Who – apart from quacks – would not want to get rid of all quackery, once and for all? It would be a huge improvement to medicine, save thousands of lives, and reduce our expenditure for health care considerably.
But how? How can we possibly get rid of something that is as ancient as medicine itself?
All we need to do is to employ the existing ethical imperatives. I am thinking in particular about INFORMED CONSENT.
Informed consent is a process for obtaining permission from a patient before treating him/her. It requires the patient’s clear and full understanding of the relevant facts, implications, and consequences of the treatment. It is a ‘condition sine qua non’; no health care professional must commence a treatment without it.
And how would informed consent get rid of all quackery?
This is perhaps best explained by giving an example. Imagine a patient is about to receive a quack treatment – let’s take crystal healing (we could have chosen any other implausible non-evidence based therapy, e. g. homeopathy, chiropractic, Bach Flower Remedies, faith-healing, etc.) – for his/her condition – let’s say diabetes (we could have chosen any other condition, e. g. cancer, asthma, insomnia, etc.). Informed consent would require that, before starting the intervention, the therapist informs the patient about the relevant facts, implications and consequences of having crystal healing for diabetes. This would include the following:
- the therapy is not plausible, it is not in line with the laws of nature as we understand them today,
- there is no evidence that the treatment will cure your condition or ease your symptoms beyond a placebo-effect,
- the treatment may harm you in several ways: 1) it might cause direct harm (unlikely with crystal healing but not with chiropractic, for instance), 2) it will harm your finances because the therapist wants to be paid, 3) most importantly, if you believe that it could help you and therefore forego effective therapy for your diabetes, it could easily kill you within a few days.
It is impossible to dispute that these facts are true and relevant, I think. And if they are relevant, the practitioner must convey them in such a way that they are fully appreciated by the patient. If the patient comprehends the implications fully, he/she is unlikely to agree to the treatment. If most patients refuse to be treated, the market for crystal healing quickly collapses, and crystal healers move into other, more productive jobs. This might even help the general economy!
But quacks are not in the habit of obtaining fully informed consent, I hear you say. I agree, and this is why they must be taught to do so in their quack colleges. If informed consent was taught to all budding quacks, they would soon realise that quackery is not a viable business and go to a proper school where they lean something useful (this too might help the economy). If that happens, the quack colleges would soon run out of money and close.
Meanwhile, one could remind the existing quacks that they break the law, if they neglect informed consent. In the interest of the patient, one could closely monitor the consent giving process, and even think of increasingly heavy finds for those who break the law.
As we see, almost all the means for rendering health care quack-free already exist. All we need to do is implement them. That shouldn’t be difficult, should it?
AND NOW I STOP DAY-DREAMING AND DO SOMETHING USEFUL.
A short report about a Scottish legal case is worth a mention, I think.
Honor Watt, 73 had sued Lothian Health Board after the authority stopped in June 2013 to provide homeopathic treatments to patients. Ms Watt, an arthritis sufferer, had previously received homeopathic medicine for this condition. There is, of course, no good evidence that homeopathic remedies are better than placebos for this (or any other) disease.
Ms Watt’s lawyers decided to challenge the board’s decision in the Court of Session claiming the health board acted illegally. There is reason to believe that Ms Watt was assisted by a professional organisation of homeopathy ( the judgement mentions that the Board’s submission stated that ‘the real force behind the petition was a charity, not the petitioner’).
In any case, Watt’s legal team claimed the Equality Act 2010 placed an obligation on the health board to ask their patients for their views on whether homeopathy should be continued to be funded. The legislation states that public sector organisations have an obligation to consider their decisions on the terms of what is called a public sector equality duty.
The case went to court and the judge, Lord Uist, recently ruled that the health board had acted legally. He therefore refused to overturn the board’s original decision. In a written judgement issued on Friday, Lord Uist confirmed that the health board acted correctly: “It is clear to me from an examination of the relevant documents that the board was from the outset consciously focusing on its PSED.”
The judgement explains that Ms Watt was first referred to the homeopathic service in 2003 when she was suffering from anxiety. Later, she was given a homeopathic medicine for her arthritis after telling her doctor that conventional medicine wasn’t controlling her problems with this condition. In January 2014, she had a final appointment with the homeopathic service and told that she was no longer entitled to homeopathic treatment. However, the judgement states that Ms Watt still receives a prescription of homeopathic medicine.
Lothian Health Board decided to end homeopathic provision after concluding the money would be better spent on conventional treatments. The board made the decision after holding a consultation exercise and concluding that only few NHS users would be affected by their decision. In a report, the reasons for why the board should stop spending money on homeopthy were set out.
Judge Uist confirmed that this report “stated that the withdrawal of funding for homeopathic services would have a limited negative impact on patients and staff, the majority of patients were from more affluent areas and it was felt that they could perhaps afford to self fund alternative provision.”
Ms Watt’s lawyers claimed that the board didn’t do enough to seek the views of those who used the service. They argued that the board broke the terms of the 2010 Equality Act. After examining the evidence, Judge Uist concluded, however, that the health board had done everything in its power and had made the correct decision: “I am satisfied that reduction of the board’s decision of June 26 2013 would result only in a waste of time and public funds as it would inevitably result in exactly the same decision being taken by the board.”
From my perspective, this is an important decision. As a physician, I naturally dislike not giving patients what they want. However, I dislike it even more when there is not enough money for other patients to have essential treatments. Thus it is obvious that harsh decisions have to be made in order to spend the available funds as rationally as possible – and that, of course, means that treatments for which there is no good evidence must not be funded from public money. Homeopathy clearly falls in that category.
As I am not a lawyer, I see this case with the eyes of a medic and researcher. For me, it is about the age-old question: should patients get the treatment they want or the treatment they need? For me, health care is not a supermarket where people can their trolleys with everything they happen to fancy. For me, health care is not about satisfying the ‘wants’; it is about coping with the needs of people. For me, this is a question of medical ethics. For me, the Scottish judgement is spot on.
One of the questions that I hear regularly is: ‘What happened to your research unit at Exeter?’ Therefore it might be a good idea to put the full, shameful story on this blog.
After the complaint by Prince Charles’ secretary to my Vice Chancellor alleging that I had breached confidentiality over the Smallwood report, my University conducted a 13 months investigation into my actions. At the end of it, I was declared innocent as charged (it should have been clear from a 10 minute discussion that I had done nothing wrong: I had not disclosed any information from the report, and even if I had, it would have been a matter of public interest and medical ethics to blow the whistle. However, the Vice Chancellor never once bothered to talk to me.). Subsequently, all support that I had once enjoyed broke down, my staff’s contracts were terminated, and I eventually had to take early retirement (full details of this part of the story can be found in ‘A SCIENTIST IN WONDERLAND’).
A few months later, a new dean was appointed at my medical school. The new man seemed to have a lot more understanding for my situation than his predecessor. Provided that I accept to go into early retirement, he offered to re-employ me for one year (half time) to help him find a successor for my position.
I did accept because, above everything, I wanted to prevent the closure of my unit. We then developed criteria for advertising the post and conducted two rounds of advertisements. Several candidates applied but none them seemed suited in our view. Eventually we did find several experts who were promising; one even came to Exeter from abroad and had detailed talks with the dean and several other people.
However, Exeter was unwilling to equip my potential successor with any funds to speak of. The suggestion was to appoint the new chair with the onus to raise all the necessary funds himself. This is a proposition that no well-qualified academic at the professorial level can possibly find attractive. Consequently, the candidates all declined.
Meanwhile, there had been an initiative by several altruistic UK public figures and friends to raise funds for the new chair and thus save my unit from closure. Sadly, however, these activities did not generate in the necessary cash. When my year of half-time re-employment had expired, I left Exeter and my unit disappeared for good.
To the present day, I am not at all sure what the true intentions of Exeter had been during this final stage.
- Was I offered re-employment simply to keep me sweet?
- Did they fear that I would otherwise sue them or cause a public scandal?
- Did they truly believe they could find a suitable successor?
- If so, why did they not put up the money?
I do not expect to ever find conclusive answers for any of these questions. However, I do know what, in an ideal world, should have become of my unit. If it had been for me to decide, I would have equipped the chair with the necessary core funds and appointed an ethicist with a documented interest in alternative medicine as the new professor. I see two main reasons for this perhaps less than obvious choice:
- In my experience, Exeter would greatly benefit from an ethicist to give them guidance on a range of matters.
- After two decades of being involved in alternative medicine research, I have become convinced that this field foremost needs the input of a critical ethicist.
In case either of these last two statements puzzles you, I recommend you read ‘A SCIENTIST IN WONDERLAND’.
The task of UK Clinical Commissioning Groups (CCGs) is to ensure NHS funds are spent as effectively and responsibly as possible. This is particularly important in the current financial climate, as NHS budgets are under enormous pressure. For that reason, The Good Thinking Society (GTS, a pro-science charity) invited Liverpool CCG to reconsider whether the money (~ £ 30,000 pa) they spend on homeopathy represents good service to the public. Recently the CCG agreed to make a fresh decision on this contentious issue.
The GTS would prefer to see limited NHS resources spent on evidence-based medicine rather than on continued funding of homeopathy which, as readers of this blog will know, has repeatedly failed to demonstrate that it is doing more good than harm. It is encouraging to see Liverpool CCG take a first step in the right direction by agreeing to properly consider the best evidence and expertise on this issue.
Supporters of homeopathy frequently cite the concept of patient choice and claim that, if patients want homeopathy, they should have it free on the NHS. The principle is obviously important, but it is crucial that this choice is an informed one. The best evidence has conclusively shown that homeopathy is not an effective treatment, and to continue to offer ineffective treatments under the guise of patient choice raises troubling questions about the important concept of informed choice, and indeed of informed consent as well as medical ethics.
The GTS were represented by Salima Budhani and Jamie Potter of Bindmans LLP. Salima said: “This case underlines the necessity of transparent and accountable decision making by the controllers of health budgets, particularly in the light of the current financial climate in the NHS. CCGs have legal obligations to properly consider relevant evidence, as well as the views of experts and residents, in deciding how precious NHS resources are to be spent. It is essential that commissioning decisions are rational and evidence-based. Liverpool CCG’s decision to reconsider its position on the funding of homeopathy in these circumstances is to be welcomed.
“Our client has also called upon the Secretary of State for Health to issue guidance on the funding of homeopathy on the NHS. Public statements by the Secretary of State indicate that he does not support ongoing funding, yet he has so far declined to ask NICE to do any work on this issue. The provision of such guidance would be of significant benefit to CCGs in justifying decisions to terminate funding.”
Commenting on their decision, a Liverpool CCG spokesperson said: “Liverpool CCG currently resources a small homeopathy contract to the value of £30,000 per year that benefits a small number of patients in the city who choose to access NHS homeopathy care and treatment services. The CCG has agreed with the Good Thinking Society to carry out further engagement with patients and the general public to inform our future commissioning intentions for this service.”
Over the last two decades, prescriptions fulfilled in community pharmacies for homeopathy on the NHS in England have fallen by over 94% and homeopathic hospitals have seen their funding reallocated. This reduction indicates that the majority of doctors and commissioning bodies have acted responsibly by terminating funding for homeopathic treatments.
The GTS are currently fundraising in order to fund further legal challenges – donate now to support our campaign at justgiving.com/Good-Thinking-Society-Appeal/.
Some people are their worst enemies, and it seems as though chiropractors are no strangers to this strange phenomenon.
On this blog, I frequently criticise chiropractic; my main concerns are that
- chiropractors make far too many bogus claims far too often,
- there is precious little evidence that their hallmark treatment, spinal manipulation, generates more good than harm.
I repeatedly voice those concerns because I feel strongly that consumers have the right to unbiased information for making evidence-based therapeutic decisions. When I do this, I get invariably attacked by some chiropractors who disagree with me. Frequently, these chiropractors are not interested to discuss the issues I raised with me; instead they insult me in the most primitive way imaginable.
This happens far too often to write about each time, but occasionally things are so extraordinary that I do blog about them. A case in point is the email I recently received out of the blue from “Dr” Brian Moravec, a chiropractor who believes in subluxation and claims that new-born babies should have spinal adjustments. My last post quotes his astonishing views in full; he believes I am a self proclaimed “expert” on alternative medicine, promoting so much misinformation with regard to chiropractic care. Unfortunately he failed to tell me which of my statements he considers to be misleading and he continued: fortunately you look old. and soon will be gone.
Rejoicing at the (hopefully not so) imminent demise of a fellow human being is perhaps not what one might expect from a health care professional. Yet it does fit into the behaviour of chiropractors which tends to turn outright self-destructive when challenged. The comments by chiropractors that followed my post seem to confirm this tendency. They show that the demolition of chiropractic’s reputation by chiropractors is relentless.
One chiropractor claimed Moravec’s opinion could “have been better put”… and “come over as a somewhat personal attack” while quickly changing the subject by starting a discussion on the evidence-base of chiropractic. This ended abruptly in him agreeing with me to disagree. Other chiropractors seemed to concur.
At that stage, one chiropractor noted that Moeavec’s email is doing no favours to the reputation of chiropractic, a ray of light which quickly was instantly overshadowed by a further chiropractor’s comments. This man – or perhaps woman (hiding behind a pseudonym) – is a regular commentator on my blog. He felt that Moravec’s comments were rather polite an opinion which he justified as follows: Dr. Moravec thinks you are old because of your unflattering (IMO) photo. The shiny, bald look adds years to a person’s looks, especially in photos. It is the old glass half-empty or half-full debate. IOW, have you lost hair or have you gained face? The mustache is so fifties, too. The perpetual scowl, however, does suit you rather well. Just sayin’.
At this point, I cannot help but laugh out loud. Someone asked how I can bear those vicious attacks. The answer is that I merely cringe at the stupidity on display. Are these guys really so limited as to not realise what they are doing to their own reputation? Do they not notice that this amounts to a relentless and general demolition of chiropractic’s reputation?
All of this would, of course, be rather trivial fun, if it were a single occurrence – but it is most definitely not!
As I already pointed out, such things happen to me all the time. More remarkably, chiropractors have repeatedly tried to get me fired. Much more importantly, chiropractors have behaved in this way when they decided to sue Simon Singh for libel. Each time, they ended up with plenty of egg on their faces.
Isn’t it time that they learn a lesson? Isn’t it time that they learn to consider criticism seriously? Isn’t it time the more rational one amongst them do something about the many cranks in their midst? Isn’t it time they got their act together?
Most pharmacies worldwide sell any bogus treatment to their unsuspecting customers, it seems – as long as it makes a profit, anything goes! Not in New Zealand!
The New Zealand’s Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics 2011 section 6.9 requires of pharmacists that:
“YOU MUST… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.”
This instruction was the basis for a complaint against a New Zealand pharmacy selling a homeopathic remedy against jet lag called “No-Jet-Lag”. The New Zealand Advertising Standards Authority (ASA) considered the complaint and decided to uphold it. The complaint, which was lodged with the ASA by the Society for Science Based Healthcare in July 2014, alleged that the advertisement’s claims about the product that “It Really Works” for “Homeopathic Jet Lag Prevention” were unsubstantiated and misleading.
In defence of their advertising, the manufacturer of the product, Miers Laboratories, submitted a study they had conducted with their product. However, the Advertising Standards Complaints Board ruled that: “the trial population in the pilot study was small, the methodology was not robust and the results had not been published or peer reviewed. The Complaints Board also noted the study was an in-house trial conducted by the Advertiser rather than independent research…Given the weaknesses in the study, the majority of the Complaints Board said the Advertiser had not satisfactorily substantiated the claim the product “really works” and, as such, the Complaints Board said the advertisement had the potential to mislead consumers. Consequently, the Complaints Board said the advertisement did not observe a high standard of social responsibility required of advertisements of this type.”
However, today I found the following text still on the website of the company: Jet lag is the curse of modern jet travel, but it doesn´t have to spoil your trip. The unique homeopathic remedy No-Jet-Lag helps ensure holiday enjoyment and working efficiency even after long airline flights. No-Jet-Lag is raved about by satisfied travellers globally, including business executives, sports teams, tour operators, and flight crews. It is safe, easy to take, and proven effective in tests.
Are the days of “No-Jet-Lag” counted?
Why do not all countries’ pharmacists have such codes of ethics?
Manufacturers of homeopathic remedies are having a hard time, it seems. The following press release has just reached me, and I thought it might be worth sharing it with my readers:
Baden-Baden, Germany, May 23, 2014 – Heel Group today announced the cessation of its business activities in the United States and Canada on August 31, 2014.
In the USA and Canada, manufacturers of OTC homeopathic medicinal products have been confronted with accusations through class action lawsuits. Heel Inc., the Heel Group’s U.S.-based subsidiary, was also faced with two such attempts recently. Both cases have been settled without conceding the allegations. The financial burden on Heel Inc., however, was substantial.
In a subsequent risk-benefit analysis of its global activities, the Heel Group decided to focus on strengthening its excellent position in South America, Central Europe and Eastern Europe and to withdraw from business activities in the USA and Canada for the time being.
Heel’s operations in both the USA and Canada will accordingly be discontinued as of August 31, 2014.
In the USA, negotiations with MediNatura Inc., a Delaware Corporation, are close to completion by which the Heel Group will transfer its stock in Heel Inc., to MediNatura by the end of August 2014. The transaction does, however, not include any of Heel’s trusted and leading global brands such as Traumeel, Neurexan, Zeel, Oculoheel, Luffeel, Sinusin, Vinceel, Nectadyn, Adrisin, Gripp-Heel, Viburcol, Vertigoheel, Spascupreel, Engystol, and Lymphomyosot*. Completion of the acquisition is subject to standard closing procedures.
As a trailblazer and leader in the field of scientific research into natural healthcare and a leading manufacturer of homeopathic medicines, the Heel Group will continue to invest in research and development on a global scale, also involving the medical-scientific community in North America.
Ralph Schmidt, CEO of the Heel Group: “As a global player, we are continuously reviewing our portfolio. This means that we are sometimes required to focus on specific regions at the expense of others in order to efficiently carry out our ambitious expansion plans. I would not exclude the possibility of re-entering the markets in the USA and Canada with a new business concept.”
It is somewhat sobering from my point of view to realise that all the science proving that homeopathy had no health effects beyond placebo had little effect on the market for homeopathic remedies. If anything, the sales figures seemed to get better and better as the evidence got more and more negative during the last decades. The ‘globulisation’ of the world seemed imminent due to those homeopathic manufacturers who wanted to become ‘global players’ (is there not a homeopathic remedy against megalomania?). It was only the legal actions that seemed to have an effect. The multiple North American class actions were more effective than the science, it seems.
Is there a lesson here? Perhaps! It could be that scientists working on their own are not always powerful enough to improve health care. Particularly when confronted with an alliance of evangelic belief and commercial interests, scientists, sceptics, journalists, lawyers, politicians and other professions might have to co-operate to bring about meaningful change.