information’, we soon realise why there might be profound differences between alternative and conventional medicine. These differences relate not so much to the nature of the procedures but to the competence of the clinicians.

At medical school, doctors-to-be learn the necessary facts that should enable them to adequately deal with the 5 elements listed above. (This does not necessarily mean that, in conventional medical or surgical practice, informed consent is always optimal. But there is little doubt that, in theory, it could be optimal.)

By contrast, alternative practitioners have not normally been to medical school and will have gone through an entirely different type of training. Therefore, the question arises whether – even in theory – they are able to transmit to their patients all essential information as outlined above.

Let’s try to address this question by looking at concrete cases: a patient with frequent headaches consults an alternative practitioner for help. For the sake of argument, the practitioner could be:

  • a chiropractor,
  • an acupuncturist,
  • a homeopath,
  • a naturopath,
  • a traditional herbalist.

Are these alternative practitioners able to convey all the relevant information to their patient before starting their respective treatments?

THE CHIROPRACTOR

  1. Can he provide full information on the indication? In all likelihood he would treat the headache as though it was caused by a spinal subluxation. If our patient were suffering from a brain tumour, for instance, this might dangerously delay the diagnosis.
  2. Can he explain the nature of the procedure? Yes.
  3. Can he explain its potential benefits? He is likely to have a too optimistic view on this.
  4. Can he explain its risks? Many chiropractors deny any risk of spinal manipulation.
  5. Can he provide details about the other options for the proposed procedure, including the option of doing nothing at all? Probably yes for cervicogenic headache. No for most other differential diagnoses.

THE TRADITIONAL ACUPUNCTURIST

  1. Can he provide full information on the indication? The patient might be treated for an assumed ‘energy blockage’; other diagnoses might not be given adequate consideration.
  2. Can he explain the nature of the procedure? Yes.
  3. Can he explain its potential benefits? He is likely to have a too optimistic view on this.
  4. Can he explain its risks? Perhaps.
  5. Can he provide details about the other options for the proposed procedure, including the option of doing nothing at all? No

THE CLASSICAL HOMEOPATH

  1. Can he provide full information on the indication? No, for a classical homeopath, the totality of the symptoms is the only valid diagnosis.
  2. Can he explain the nature of the procedure? Yes.
  3. Can he explain its potential benefits? Doubtful.
  4. Can he explain its risks? Doubtful.
  5. Can he provide details about the other options for the proposed procedure, including the option of doing nothing at all? No.

THE NATUROPATH

  1. Can he provide full information on the indication? Doubtful.
  2. Can he explain the nature of the procedure? Yes.
  3. Can he explain its potential benefits? He is likely to have a too optimistic view on this.
  4. Can he explain its risks? Doubtful.
  5. Can he provide details about the other options for the proposed procedure, including the option of doing nothing at all? No.

THE TRADITIONAL HERBALIST

  1. Can he provide full information on the indication? No.
  2. Can he explain the nature of the procedure? Yes.
  3. Can he explain its potential benefits? He is likely to have a too optimistic view on this.
  4. Can he explain its risks? He is likely to have a too optimistic view on this.
  5. Can he provide details about the other options for the proposed procedure, including the option of doing nothing at all? No.

The answers provided above are based on my experience of more than 20 years with alternative practitioners; I am aware of the degree of simplification required to give short, succinct replies. The answers are, of course, assumptions as well as generalisations. There may well be individual practitioners who would do better (or worse) than the fictitious average I had in mind when answering the questions. Moreover, one would expect important national differences.

If my experience-based assumptions are not totally incorrect, their implications could be most significant. In essence they suggest that, in alternative medicine, fully informed consent can rarely, if ever, be provided. In turn, this means that the current practice of alternative medicine cannot be in line with the most fundamental requirements of medical ethics.

There is very little research on any of these  issues, and thus hardly any reliable evidence. Therefore, this post is simply meant as a deliberately provocative essay to stimulate debate – debate which, in my view, is urgently required.

 

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