The most common pronouncement regarding alternative medicine that I have heard over the years from consumers, health care professionals or decision makers with a liking of alternative medicine goes as follows: “I don’t care how it works, as long as it helps.”
At first glance, this argument seems reasonable, logic and correct; it would be foolish, perhaps even unethical, to reject an effective treatment simply because we fail to understand how its effectiveness comes about – this would not be pragmatic and it is not what we do in medicine: aspirin, for instance, was used and helped many patients long before we understood how it worked. However, once we consider the way this notion is regularly used to defend the use of unproven therapies, we see that, in this context, it is fallacious – in fact, if we dissect it carefully, we find that it crams three large fallacies in one tiny sentence.
The first thing we notice is that the argument combines two fundamentally different issues which really should be separate 1) the mechanism of action of a therapy and 2) its clinical effectiveness. The matter gets clearer, if we discuss it not in the abstract, but in relation to a concrete example: BACH FLOWER REMEDIES (BFRs). I could have selected many other alternative therapies but BFRs seem fine, particularly as they have so far received no mention on this blog.
Similar to homeopathic preparations, BFRs are so dilute that they do not contain any active ingredients to speak of (they differ from homeopathic preparations, however, in that they do not follow the ‘like cures like’ principle). Several clinical trials of BFRs have been published; collectively, their results show very clearly that the clinical effects of BFRs do not differ from those of placebo. (This does not stop manufacturers selling and consumers buying them; in fact, BFRs are a thriving business.)
The principles backing up BFRs are scientifically implausible, and even BFR-practitioners would probably admit that they have no scientifically defensible idea how their remedies work. Scientists might add that a mechanism of action of such highly dilute remedies is not just unknown but unknowable; there is no way to explain how they work without re-writing several laws of nature.
The overall situation is thus quite clear: BFRs are not effective and there is no plausible mechanism of action.Yet it is hard to deny that many patients feel better after having consulted a BFR-practitioner (or after self-medicating BFRs), and those satisfied customers often insist: “I don’t care how BFRs work, as long as they help me.”
As previously discussed, symptoms can improve for a range of reasons which are related to any specific therapeutic effect: the natural history of the condition, regression towards the mean, placebo-effects etc. Only rigorously controlled trials can tell us whether the therapy or other factors caused the clinical outcome; our perception alone cannot identify cause and effect.
The fact that thousands of patients swear by BFRs, does therefore not constitute proof for their efficacy. The explanation of the apparently different impressions from experience and the results of clinical trials is therefore simple: the empathetic encounter with a therapist and/or a placebo-effect and/or the natural history of the condition are perceived as helpful, while the BFRs are pure placebos.
Back to the notion “I don’t care how this therapy works, as long as it helps” – it turns out to be based on at least three misunderstandings all tightly woven together.
Firstly, it was not the treatment itself that helped, but something else (see above). To imply that the treatment worked is therefore a fallacy.
Secondly, the reference to an unknown mechanism of action is aimed at misleading the opponent: it distracts from the first fallacy (“the treatment is effective”) by super-imposing a second fallacy (that there might be a mechanism of action). Crucially it attempts to wrong-foot the opponent by implying: “you reject something useful simply because you cannot explain it; this is poor logic and even worse ethics – shame on you!”.
BFR-enthusiasts are bound to see all this quite differently. They will probably claim that a placebo-effect is also a plausible mechanism. “Surely” they might say “this means that BFRs are useful and should be widely employed”.
In proclaiming this, they turn the double-fallacy into a triple fallacy. What they forget is that we do not need a placebo to generate placebo-effects. An effective treatment administered with time, compassion and empathy will, of course, also generate a placebo-effect – what is more, it would generate a specific therapeutic effect on top of it. Thus the BFR are quite useless in comparison. There is rarely a good justification for using placebos in clinical routine.
In conclusion, the often-used and seemingly reasonable sentence “I don’t care how it works, as long as it is helpful turns out to be a package of fallacies when used to support the use of unproven treatments.
I don’t suppose that many readers of this blog believe all things natural to be entirely safe, but the general public seems to be hard-wired victims of this myth: Mother Nature is benign, and herbal remedies must be harmless!
There are, of course, several reasons why supposedly “natural” herbal treatments can be unsafe. Plants extracts can be toxic, they might interact with prescribed drugs or they can be contaminated or adulterated.
The latter two terms describe similar but not identical phenomena: contamination means the accidental addition of substances which should not be present in an herbal remedy; and adulteration signifies the deliberate addition of ingredients. If the substances in question are not pharmacologically inert, their presence in herbal remedies can cause adverse effects.
Both contamination and adulteration break laws and regulations; both are therefore illegal. Sadly, this does not mean that such things do not happen.
We have recently published an overview of the existing knowledge in this area. For this purpose, we summarised the evidence from 26 previously published reviews. Our findings were interesting but far from reassuring: the most commonly found contaminants were dust, pollen, insects, rodents, parasites, microbes, fungi, mould, pesticides, and heavy metals. The adulterants invariably were prescription drugs such as steroids, anti-diabetic medications etc.
These substances were implicated in a wide range of serious adverse effects in the unfortunate patients who took the remedies in question: agranulocytosis, meningitis, multi-organ failure, stroke, arsenic poisoning, mercury poisoning, lead poisoning, caner, encephalopathy, hepato-renal syndrome, kidney damage, rhabdomyolosis, metabolic acidosis, renal failure, liver failure, cerebral oedema, coma, and intra-cerebral bleeding. Several patients did not survive.
To avoid such disasters, consumers need to know which types of herbal remedies are most frequently implicated; our review showed that these were foremost Chinese and Indian remedies. While herbal medicines from the US or Europe ought to comply with certain rules and regulations regarding their quality and safety, Chinese and Indian herbal mixtures frequently enter our countries illegally or are bought from dubious sources, for instance, over the Internet. It is this type of herbal remedy that we should be concerned about.
We have to ask whether the risks outweigh the proven benefits of Chinese or Indian herbal mixtures. The short answer to this question is NO. There is very little compelling evidence to suggest that these treatments are efficacious. In the absence of proven benefit, even small or rare risks weigh heavily.
If the risk-benefit profile for any medical intervention fails to be positive, there can only be one reasonable conclusion regarding the use of this therapy – and that is: DON’T DO IT!
Let me briefly pick up the issue about ad hominem attacks mentioned at the end of my last post.
One of the most striking feature of the debates about alternative medicine is, in my experience, the fact that, whenever the defenders of the indefensible ran out of rational arguments, personal attacks are rarely far. Personal or ad hominem attacks are fallacious arguments directly directed at a named individual which serve as substitutes for that individual’s arguments. In football terminology, they play the player instead of the ball.
After many years of being at the receiving end of this phenomenon, I have grown to be amused by it, not just amused, I have slowly started to appreciate it. Strange? Let me explain.
Initially, I have to admit, I was annoyed, sometimes livid when someone hurled a personal attack in my direction. At one stage, I even investigated whether my university did not have the obligation to legally protect me in such situations. Predictably, the answer was negative.
Later I considered on one or two occasions taking legal action myself. However, after just a minimum of reflection, I dismissed the idea: it is bad enough that the British Chiropractic Association sued my friend and co-author Simon Singh for libel, but under no circumstances did I want to display a similarly deplorable behaviour.
Eventually, I realised that an ad hominem attack often is an important signal indicating that the attacker is wrong, very wrong indeed. It is nothing else than an open admission by “the other side” that they have no more reasonable arguments, that they are resorting to unreasonable notions, and that they have lost not just the plot but also the debate. In other words, being personally attacked in this way is a compliment and an unfailing sign of victory – and, if that is so, we should be proud of every single ad hominem attack we get after a well-reasoned debate.
Even on this relatively young blog, we have already seen signs of such victories; most notably a chiropractor recently conceded defeat after a perfectly reasonable debate on the safety of spinal manipulation by stating that “Ernst is an infamous medical demagogue who speaks nonsense“. Yet this little outburst of chiropractic self-humiliation is nothing compared to plethora of similar statements elsewhere on the internet. The following list is the result of just ~10 minutes of searching; I took the liberty of copying a short quote from each site but enthusiasts will find much more revealing stuff, I’m sure.
“…whether he [Ernst] has only written or also read them [the reviews he has published], is a matter of dispute between experts…”
“…he’s really just another dull academic who knows nothing about it. The fact that someone decided he could have a title that makes it sound like he’s knowledgable [sic] is irrelevant, he remains a nobody in the field of complementary therapy, his own university don’t even seem to like him, just about everything he says is negative and no ordinary member of the public I’ve ever mentioned him to has heard of him at all, so although he’s beloved by a few hacks and a small platoon of cynics, the rest of the world could not give a toss.”
“Edzard Ernst Exposed as a Fraud and a Liar”
“Edzard Ernst, Britains self proclaimed “first Professor of Complementary Medicine” is finding himself with a lack of funding and his unit is facing closure.
He is blaming his clash with Prince Charles, but why Professor Ernst thinks anyone wants to fund someone who claims to be a professor of CAM, yet spends all his time debunking CAM we will never know. Its a rather strange scenario we feel!”
“From time to time you may see news reports about “an expert” named Edzard Ernst who regularly offers commentary about the value of homeopathic medicine. Ignore any such references he makes on the subject. He has never received even an introductory education on the subject of homeopathy”
“Why should anyone believe what Professor Edzard Ernst says, after he put his name to a BBC programme, he now describes as “deception”.”
“EDZARD ERNST and the Evil Empire at Exeter”
“Edzard Ernst, is not a credible source of information about the effectiveness of homeopathy”
“Prof Edzard Ernst (family motto: ‘I have not come to praise alternative medicine, I have come to bury it’) who has hardly said a good word for alternative medicine in all the years he has held the recently-created Complementary Medicine chair at Exter [sic]University. ”
“the pharma-friendly gold standard that Ernst and his colleagues seem to worship”
“Edzard Ernst of the Medical School at the University of Exeter wrote his infamous 2010 study from England, “Deaths After Chiropractic: A Review Of Published Cases,” that once again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles”
It is hard to deny that these statements are amusing. But by far my favourite personal attacker is a German chap called Claus Fritzsche. He runs a website which, at one stage, seemed almost entirely dedicated to telling lies about me; and, what is best of all, he even took money for these efforts from several homeopathic manufacturers. Surely, apart from perhaps the Nobel Prize, this must be the nicest recognition, the sweetest feast of victory and greatest compliment any scientist might ever wish for.
So, ad hominem attackers of all ages, types, nationalities and persuasions, please keep them coming. I am unlikely to sue for libel; on the contrary, I will celebrate them for what they truly are: they are compliments for me, victories for reason and admissions of defeat for you.