Medical ethics are central to any type of healthcare – and this includes, of course, alternative medicine. The American Medical Association (AMA) have just published their newly revised code of ethics, AMA Principles of Medical Ethics.
It has long been my impression that, in alternative medicine, ethics receive no or far too little attention. Some alternative practitioners thrive to be able to call themselves ‘physicians’. Therefore, it seems interesting to ask whether they would also be able to comply with the ethical duties of a physician as outlined by the AMA.
The following 9 points are taken without change from the new AMA code; in brackets I have put my own, very brief comments pertaining to alternative practitioners. There is much more to be said about each of these points, of course, and I encourage my readers to do so in the comments section.
- A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. [Most alternative practitioners use unproven treatments; I doubt whether this can be called ‘competent medical care’.]
- A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. [Treating patients with unproven therapies in the absence of fully informed consent is arguably unprofessional, dishonest and deceptive. Crucially, alternative practitioners never object to even the worst excesses of quackery that occur in their realm.]
- A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. [Treatment with unproven therapies can hardly be in the best interest of the patient.]
- A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. [The right of patients includes full informed consent which is, according to my impression, rare in alternative medicine.]
- A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. [Alternative medicine is frequently out of line with or even opposed to medical knowledge.]
- A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
- A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. [Some activities of some alternative practitioners are directly opposed to public health, for instance when they advise against immunising children.]
- A physician shall, while caring for a patient, regard responsibility to the patient as paramount. [Arguably this is not possible when using unproven therapies.]
- A physician shall support access to medical care for all people. [Some alternative practitioners advise their patients against accessing conventional healthcare.]
As I stated above, medical ethics are neglected in alternative medicine. The 9 points of the AMA together with my comments go some way towards explaining why this is so. If ethical principles were applied to alternative medicine, much of it would have to stop instantly.
The UK petition to ban homeopathy for animals has so far achieved well over 3 000 signatures. Remarkably, it also prompted a reaction from the Faculty of Homeopathy which I reproduce here in full:
Homeopathy has a long history of being used successfully in veterinary practice for both domestic and farm animals. The EU recommends its use in its regulations on organic farms and is funding research into veterinary homeopathy as a way of reducing antibiotic use in livestock. It is nonsense to suggest that responsible pet owners and farmers are unable to distinguish between effective and ineffective medicines; they continue to use homeopathy because they see its benefits.
Membership of the Faculty of Homeopathy (VetMFHom) is bestowed on qualified veterinary surgeons who have completed a minimum of three years study of homeopathy and after a rigorous examination procedure. It differentiates the qualified veterinary homeopath from an unlicensed healer.
In a statement, the Royal College of Veterinary Surgeons said “… homeopathy is currently accepted by society and recognised by UK medicines legislation, and does not, in itself, cause harm to animals”. Before going on to say it could see no justification for banning veterinary surgeons from practising homeopathy.
In an age when antibiotic resistance is such an important issue, veterinary surgeons and farmers who have found they can limit the use of these drugs by using homeopathy should be applauded and not attacked.
Peter Gregory BVSc MRCVS VetFFHom
Veterinary Dean, Faculty of Homeopathy
Such sentiments resonate with those of the UK’s most influential supporter of homeopathy, Prince Charles. Speaking at a global leaders summit on antimicrobial resistance, Prince Charles recently warned that Britain faced a “potentially disastrous scenario” because of the “overuse and abuse” of antibiotics. The Prince explained that he had switched to organic farming on his estates because of the growing threat from antibiotic resistance and now treats his cattle with homeopathic remedies rather than conventional medication. “As some of you may be aware, this issue has been a long-standing and acute concern to me,” he told delegates from 20 countries at The Royal Society in London. “I have enormous sympathy for those engaged in the vital task of ensuring that, as the world population continues to increase unsustainably and travel becomes easier, antibiotics retain their availability to overcome disease… It must be incredibly frustrating to witness the fact that antibiotics have too often simply acted as a substitute for basic hygiene, or as it would seem, a way of placating a patient who has a viral infection or who actually needs little more than patience to allow a minor bacterial infection to resolve itself.”
It seems that both Prince Charles and Peter Gregory believe that homeopathy can be employed to reduce the use of antibiotics in animals. So, let’s analyse this hypothesis a little closer.
The way I see it, the belief must be based on one of two assumptions:
- Homeopathic remedies are effective in treating or preventing bacterial infections.
- If farmers administer homeopathic remedies to their life-stock, they are less likely to administer unnecessary antibiotics.
Assumption No 1 can be rejected without much further debate; there is no evidence whatsoever that homeopathic remedies have antibiotic efficacy. In fact, the consensus today is that highly diluted homeopathic remedies are pure placebos.
Assumption No 2, however, might be more plausible and therefore deserves further scrutiny. If we do not tell the farmers nor the vets that homeopathic remedies are placebos, if, in other words, we mislead them to think they are efficacious medicines, they might give them to their animals instead of antibiotics. Consequently, the usage of antibiotics in animals would decrease. This strategy sounds plausible but, on second thought, it has many serious drawbacks:
- The truth has a high value in itself which we would disregard at our peril.
- One might not be able to keep the truth from the farmers and even less able to hide it from vets.
- If we mislead farmers and vets, we must also mislead the rest of the population; this means lots of people might start using homeopathic placebos even for serious conditions.
- Misleading farmers, vets and the rest of the population is clearly unethical.
- Misleading farmers and vets in this way might not be necessary; if there is abuse of antibiotics in farming, we ought to tackle this phenomenon directly.
- Misleading farmers and vets might be dangerous for at least two reasons: firstly, animals who truly need antibiotics would not receive adequate treatment; secondly, farmers and vets might eventually become convinced that homeopathy is efficacious and would therefore use it in all sorts of situations, even for serious diseases of humans.
Whichever way I twist and turn the assumption No 2, I fail to arrive at anything remotely sensible. But this leaves me with a huge problem: I would have to conclude that both the Veterinary Dean, Faculty of Homeopathy and the heir to the throne are bonkers… and, surely, this cannot be right either!!!
Nobody can doubt that, during the last 200 years, conventional medicine has made monumental progress. Homeopathy, however, has remained more or less like Hahnemann invented it. But now it seems as though homeopathy can celebrate an unprecedented step ahead. As so often in medicine, it originates from a commercial enterprise.
Genexa is a US firm that produces natural health products. On their website, they state that “At Genexa, we believe medicine should be free from unhealthy fillers and toxins”. They recently published a press-release introducing a line of homeopathic medicines certified organic by the U.S. Department of Agriculture and Non-GMO Project verified. They are keen to point out that these products “do not contain any genetically modified ingredients.” In fact, several of their remedies do not contain any active ingredients to speak of: they are homeopathic!
“We are extremely proud of our organic and non-GMO certifications – the seals are prominently featured on all our products and website for easy label reading and patient education,” stated David Johnson, CEO of Genexa, in their press-release. “Our quality standards are among the highest in the over-the-counter medicine industry.”
Genexa’s 11 homeopathic formulations are being advertised for the treatment of common health issues such as flu, cold, allergies, stress, pain, leg cramps, sleeplessness and jet lag. An entire line of products is, according to the press-release, specially formulated for children and includes treatments for cold, allergy and calming.
Genexa’s CMO proudly announced that “It’s important to us that our retail customers feel confident in the products and know they can trust they are purchasing medicines free from unhealthy fillers and toxins and simply focus on healing.” Presumably that trust must include the trust into the efficacy of the homeopathic remedies! Yes, I am pleased to report that, apparently it does; elsewhere they confirm this by stating that “Genexa holds itself to the highest standards in both quality and ethics.” The highest standards of ethics surely include that the remedies in question are demonstrably efficacious.
But how can we be sure? Are any of these homeopathic remedies supported by reasonably strong evidence? Oddly enough, despite all these affirmations, I did get my doubts when I tried to dig a bit deeper.
Take the homeopathic remedy called SLEEPOLOGY, for instance. The website informs us that “This homeopathic formulation consists of nine leading remedies designed to treat sleeplessness, inability to fall asleep, frequent waking, restless sleep and sleeplessness from stress, exhaustion, nervousness, excitability, restlessness, worries, irritability, and pain.” So, it’s a complex homeopathic remedy with 9 different ingredients. But is there any evidence of efficacy for this mixture? I am not aware of any clinical trials that have tested its efficacy. But I must be wrong, because on the website we are being told that “Clinical trials have demonstrated efficacy for treating sleeplessness for piper methysticum, and valeriana officinalis.” That may be so, but the trials were done with herbal extracts, not with homeopathic potencies! Could the statement therefore be more than a little misleading?
On the internet, I found all sorts of fascinating bits about the new homeopathic lines (my compliments to the PR firm that organised the launch!); for instance the revelation that: “The company’s proprietary medicines were created by and are regularly reviewed and enhanced by its chief medical officer, Dr. Todd Rowe*, a nationally respected physician with an expertise in homeopathic medicine formulation. Working with the Genexa team, Dr. Rowe and his team of chemists and pharmacists spent hundreds of hours meticulously formulating and testing the products. The result is a line of effective, potent medicines that are certified organic by the USDA and non-GMO verified by the Non-GMO Project. “Our formulations are based on tried and true principles for miasmatic and energetic balance, so that the remedies potentiate each other and promote the most positive patient outcomes,” said Dr. Rowe. “These powerful medicines work with your body to help it heal itself.”” However, I was unable to find out which potencies are being used for the Genexa homeopathic products. This information might not be that relevant: according to the homeopathic ‘like cures like’ principle, the effects of a substance are reversed through potentiation. This is why coffee, for instance, is potentised by homeopath to generate a sleeping remedy. Does it not follow then that, potentising two or more herbal ingredients that have hypnotic effects (as in SLEEPOLOGY), must generate a remedy for preventing sleep? A similarly puzzling lack of ‘homeopathic logic’ seems to apply to several other products in Genexa’s line of homeopathic remedies.
I have to admit, I am confused.
Could it be that the ‘breakthrough’ turns out to be a breakdown of ‘homeopathic logic’?
Let’s hope someone from Genexa reads these lines and can enlighten us.[*he is the President of the American Medical College of Homeopathy]
“When orthodox medicine has nothing more to offer” is the title of an article by Dr Elizabeth Thompson, a UK medical homeopath. The article was written years ago, but it is still an excellent example for disclosing the dangerously false and deeply unethical reasoning used by many alternative practitioners. The notion that all sorts of disproven treatments like homeopathy are justified when orthodox medicine has nothing more to offer is so very prevalent that I decided to do this post analysing it.
In the following, you see the most relevant sections of Dr Thompson’s original article (in normal print) and my brief comments (in brackets and in bold):
…Some people come when conventional treatments can no longer offer them anything to save their lives. This is a frightening time for them and although the homeopathic approach may not offer a cure at this late stage of their illness (Is she implying that, in some cases, homeopathy can cure cancer?), it can often offer hope of a different kind. (Surely, one does not need homeopathy for giving patients hope). Sometimes it helps people to outlive the prognosis given to them by months or even years. (A prognosis is not a precise time of death; it is based on statistics and therefore depicts a likelihood, not a certainty. Thus patients outlive their prognosis all the time regardless of treatments.) Sometimes it helps them need less (less than what? there is no control group and therefore the statement seems nonsensical) in the way of conventional medicine including pain killers and offers them continuing support despite progressive disease (is she trying to say that in conventional medicine patients with progressive disease do not get continuing support?).
As a doctor working in both conventional and complementary cancer care I have learned the importance of integrating these two perspectives (the integration of unproven therapies into EBM can only render the latter less effective). Ideally the doctor practising homeopathy would work as an integral part of a much wider team which would include family members, nurses, general practitioners, oncologists, surgeons, palliative physicians and other complementary therapists (the concept of a multi-disciplinary team for cancer is one from conventional medicine where it has long been routine). It is disappointing sometimes to see that other healthcare professionals can be unsupportive of a person’s desire to use complementary therapies and for some people the knowledge that the team is not working together can cause doubt and insecurity (for the majority of patients, however, it might be reassuring to know that their oncology-team is evidence-based).
Some patients come at the beginning of their diagnosis wanting to support their bodies with gentler (homeopathic remedies are not gentler, they are ineffective) approaches and help themselves recover from some difficult and powerful treatments such as chemotherapy and radiotherapy (Why are they being told that alternative therapies are effective in achieving these aims when there is no good evidence to show that this is true? Isn’t that unethical?). As well as using homeopathic medicines (no good evidence of effectiveness!!!), the GHH also has experience in using Mistletoe which is given by injection and has been shown to stimulate the group of white cells whose numbers can be depleted during chemotherapy and radiotherapy (also no good evidence that it works clinically!!!).
Other patients come when they have finished most of their treatments but may still not be feeling well despite being given the all clear by their doctors (same again: no good evidence!!!)…
One wonderful aspect of the homeopathic approach is that it can be a very important opportunity to help someone re-evaluate their life and their health (We don’t need to prescribe placebos for that, this aim is better reached by employing a clinical psychologist).
Sometimes hurts in the past have never been healed and sitting with someone as they describe difficult experiences can be itself therapeutic. Combining this therapeutic listening time with substances from nature that gently stimulate the body’s own healing potential (where is the evidence for that claim?) can be an approach that through patient demand and research (what research?) we can demonstrate is really worth offering to many more people…
END OF QUOTE
This text shows in an exemplary fashion how desperate patients can be convinced to make dramatically wrong choices. If you read Dr Thompson’s text without my comments, it probably sounds fairly reasonable to many people. I can understand why patients and carers end up thinking that homeopathy or other disproven therapies are reasonable options WHEN ORTHODOX MEDICINE HAS NOTHING MORE TO OFFER.
But the claim of homeopaths and others that mainstream medicine has, in certain cases, nothing more to offer is demonstrably wrong. Supportive and palliative care are established and important parts of conventional medicine. To deny this fact amounts to a lie! The implied scenario where a patient is told by her oncology team: “sorry but we cannot do anything else for you”, does quite simply not exist. The argument is nothing else but a straw-man – and a vicious one at that.
Moreover, the subsequent argument of homeopaths, “as ‘they’ have given you up, we now offer you our effective homeopathic remedies”, is not supported by good evidence. In other words, one lie is added to another. To call this unethical, would be the understatement of the year, I think.
It has been reported that ‘Boots the Chemist’ have filed several legal complaints against The Guardian in relation to articles published by the paper in relation to its April 2016 investigation. The Guardian articles in question alleged that Boots, the UK’s largest pharmacy chain, had placed undue pressure on its pharmacists to perform medicines use reviews so that it could claim the maximum payments possible from the NHS. In other words, The Guardian implied that Boots was trying to get more money from our NHS than might have been due.
Personally, I am always uneasy when I hear that someone takes legal action on such matters. I think that legal complaints of such a nature can turn out to be counter-productive, both in general and in this particular instance.
There could be several reasons. For instance, such actions might give someone the idea of filing complaints against Boots. I am sure it is not difficult to find reasons for that.
In the realm of alternative medicine, for example, someone might question whether selling homeopathic remedies in Boot’s section ‘pharmacy and health’ is not misleading. These remedies might be seen by a naïve customer as masquerading as medicines. As readers of this blog know all too well, they do not, in fact, contain anything (other than lactose) that has any pharmacological activity. Therefore Boots should best market them in the category of ‘confectionary’.
One might even suspect that Boots are fully aware of all this. After all, a spokesperson for the company stated years ago during a parliamentary inquiry: “I have no evidence to suggest that they [homeopathic remedies sold by Boots] are efficacious …”
And it is also not the first time that Boots have been challenged for selling products they know to be placebos. This is what The Guardian reported in 2008 about the issue: “Ernst accuses the company [Boots] of breaching ethical guidelines drawn up by the Royal Pharmaceutical Society of Great Britain, by failing to tell customers that its homeopathic medicines contain no active ingredients and are ineffective in clinical trials.”
A similar void of evidence also applies to Boot’s wide range of Bach Flower Remedies and aromatherapy oils.
Or am I wrong?
Perhaps Boots want to post links to the evidence in the comment section below?
I am always keen to learn and only too happy to change my mind in view of new, compelling evidence!
Boots also sell a very wide range of herbal medicines, and here the situation is quite different: herbal medicines actually contain molecules that might have pharmacological effects, i. e. they might heal or might harm you. And many of these products imply indications for which they should be taken. I will pick just one example to explain: HERBAL SLIM AID.
Yes, you are absolutely correct – this product is (according to its name) not for gaining weight, it’s for reducing it. Each coated tablet contains 45 mg of extract (as dry extract) from Bladderwrack thallus (Fucus vesiculosus L.) (5:1) (equivalent to 225 mg of Fucus) Extraction solvent: water, ,30 mg Dandelion Root (Taraxacum officinale Weber ex Wigg), 27 mg of extract (as dry extract) from Boldo leaf (Peumus boldus Molina) (4-6:1) (equivalent to 108-162 mg of Boldo leaf) Extraction solvent: Methanol 70% v/v, 10 mg Butternut Bark (Juglans cinerea L.).
Now, I thought I know quite a bit about herbal slimming aids, after all, we had a research focus on this topic for several years and have published about a dozen papers on the subject. But oddly, I cannot remember that this mixture of herbs has been shown to reduce body weight.
Perhaps Boots want to post evidence for the efficacy and safety of this product as well?
I certainly hope so, and I would instantly withdraw any hint of a suspicion that Boots are selling unproven or disproven medicines.
Where is all this going?
I have to admit that am not entirely sure myself.
I suppose all I wanted to express was that it might be unwise to throw stones when one is sitting in a glass-house – a cliché, I know, but it’s true nevertheless.
CONFLICTS OF INTEREST:
None [except I don’t like those who easily take legal action against others]
Turmeric (Curcuma longa) is a truly fascinating plant with plenty of therapeutic potential. It belongs to the ginger family, Zingiberaceae and is native to southern Asia. Its main active ingredients are curcumin (diferuloylmethane) and the related compounds, demethoxycurcumin and bis-demethoxycurcumin (curcuminoids) which are secondary metabolites. Turmeric has been used extensively in Ayurvedic medicine and has a variety of pharmacologic properties including antioxidant, analgesic, anti-inflammatory, and antiseptic activities.
In the often weird world of alternative medicine, turmeric is currently being heavily hyped as the new panacea. Take this website, for instance; it promotes turmeric for just about any ailment known to mankind. Here is a short excerpt to give you a flavour (pun intended, turmeric is, of course, a main ingredient in many curries):
It comes at a surprise to a lot of people that herbs can be highly effective, if not more effective, than conventional medications …
To date, turmeric is one of the top researched plants. It was involved in more than 5,600 peer-reviewed and published biomedical studies. In one research project that extended over a five year period, it was found that turmeric could potentially be used in preventive and therapeutic applications. It was also noted that it has 175 beneficial effects for psychological health…
The 14 Medications it Mimics
Or should we say the 14 medications that mimic turmeric, since turmeric has been around much longer than any chemical prescription drug. Here’s a quick look at some of them:
- Lipitor: This is a cholesterol drug that is used to reduce inflammation and oxidative stress inside of patients suffering from type 2 diabetes. When the curcuminoid component inside of turmeric is properly prepared, it can offer the same effects (according to a study published in 2008).
- Prozac: This is an antidepressant that has been overused throughout the past decade. In a study published back in 2011, turmeric was shown to offer beneficial effects that helped to reduce depressive behaviors (using animal models).
- Aspirin: This is a blood thinner and pain relief drug. In a study done in 1986, it was found that turmeric has similar affects, which makes it a candidate for patients that are susceptible to vascular thrombosis and arthritis.
- Metformin: This is a drug that treats diabetes. It is used to activate AMPK (to increase uptake of glucose) and helps to suppress the liver’s production of glucose. In a study published in 2009, it was found that curcumin was 500 to 100,000 times more effective at activating AMPK ad ACC.
- Anti-Inflammatory Drugs: This includes medications like ibuprofen, aspirin and dexamethasone, which are designed to reduce inflammation. Again, in 2004, it was proven that curcumin was an effective alternative option to these chemical drugs.
- Oxaliplatin: This is a chemotherapy drug. A study done in 2007 showed that curcumin is very similar to the drug, acting as an antiproliferative agent in colorectal cell lines.
- Corticosteroids: This is a steroid medication, which is used to treat inflammatory eye diseases. In 1999, it was found that curcumin was effective at managing this chronic condition. Then in 2008, curcumin was used in an animal model that proved it could also aid in therapy used to protect patients from lung transplantation-associated injuries by “deactivating” inflammatory genes.
Turmeric Fights Drug-Resistant Cancers… it’s been shown that curcumin can battle against cancers that are resistant to chemotherapy and radiation…
END OF QUOTE
As I said, turmeric is fascinating and promising, but such hype is clearly counter-productive and dangerous. As so often, the reality is much more sobering than the fantasy of uncritical quacks. Research is currently very active and has produced a host of interesting findings. Here are the conclusions (+links) of a few, recent reviews:
Overall, there is early evidence that turmeric/curcumin products and supplements, both oral and topical, may provide therapeutic benefits for skin health. However, currently published studies are limited and further studies will be essential to better evaluate efficacy and the mechanisms involved.
While statistical significant differences in outcomes were reported in a majority of studies, the small magnitude of effect and presence of major study limitations hinder application of these results.
The highlighted studies in the review provide evidence of the ability of curcumin to reduce the body’s natural response to cutaneous wounds such as inflammation and oxidation. The recent literature on the wound healing properties of curcumin also provides evidence for its ability to enhance granulation tissue formation, collagen deposition, tissue remodeling and wound contraction. It has become evident that optimizing the topical application of curcumin through altering its formulation is essential to ensure the maximum therapeutical effects of curcumin on skin wounds.
What emerges from a critical reading of the evidence is that turmeric has potential in several different areas. Generally speaking, clinical trials are still thin on the ground, not of sufficient rigor and therefore not conclusive. In other words, it is far too early to state or imply that we all should rush to the next health food store and buy the supplements.
On the contrary, at this stage, I would even warn people not to be seduced by the unprofessional hype and wait until we know more – much more. There might be risks associated with ingesting turmeric at high doses over long periods of time. And there are fundamental open questions about oral intake. One recent review cautioned: …its extremely low oral bioavailability hampers its application as therapeutic agent.
WATCH THIS SPACE!
The ACUPUNCTURE NOW FOUNDATION (ANF) have recently published a document that is worth drawing your attention to. But first I should perhaps explain who the ANF are. They state that “The Acupuncture Now Foundation (ANF) was founded in 2014 by a diverse group of people from around the world who were concerned about common misunderstandings regarding acupuncture and wanted to help acupuncture reach its full potential. Our goal is to become recognized as a leader in the collection and dissemination of unbiased and authoritative information about all aspects of the practice of acupuncture.”
This, I have to admit, sounds like music to my ears! So, I studied the document in some detail – and the music quickly turned into musac.
The document which they call a ‘white paper’ promises ‘a review of the research’. Reading even just the very first sentence, my initial enthusiasm turned into bewilderment: “It is now widely accepted across health care disciplines throughout the world that acupuncture can be effective in treating such painful conditions as migraine headaches, and low back, neck and knee pain, as well as a range of painful musculoskeletal conditions.” Any review of research that starts with such a deeply uncritical and overtly promotional statement, must be peculiar (quite apart from the fact that the ANF do not seem to appreciate that back and neck pain are musculoskeletal by nature).
As I read on, my amazement grew into bewilderment. Allow me to present a few further statements from this review (together with a link to the article provided by the ANF in support and a very brief comment by myself) which I found more than a little over-optimistic, far-fetched or plainly wrong:
“Male fertility, especially sperm production and motility, has also been shown to improve with acupuncture. In a recent animal study, electro-acupuncture was found to enhance germ cell proliferation. This action is believed to facilitate the recovery of sperm production (spermatogenesis) and may restore normal semen parameters in subfertile patients.”
The article supplied as evidence for this statement refers to an animal experiment using a model where sperm are exposed to heat. This has almost no bearing on the clinical situation in humans and does not lend itself to any clinical conclusions regarding the treatment of sub-fertile men.
“In a recent meta-analysis, researchers concluded that the efficacy of acupuncture as a stand-alone therapy was comparable to antidepressants in improving clinical response and alleviating symptom severity of major depressive disorder (MDD). Also, acupuncture was superior to antidepressants and waitlist controls in improving both response and symptom severity of post-traumatic stress disorder (PTSD). The incidence of adverse events with acupuncture was significantly lower than antidepressants.”
The review provided as evidence is wide open to bias; it was criticised thus: “the authors’ findings did not reflect the evidence presented and limitations in study numbers, sample sizes and study pooling, particularly in some subgroup analyses, suggested that the conclusions are not reliable”. Moreover, we need to know that by no means all reviews of the subject confirm this positive conclusion, for instance, this, this, or this one; all of the latter reviews are more up-to-date than the one provided by ANF. Crucially, a Cochrane review concluded that “the evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture”.
“A randomized controlled trial of acupuncture and counseling for patients presenting with depression, after having consulted their general practitioner in primary care, showed that both interventions were associated with significantly reduced depression at three months when compared to usual care alone.”
We have discussed the trial in question on this blog. It follows the infamous ‘A+B versus B’ design which cannot possibly produce a negative result.
Now, please re-read the first paragraph of this post; but be careful not to fall off your chair laughing.
There would be more (much more) to criticise in the ANF report but, I think, these examples are ENOUGH!
Let me finish by quoting from the ANF’s view on the future as cited in their new ‘white paper’: “Looking ahead, it is clear that acupuncture is poised to make significant inroads into conventional medicine. It has the potential to become a part of every hospital’s standard of care and, in fact, this is already starting to take place not only in the U.S., but internationally. The treatment is a cost-effective and safe method of relieving pain in emergency rooms, during in-patient stays and after surgery. It can lessen post-operative nausea, constipation and urinary difficulties, and have a positive impact on conditions like hypertension, anxiety and insomnia…
Driven by popular demand and a growing body of scientific evidence, acupuncture is beginning to be taken seriously by mainstream conventional medicine, which is incorporating it into holistic health programs for the good of patients and the future of health care. In order for this transition to take place most effectively, misunderstandings about acupuncture need to be addressed. We hope this white paper has helped to clarify some of those misunderstandings and encourage anyone with questions to contact the Acupuncture Now Foundation.”
My question is short and simple: IGNORANCE OR FRAUD?
Yes, yes, yes, I know: we have too few women in our ‘ALT MED HALL OF FAME’. This is not because I have anything against them (quite the contrary) but, in alternative medicine research, the boys by far outnumber the girls, I am afraid.
You do remember, of course, you has previously been admitted to this austere club of excellence; only two women so far. Here is the current list of members to remind you:
David Peters (osteopathy, homeopathy, UK)
Nicola Robinson (TCM, UK)
Peter Fisher (homeopathy, UK)
Simon Mills (herbal medicine, UK)
Gustav Dobos (various, Germany)
Claudia Witt (homeopathy, Germany and Switzerland)
George Lewith (acupuncture, UK)
John Licciardone (osteopathy, US)
If you study the list carefully, you will also notice that, until now, I have totally ignored the chiropractic profession. This is a truly embarrassing omission! When it comes to excellence in research, who could possibly bypass our friends, the chiropractors?
Today we are going to correct these mistakes. Specifically, we are going to increase the number of women by 50% (adding one more to the previous two) and, at the same time, admit a deserving chiropractor to the ALT MED HALL OF FAME.
Cheryl Hawk is currently the Executive Director of Northwest Center for Lifestyle and Functional Medicine, University of Western States, Portland, USA. Previously she worked as Director of Clinical Research at the Logan University College of Chiropractic, Chesterfield, USA, and prior to that she was employed at various other institutions. Since many years she has been a shining light of chiropractic research. She is certainly not ‘small fry’ when it comes to the promotion of chiropractic.
Cheryl seems to prefer surveys as a research tool over clinical trials, and it was therefore not always easy to identify those of her 67 Medline-listed articles that reported some kind of evaluation of the value of chiropractic. Here are, as always, the 10 most recent papers where I could extract something like a data-based conclusion (in bold) from the abstract.
Hawk C, Schneider MJ, Vallone S, Hewitt EG.
J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-68
All of the seed statements in this best practices document achieved a high level of consensus and thus represent a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of infants, children, and adolescents.
Clinical Practice Guideline: Chiropractic Care for Low Back Pain.
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, Walters S, Kaeser M, Dehen M, Augat T.
J Manipulative Physiol Ther. 2016 Jan;39(1):1-22
The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.
Ndetan H, Hawk C, Sekhon VK, Chiusano M.
J Evid Based Complementary Altern Med. 2016 Apr;21(2):138-42.
The odds ratio for perceiving being helped by a chiropractor was 4.36 (95% CI, 1.17-16.31) for respondents aged 65 years or older; 9.5 (95% CI, 7.92-11.40) for respondents reporting head or neck trauma; and 13.78 (95% CI, 5.59-33.99) for those reporting neurological or muscular conditions as the cause of their balance or dizziness.
Schneider MJ, Evans R, Haas M, Leach M, Hawk C, Long C, Cramer GD, Walters O, Vihstadt C, Terhorst L.
Chiropr Man Therap. 2015 May 4;23:16.
American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.
Chiropractic identity, role and future: a survey of North American chiropractic students.
Gliedt JA, Hawk C, Anderson M, Ahmad K, Bunn D, Cambron J, Gleberzon B, Hart J, Kizhakkeveettil A, Perle SM, Ramcharan M, Sullivan S, Zhang L.
Chiropr Man Therap. 2015 Feb 2;23(1):4
The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.
Twist E, Lawrence DJ, Salsbury SA, Hawk C.
Chiropr Man Therap. 2014 Dec 10;22(1):40
These results strongly suggest that chiropractic clinical researchers are not developing ICDs at a readability level congruent with the national average acceptable level. The low number of elements in some of the informed consent documents raises concern that not all research participants were fully informed when given the informed consent, and it may suggest that some documents may not be in compliance with federal requirements. Risk varies among institutions and even within institutions for the same intervention.
Hawk C, Kaeser MA, Beavers DV.
J Chiropr Educ. 2013 Fall;27(2):135-40.
This active learning exercise appeared to be a feasible way to introduce tobacco counseling into the curriculum.
Hawk C, Schneider M, Evans MW Jr, Redwood D.
J Manipulative Physiol Ther. 2012 Sep;35(7):556-67
This living document provides a general framework for an evidence-based approach to chiropractic wellness care.
Ndetan H, Evans MW Jr, Hawk C, Walker C.
J Altern Complement Med. 2012 Apr;18(4):347-53.
C/OM is primarily used for back and neck pain, which is increasing in prevalence in children. Teens are more likely to use it than are younger children.
Dougherty PE, Hawk C, Weiner DK, Gleberzon B, Andrew K, Killinger L.
Chiropr Man Therap. 2012 Feb 21;20(1):3.
Given the utilization of chiropractic services by the older adult, it is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.
I am pleased to say that Prof Hawk gave me no problems at all; her case is clear: she is a champion of using research as a means for promoting chiropractic, has published many papers in this vein, clearly prefers the journals of chiropractic that nobody other than chiropractors ever access, and has an impeccable track record when it comes to avoiding negative conclusions which could harm chiropractic in any way.
Very well done indeed!
WELCOME, PROF HAWK, TO THE ‘ALT MED HALL OF FAME’.
You have to excuse me, if I keep coming back to this theme: so-called ‘alternative cancer cures’ are truly dangerous. I have tried to explain this already many times, for instance here, here and here. And it is by no means just alternative therapists who make a living of such quackery. Sadly qualified medical doctors are often involved as well. As to prove my point, here is a tragic story that broke yesterday:
Former Miss New Hampshire, Rachel Petz Dowd, lost her battle with cancer on Sunday 12 June 2016 — a battle she fought publicly through personal writings in a blog in hopes of helping others on a similar journey toward healing. The singer/songwriter and mother of three from Auburn died about a month after traveling to Mexico for an aggressive form of alternative cancer treatment. She turned 47 last week. Dowd was diagnosed with stage 2 triple negative breast cancer in May 2014. The diagnosis led her to create a blog called “Rachel’s Healing” to document what she hoped would be a journey back to health. “I hope my readers can gain something from my journey and that they find their own personal way to combat this disease impacting too many women today,” she wrote. Dowd used the blog to share her experiences with traditional and natural medicine during her cancer fight.
On 5/3/16 Mrs Dowd wrote on her blog: “Well after some careful consideration and looking at different clinics and hospitals we’ve made a decision. Will be going to the CMN Hospital on the Yuma, Arizona border*. For 28 days of treatments. It’s not a day clinic but a full hospital servicing over the past 30 years. There’s a special wing dedicated to alternative cancer care and the treatment list is impressive. Many treatments that are not available in this country. We feel this would be the best course of care daily for 28 days and then at the end of the 4 weeks I intend my immune system to be back on-line. I will be doing a stem cell boost of my bone marrow the last week. I know of a women, Shannon Knight, from The Truth About Cancer documentary, who had stage 4 metastasized into locations of her bones and her lungs and she came out of there completely cured. Her oncologist said it was nothing short of a miracle, but she said no it was just clean hard work! She said no it was just clean the hard, aggressive treatments that only attack cancer, boost and prime your immune system, become a whole, healthy being once again:) It is possible and I am planning on being one of the exceptions like Shannon!”
- The hospital is across the US border in Mexico; it is run by medically qualified personnel.
The hospital [“CMN Hospital’s facility is only 14 blocks away once you cross the border to begin your alternative cancer treatment”] has a website where they tell a somewhat confusing story about their treatment plans; here is a short but telling excerpt:
“CMN’s protocols are individualized and comprehensive. You will benefit from oxidative therapies, IV minerals selenium and bicarbonate IV vitamins such as vitamin B-17 and IV vitamin C. Far infrared and others including MAHT, Cold Laser Therapy, Hyperbaric Oxygen Therapy and Ozone Therapy are a daily part of your protocol. Ultraviolet Blood Irradiation is effective in destroying pathogens in your blood and slows the growth of cancer cell growth. CMN’s Stem cell therapy and Dendritic cell therapy are just two of the advanced cancer treatments applied to patients.”
IV Vitamin C If large amounts of vitamin C are presented to cancer cells, large amounts will be absorbed. In these unusually large concentrations, the antioxidant vitamin C will start behaving as a pro-oxidant as it interacts with intracellular copper and iron. This chemical interaction produces small amounts of hydrogen peroxide. Because cancer cells are relatively low in an intracellular anti-oxidant enzyme called catalase, the high dose vitamin C induction of peroxide will continue to build up until it eventually lyses the cancer cell from the inside out!
IV Vitamin B17 / Laetrile Also known as amygdaline, Vitamin B-17 is a molecule made up of four parts: -2 parts Glucose -1 part Benzaldahyde-1 part Hydrogen Cyanide. Laetrile is found in at least 1200 different plants, including apricots, peaches, apple seeds, lentils, cashews, brown rice, millet, and alfalfa. Commercial preparations of laetrile are obtained from the kernels of apricots, peaches and bitter almonds. The body requires an enzyme called beta-glucosidase in order to process laetrile and release the cyanide. Studies have shown that cancer cells contain more of this enzyme than normal cells, which allows for a higher release of cyanide at tumor sites. Another enzyme known as rhodanese is important in this process. Normal healthy cells contain rhodanese which protects them from the activated cyanide. Most cancer cells are deficient in this enzyme, leaving them vulnerable to the poison. Tumor destruction begins once the cyanide is released within the malignancies, meaning laetrile therapy is selectively toxic to cancer cells while remaining non-toxic to normal cells.
Essiac Tea / Order Original Essiac Tea Essiac, given its name by Rene Caisse (“caisse” spelt backwards), consists of four main herbs that grow in the wilderness of Ontario, Canada. The original formula is believed to have its roots from the native Canadian Ojibway Indians. The four main herbs that make up Essiac are Burdock Root, Slippery Elm Inner Bark, Sheep Sorrel and Indian Rhubarb Root. Essiac tea helps release toxins that build up in fat and tissues into the blood stream where they can be filtered and excreted by the liver and kidneys. Cleaning the body of toxins and impurities frees up the immune system to focus on killing cancer cells and protecting the body.
I think I will abstain from further comments, firstly because I want to avoid getting sued by these people and secondly because it seems all too depressingly obvious.
Seasonal allergic rhinitis (hay fever) is a common condition which can considerably reduce the quality of life of sufferers. Homeopathy is often advocated – but does it work?
A new study was meant to be an “assessment of the clinical effectiveness of homeopathic remedies in the alleviation of hay fever symptoms in a typical clinical setting.”
The investigator performed a ‘clinical observational study’ of eight patients from his private practice using Measure Yourself Medical Outcome Profile (MYMOP) self-evaluation questionnaires at baseline and again after two weeks and 4 weeks of individualized homeopathic treatment which was given as an add-on to conventional treatments.
The average MYMOP scores for the eyes, nose, activity and wellbeing had improved significantly after two and 4 weeks of homeopathic treatment. The overall average MYMOP profile score at baseline was 3.83 (standard deviation, SD, 0.78). After 14 and 28 days of treatment the average score had fallen to 1.14 (SD, 0.36; P<0.001) and 1.06 (SD, 0.25; P<0.001) respectively.
The author concluded as follows: Individualized homeopathic treatment was associated with significant alleviation of hay fever symptoms, enabling the reduction in use of conventional treatment. The results presented in this study can be considered as a step towards a pilot pragmatic study that would use more robust outcome measures and include a larger number of patients prescribed a single or a multiple homeopathic prescription on an individualized basis.
It is hard to name the things that are most offensively wrong here; the choice is too large. Let me just list three points:
- The study design is not matched to the research question.
- The implication that homeopathy had anything to do with the observed outcome is unwarranted.
- The conclusion that the results might lend themselves to develop a pilot study is meaningless.
The question whether homeopathy is an effective therapy for hay fever has been tested before, even in RCTs. It seems therefore mysterious why one needs to revert to tiny observational studies in order to plan a pilot, and even less for an assessment of effectiveness.
There are few conditions which are more time-dependent than hay fever. Any attempt of testing the effectiveness of medical interventions without a control group seems therefore not just questionable but wasteful. Clinical studies absorb resources; even if the author was happy to waste his time, he should not assume that he can freely waste the time, effort and availability of his patients.
Two final points, if I may:
- An observational study of homeopathy for hay-fever without a control group might be utterly useless but it is still an investigation that requires certain things. As far as I can see, this study did not even have ethics approval nor is there a mention of informed consent. Strictly speaking, this makes it an unethical study.
- If we allow research of this nature to take place and be published, we give clinical research a bad name and undermine the confidence of the public in science.
I am puzzled how such a paper could pass peer review and how an Elsevier journal could even consider publishing it.