MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

patient choice

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The ‘Pharmaceutical Journal’ just published a ‘pro/contra’ piece discussing whether UK community pharmacists should be selling homeopathic remedies to the public. Here are the essential parts of both arguments:

PRO

… I do not believe there is good scientific evidence to validate homeopathic remedies as medicines, but it is important to provide patients with choice in an informed environment — pharmacists and pharmacy teams are able to provide this expertise.

It is better for the public to buy these products from a reputable source where the community pharmacist — the expert on medicines — can provide professional advice, which is not available from unregulated online suppliers or other non-healthcare outlets…

So, I’m not here to argue the science: I argue that some people can benefit from homeopathy.

We ought to explore homeopathy’s placebo effect. Placebos are often dismissed as fakes, but they seem to act on the same brain pathways that are targeted by ‘real’ treatments. I wonder whether, through the placebo effect, homeopathy has a role to play in mental health treatment and pain relief. Whether for anxiety, mild-to-moderate depression, sleeplessness or stress, taking a little white tablet may benefit the patient, have fewer side effects than conventional medication, cause no harm, and is better than an excess of alcohol or illegal drugs.

Of course, homeopathy should not replace conventional medicines, and people should continue to be vaccinated, should use their inhalers and take their insulin. Homeopathy should not be funded on the NHS, but we do not live in a nanny state.

The clinical efficacy of many other products sold in the pharmacy is also questionable, but we still provide them. One example is guaifenesin for chesty coughs, which, at over-the-counter strength, provides a suboptimal dose. Many people are sceptical of the benefits of vitamin and mineral supplements. Bach flower remedies claim to tackle stress. We drink herbal tea for its ‘health’ benefits or buy fortified cereals because they are ‘better for you’, but these benefits are not clinically proven.

If the public finds comfort in a complementary therapy — whether it is acupuncture, reflexology, vitamins or homeopathy — I am happy to offer that choice, as long as the chosen therapies do no harm, and people continue to take their prescribed medicines.

If the patient wants my professional advice, I will explain that homeopathic medicines are not clinically proven but they may help certain conditions. I will probably recommend a different product, but at least I am there to do so.

You will not find a pharmacist in a health shop or on the internet, but in the community pharmacy you will find a highly qualified medicines expert, who will advise and inform, and who truly cares about the public’s health.

 

CONTRA

… given pharmacy’s heavy promotion of homeopathy, I feared that the profession was in danger of losing science as its bedrock.

… in 2009, a London-based pharmacy was supplying homeopathic ‘swine flu formula’. This was a dangerous practice but government agencies failed to regulate it effectively or to close it down.

In 2010, the then professional standards director at Boots, Paul Bennett (now chief executive, Royal Pharmaceutical Society), appeared before the Science and Technology Committee in its discussion of homeopathy’s availability on the NHS. Bennett stood by the sale of homeopathic remedies in Boots’ stores: “It is about consumer choice for us,” he said. I disagree with this argument.

Like the sale of cigarettes in US pharmacies, homeopathy threatens to fatally damage the reputation of community pharmacy. Pharmacies that sell homeopathic remedies give them unjustified credibility. Informed patient choice should be king; if pharmacists, pharmacy staff and shelf-barkers fail to clearly inform customers that homeopathic remedies are no more effective than placebo, we have acted unethically.

Yet Boots, perhaps alarmed by the number of subsequent protests against homeopathy outside its stores, got the message. Its website now reflects a more scientific approach: the homeopathic remedies it supplies state that they are “without approved therapeutic indications”. Boots also seems to have modified its range and offering of homeopathic remedies. So there is hope for community pharmacy.

Homeopathic remedies are still sold in pharmacies only because they make a profit. Sales in pharmacy are nonsense because, as most homeopathic practitioners claim, it is not possible to sell homeopathic remedies in isolation of a homeopathic consultation. The consultation determines the remedy. Off-the-shelf homeopathy is a relatively recent phenomenon.

The remedies are no more effective compared with placebo, anyway. Systematic reviews from the Cochrane Library — the gold standard of medical science — have considered homeopathy in the treatment of dementia, asthma and attention deficit hyperactivity disorder, all of which have confirmed the placebo effect. Irritatingly, supporters of homeopathy will always, in any debate, quote a bunkum study that shows some possible efficacy. Some might argue that placebo, or suggestion, is effective therapy, so why not use it? We must question the ethics of this approach.

Pharmacists act immorally when they sell the products without making clients aware that homeopathy does not work.

… I find that most pharmacists, when asked, appreciate that homeopathy has no scientific basis and provides merely a placebo effect. I sincerely hope that with this insight, pharmacy will finally clear its shelves of this expensive hocus pocus for good.

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I find both pieces quite weak and poorly argued. In fact, the ‘pro’ – arguments are quite laughable and could easily be used for teaching students the meaning and use of logical fallacies. In my view, all that needs to be pointed out here is this:

  1. Homeopathy is based on implausible assumptions.
  2. Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.
  3. Therefore, selling them to the naïve public, while pretending they are real medicines, is dishonest, arguably fraudulent and certainly not the behaviour one would expect of a healthcare professional.
  4. Pharmacists who nevertheless sell these remedies as medicines are in breach of their very own regulations.

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Strangely enough, when trying to find the relevant passage from the code of ethics for UK pharmacists, I struggled. The General Pharmaceutical Council’s ‘Standards fro Pharmacy Professionals‘ merely states this:

People receive safe and effective care when pharmacy professionals reflect on the application of their knowledge and skills and keep them up-to-date, including using evidence in their decision making. A pharmacy professional’s knowledge and skills must develop over the course of their career to reflect the changing nature of healthcare, the population they provide care to and the roles they carry out. There are a number of ways to meet this standard and below are examples of the attitudes and behaviours expected.

People receive safe and effective care when pharmacy professionals:

  • recognise and work within the limits of their knowledge and skills, and refer to others when needed
  • use their skills and knowledge, including up-to-date evidence, to deliver care and improve the quality of care they provide
  • carry out a range of continuing professional development (CPD) activities relevant to their practice
  • record their development activities to demonstrate that their knowledge and skills are up to date
  • use a variety of methods to regularly monitor and reflect on their practice, skills and knowledge

This, I admit, is not as clear as I had hoped (if my memory serves me right, this used to be much more explicit; in case anyone knows of a more suitable section in the code of ethics, please let me know); but it does preclude selling placebos, while pretending they are effective medicines.

I am not a regular reader of the ‘HALTERNER ZEITUNG’, I have to admit; but this article from the paper came to me because of my interest in homeopathy. It tells a tragic story of a German women who paid dearly for consulting a homeopath.

Here is an excerpt – as it is in German, I will sum up the essence of the story below in English.

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…Die traurige Geschichte beginnt im Jahr 2012. Die später verstorbene Frau aus Haltern lässt sich von ihrer Ärztin wegen Heiserkeit behandeln und bekommt homöopathische Mittel. Rund zehn Monate später wechselt die Seniorin den Arzt und muss umgehend ins Krankenhaus: Luftröhrenschnitt, Kehlkopf-Entfernung, Krebs. Die Frau verstirbt nach vierjähriger Leidenszeit.

Für Schwester und Tochter war das nicht nur ein Schock, sie machen der Ärztin nun auch schwere Vorwürfe. Aus ihrer Sicht hätte praktisch sofort eine Überweisung zu einem HNO-Arzt und damit eine schulmedizinische Behandlung erfolgen müssen.

Genau das habe die Patientin aber nicht gewollt, sagte die Ärztin. „Sie hat sich immer dagegen gewehrt.“ Angeblich soll das auch dokumentiert sein. Doch auch das ist umstritten. Die Hinterbliebenen werfen der Ärztin nämlich vor, die Unterlagen gefälscht zu haben.

150.000 Euro haben sie als Schmerzensgeld eingeklagt. Dafür sah die Medizinkammer zum jetzigen Zeitpunkt jedoch keine Grundlage. „Die Haftung ist vollkommen offen“, sagte Richter Norbert Schalla.

Man wolle die Leiden der Frau zwar nicht in Abrede stellen. Die Frage sei jedoch, inwieweit die Behandlung eines krankheitsbedingten Leidens tatsächlich verzögert worden sei. „Wir müssten erstens eine Pflichtverletzung und zweitens die Kausalität feststellen“, so Schalla. Beides sei aber außerordentlich schwierig, weil es außer der Ärztin keine Zeugen gebe.

Trotzdem hatten die Richter am Essener Landgericht am Ende eine „Goodwill-Zahlung“ vorgeschlagen, um einen möglicherweise jahrelangen Rechtsstreit zu verhindern. „Manchmal ist es besser, zu einem Abschluss zu kommen, damit man seinen inneren Frieden wiederfinden kann.“

Genau so hat es die Ärztin am Ende wohl auch gesehen. Ob die 10.000 Euro aber wirklich gezahlt werden, hängt allerdings noch von ihrer Haftpflicht-Versicherung ab. Die kann in den nächsten zwei Wochen noch ihr Veto einlegen.

Auch die Hinterbliebenen können die Einigung noch immer widerrufen. Sie müssen von dem Geld nämlich 94 Prozent der Prozesskosten tragen.

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Here is my summary:

  • An elderly woman with a sore throat consults her doctor who happens to be a homeopath.
  • The doctor prescribes homeopathic remedies.
  • The homeopathic treatment continues for months, evidently without success.
  • 10 months later, the patient changes her doctor, and her new physician sends her straight away into hospital.
  • There she is diagnosed with throat cancer.
  • After 4 years of suffering, the woman dies.
  • The patients relatives sue the homeopath for the relatively modest sum of 150 000 Euros.
  • The homeopath claims that the old woman had refused to be referred to a specialist and that the case notes provide proof for that claim.
  • The relatives suspect that the case notes have been altered retrospectively.
  • The judge suggest a ‘good will’ payment of 10 000 Euro.
  • The homeopath accepts, but it remains unclear whether the insurance agrees to pay this sum.
  • The relatives have to pay 94% of the costs for the court proceedings.

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Anyone who claims that homeopathy is harmless should remember this story. Similar (but hopefully less dramatic) things happen almost every time a homeopath treats a patient, we argue in our book. The practice of homeopathy is by and large medical neglect. Because homeopathy is employed mostly for minor, self-limiting conditions, the neglect usually remains invisible. However, as soon as homeopath venture to treat serious diseases, the neglect (the deliberate treatment of a disease with an ineffective therapy) becomes obvious.

In Germany, homeopathy had been an undisputed favourite for a very long time. Doctors prescribed it, Heilpraktiker recommended it, patients took it and consumers, politicians, journalists, etc. hardly ever questioned it. But recently, this has changed; thanks not least to the INH and the ‘Muensteraner Kreis‘, some Germans are finally objecting to paying for the homeopathic follies of others. Remarkably, this might even have led to a dent in the sizable profits of homeopathy producers: while in 2016 the industry sold about 55 million units of homeopathic preparations, the figure had decreased to ‘just’ ~53 million in 2017.

Enough reason, it seems, for some manufacturers to panic. The largest one is the DHU (Deutsche Homoeopathische Union), and they recently decided to go on the counter attack by investing into a large PR campaign. This article (in German, I’m afraid) explains:

…Unter dem Hashtag #MachAuchDuMit lädt die Initiative Anwenderinnen und Anwender ein, ihre guten Erfahrungen in Sachen Homöopathie zu teilen. “Über 30 Millionen zufriedene Menschen setzen für ihre Gesundheit auf Homöopathie und vertrauen ihr. Mit unserer Initiative wollen wir das Selbstbewusstsein der Menschen stärken, sich für die Homöopathie zu entscheiden oder mindestens für eine freie Wahl einzustehen,” so Peter Braun, Geschäftsführer der DHU…

“Die Therapiefreiheit, die in unserem Slogan mit “Meine Entscheidung!” zum Ausdruck kommt, ist uns das wichtigste in dieser Initiative”, unterstreicht Peter Braun. Und dafür lohnt es sich aktiv zu werden, wie der Schweizer weiß. 2017 haben sich die Menschen in der Schweiz per Volksabstimmung für das Konzept einer integrativen Medizin entschieden. Neben der Schulmedizin können dort auch weitere Therapieverfahren wie Homöopathie oder Naturmedizin zum Einsatz kommen.

In Deutschland will die DHU mit ihrer Initiative Transparenz schaffen und die Homöopathie hinsichtlich Fakten und Erfolge realistisch darstellen. Dafür besteht offensichtlich Bedarf: “Wir als DHU haben in der jüngsten Vergangenheit dutzende spontane Anfragen bekommen, für die Homöopathie Flagge zu zeigen”.

Was die Inhalte der Initiative angeht betont Peter Braun, dass es dabei nie um ein “Entweder-Oder” zwischen Schulmedizin und anderen Therapieverfahren gehen soll: “Die Kombination der jeweils am besten für den Patienten passenden Methode im Sinne von “Hand-in-Hand” ist das Ziel der modernen integrativen Medizin. In keiner Art und Weise ist eine Entscheidung für die Homöopathie eine Entscheidung gegen die Schulmedizin. Beides hat seine Berechtigung und ergänzt sich in vielen Fällen.”

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For those who do not read German, I will pick out a few central themes from the text.

Amongst other things, the DHU proclaim that:

  1. Homeopathy has millions of satisfied customers in Germany.
  2. The campaign aims at defending customers’ choice.
  3. The campaign declares to present the facts realistically.
  4. The decision is “never an ‘either or’ between conventional medicine (Schulmedizin) and other methods”; combining those therapies that suit the patient best is the aim of modern Integrative Medicine.

It is clear to anyone who is capable of critical thinking tha
t these 4 points are fallacious to the extreme. For those to whom it isn’t so clear, let me briefly explain:

  1. The ‘appeal to popularity’ is a classical fallacy.
  2. Nobody wants to curtail patients’ freedom to chose the therapy they want. The discussion is about who should pay for ineffective remedies. Even if homeopathy will, one day, be no longer reimbursable in Germany, consumers will still be able to buy it with their own money.
  3. The campaign has so far not presented the facts about homeopathy (i. e. the remedies contain nothing, homeopathy relies on implausible assumptions, the evidence fails to show that highly diluted homeopathic remedies are effective beyond placebo).
  4. Hahnemann called all homeopaths who combined his remedies with conventional treatments ‘traitors’ (‘Verraeter’) and coined the term ‘Schulmedizin’ to defame mainstream medicine.

The DHU campaign has only started recently, but already it seems to backfire big way. Social media are full with comments pointing out how pathetic it truly is, and many Germans have taken to making fun at it on social media. Personally, I cannot say I blame them – not least because the latest DHU campaign reminds me of the 2012 DHU-sponsored PR campaign. At the time, quackometer reported:

A consortium of pharmaceutical companies in Germany have been paying a journalist €43,000 to run a set of web sites that denigrates an academic who has published research into  their products.

These companies, who make homeopathic sugar pills, were exposed in the German newspaper Süddeutsche Zeitung in an article, Schmutzige Methoden der sanften Medizin (The Dirty Tricks of Alternative Medicine.)

This story has not appeared in the UK media. And it should. Because it is a scandal that directly involves the UK’s most prominent academic in Complementary and Alternative Medicine.

The newspaper accuses the companies of funding the journalist, Claus Fritzsche, to denigrate critics of homeopathy. In particular, the accusation is that Fritzsche wrote about UK academic Professor Edzard Ernst on several web sites and then linked them together in order to raise their Google ranking. Fritzsche continually attacks Ernst of being frivolous, incompetent and partisan…

This story ended tragically; Fritzsche committed suicide.

My impression is that the PR-campaigns of homeopaths in general and the DHU in particular are rather ill-fated. Perhaps they should just forget about PR and do what responsible manufacturers should aim at doing: inform the public according to the best evidence currently available, even if this might make a tiny dent in their huge profits.

I have written about the use of homeopathy in France before (as I now live half of my time in France, this is a subject of considerable interest to me). After decades of deafening silence and uncritical acceptance by the French public, it seems that finally some change to the better might be on its way. Recently, a sizable number of prominent doctors protested publicly against the fact that, despite its implausibility and the lack of proof of efficacy, homeopathy continues to be reimbursed in France and scarce funds are being wasted on it. This action seems to have put pressure on officials to respond.

Yesterday (just in time for the ‘HOMEOPATHIC AWARENESS WEEK’) the French minister of health was quoted making a statement on homeopathy. Here is my translation of what Agnès Buzyn was quoted saying:

“There is a continuous evaluation of the medicines we call complementary. A working group* at the head office of my department checks that all these practices are not dangerous. If a therapy continues to be beneficial without being harmful, it continues to be reimbursed… The French are very attached [to homeopathy]; it’s probably a placebo effect. If it can prevent the use of toxic medicine, I think that we all win. I does not hurt.”

Agnès Buzyn

  • I would like to know who they are, how they can be contacted, and whether they would consider recruiting my assistance in evaluating alternative therapies.

So, if I understand her correctly, Agnès Buzyn believes that:

  1. the French people are fond of homeopathy;
  2. homeopathy is a placebo-therapy;
  3. homeopathy does no harm;
  4. homeopathy can even prevent harm from conventional medicine;
  5. on balance, therefore, homeopathy should continue to be reimbursed in France.

My views of this type of reasoning have been expressed repeatedly. Nevertheless, I will briefly state them again:

  1. true but not relevant; healthcare is not a popularity contest; and the current popularity is essentially the result of decades of systematic misinformation of consumers;
  2. correct;
  3. wrong: we have, on this blog, discussed ad nauseam how homeopathy can cause serious harm; for instance, whenever it replaces effective treatments, it can cause serious harm and might even kill patients;
  4. if doctors harm patients by needlessly prescribing harmful treatments, we need to re-train them and stop this abuse; using homeopathy is not the solution to bad medicine;
  5. wrong: the reimbursement of homeopathy is a waste of money and undermines evidence-based medicine.

So, what’s the conclusion?

Politicians are usually not good at understanding science or scientific evidence. They (have to?) think in time spans from one election to the next. And they are, of course, keenly aware that, in order to stay in power, they rely on the vote of the people. Therefore, the popularity of homeopathy (even though it is scientifically irrelevant) is a very real factor for them. This means that, on a political level, homeopathy is sadly much more secure than it should be. In turn, this means we need to:

  • use different arguments when arguing with politicians (for instance, the economic impact of wasting money on placebo-therapies, or the fact that systematically misinforming the public is highly unethical and counter-productive),
  • and make politicians understand science better than they do at present, perhaps even insist that ministers are experts in their respective areas (i. e. a minister of health fully understands the fundamental issues of healthcare).

Does that mean the new developments in the realm of French homeopathy are all doomed to failure?

No, I don’t think so – at least (and at last) we have a vocal group of doctors protesting against wasteful nonsense, and a fairly sound and accurate statement from a French minister of health:

HOMEOPATHY, IT’S PROBABLY A PLACEBO EFFECT!

 

This is a question most clinicians must have asked themselves. The interest of patients in this area is enormous, and many do seek advice from their doctor, nurse, pharmacist, midwife etc. In a typical scenario, a patient might plug up her courage (yes, for many it does take courage) and ask:

What about therapy xy for my condition? My friend suffers from the same problem, and she says the treatment works very well.

The way I see it, there are essentially 4 options for formulating a reply:

1.       Uncompromisingly negative

2.       Evidence-based

3.       Open-minded

4.       Uncritically promotional

Let me explain and address these 4 options in turn.

1.       Uncompromisingly negative

I know that it can be tempting to be wholly dismissive and simply state that all alternative medicine is rubbish; if it were any good, it would have been adopted by conventional medicine. Therefore, alternative medicine is never an alternative; it is by definition implausible, ineffective and often dangerous.

Even if all of this were true, the uncompromisingly negative approach is not helpful, in my experience. Patients need and deserve some empathy and understanding of their position. If we brusque them, they feel insulted and go elsewhere. Not only would we then lose a patient, but we would run a high risk of exposing her to a practitioner who promotes quackery. The disservice seems obvious.

2.       Evidence-based

Clinicians might consider their patient’s question and reply to it by explaining what the current best available evidence tells us about the therapy in question. This can be done with empathy and compassion. For instance (if that is true), the clinician can explain that the treatment in question lacks a scientific basis, that it has nevertheless been tested in clinical trials which sadly do not show that it works. Crucially, the clinician should subsequently explain what effective treatments do exist and discuss a viable treatment plan with the patient.

The problem with this approach is that many, if not most conventional clinicians are fairly clueless about the evidence as it relates to the plethora of alternative therapies. Therefore, an honest discussion around the current best evidence is often difficult or impossible.

3.       Open-minded

This is the approach many clinicians today use as a default position. They basically tell their patient that there is not a lot of evidence for the treatment in question. However, it seems harmless, and therefore – if the patient is really keen on going down this route – why not? This type of response is, I fear, given regardless of the therapy in question and it largely ignores the evidence – some alternative treatments do work, some don’t, some are fairly safe, some aren’t.

Condoning alternative medicine in this way gives the impression of being ‘open-minded’ and ‘patient-centred’. It has the considerable advantage that it does not require any hard work, such as informing oneself about the current best evidence. It’s disadvantage is that it neither correct nor ethical.

4.       Uncritically promotional

Many clinicians go even one decisive step further. Under the banner of ‘integrative medicine’, they openly recommend using ‘the best of both worlds’ as being ‘holistic’, ’empathetic’, ‘patient-centred’, etc. By this, they usually mean employing as many unproven or disproven treatments as alternative medicine has to offer.

This approach gives the impression of being ‘modern’ and in tune with the wishes of patients. Its disadvantages are, however, obvious. Introducing bogus treatments into clinical routine can only render it less effective, more expensive, and less safe. Integrative medicine is therefore not in the best interest of patients and arguably unethical.

Conclusion

So, how should we advise patients on alternative medicine? I know what I would say and probably most of my readers can guess. But I do not want to prejudge the issue; I prefer to hear your views, please.

If you ask me, the field of alternative medicine is plagued with surveys; too many are published and most are complete, meaningless rubbish which serve merely the purpose of being misinterpreted as a means of popularising bogus treatments. Yet, every now and then, a decent and informative article appears – like this survey from Canada.

It yields a number of fascinating findings:

  • More than three-quarters of Canadians (79%) had used at least one from of CAM sometime in their lives in 2016 (74% in 2006 and 73% in 1997). British Columbians were most likely to have used an alternative therapy during their lifetime (89%), followed by Albertans (84%) and Ontarians (81%).
  • More than half (56%) of Canadians had used at least one CAM therapy in the year prior to the 2016 survey, compared to 54% in 2006 and 50% in 1997.
  • In 2016, massage was the most common type of therapy that Canadians used over their lifetime with 44 percent having tried it, followed by chiropractic care (42%), yoga (27%), relaxation techniques (25%), and acupuncture (22%).
  • The most rapidly expanding therapies over the past two decades were massage, yoga, acupuncture, chiropractic care, osteopathy, and naturopathy.
  • High dose/mega vitamins, herbal therapies, and folk remedies were in declining use over that same time period.
  • The most likely users of CAM over the past 12 months in 2016 were from the 35- to 44-year-old age group (61%). The use of CAM diminished with age, and generally rose with both income and education. These trends are similar to those observed in 2006 and 1997.
  • The majority of people choosing to use CAM in the 12 months preceding the 2016 survey did so for “wellness”.
  • Canadians spent an estimated $8.8 billion on CAM in the last 12 months ($8.0 billion in 2005/06 and $6.3 billion in 1996/97.
  • Of the $8.8 billion spent in 2016, more than $6.5 billion was spent on providers of CAM, while another $2.3 billion was spent on herbs, vitamins, special diet programs, books, classes, and equipment.
  • The majority of Canadians believe that CAM should be paid for privately and not by provincial health.

The strengths of this survey are that it is methodologically rigorous, and that it provides longitudinal data (this is in sharp contrast to the plethora of CAM surveys published recently). Many of its findings confirm what has already been known. Yet some results are new and noteworthy.

To many readers of this blog, the high CAM-usage will be disturbing. However, I am mildly encouraged by the results of this survey.

  • Firstly, the choice of CAM by Canadians seems rather more reasonable than that by other nations. Canadians seem to avoid the more ridiculous types of CAM, such as homeopathy or para-normal healing.
  • Secondly, many Canadians seem to view CAM not as medicine, but as a sort of luxurious pampering that they use to relax and feel well. Consequently, most are not pushing to get it reimbursed which I find more sensible than consumers’ attitudes in many other countries.

An article in the medical magazine ‘GP’ caught my eye. In it, a GP from Southampton argues that it is counter-productive for the NHS to ban ineffective treatments. Here are a few excerpts (my comments are inserted in brackets and are in bold print):

START OF QUOTES

NHS England’s recent decision requiring GPs stop prescribing a list of 18 medicines will reinforce the fears of many doctors that healthcare rationing is being introduced by the back door (all finite NHS resources need to be and always have been rationed). I would also argue that it is an illogical and ill-informed decision that will not achieve the professed aim of saving NHS resources (perhaps the decision is not purely based on the need to save money but also on a matter of principle and an attempt to make the NHS evidence-based?).

The decision to impose a blanket ban on these items will disproportionately affect those patients who currently receive free prescriptions: the young, the poor and the elderly (where is the evidence for this statement?). The conditions these patients are suffering from will persist (treating them with ineffective medications would also make them persist).

If in future these vulnerable patients want to continue with their medicines, they will be forced to pay for them. While wealthier patients will have the option to pay for their medications, those unable to do so will return to their GP for an alternative medication or procedure that has not been prohibited by NHS England’s recommendations. GPs will then find themselves prescribing other more costly medications. How this is helping NHS England to reduce prescribing costs is difficult to see (really? I don’t find it difficult to see that spending money on effective treatments is a better investment than wasting it on ineffective stuff)…

… ‘evidence-informed practice’… not only includes scientific research, but also evidence from clinical practice acquired over many years and endorsed by numerous clinicians. Yet this type of evidence, from the front line of medicine, is being dismissed as ‘unscientific’ or ‘anecdotal’ (no, it has never been considered to be evidence; remember: the plural of anecdote is anecdotes, not evidence)…

We all want the NHS to operate cost effectively… (as long as the NHS continues to pay for homeopathy?). Of course, treatments that have no good evidence of benefit to patients should be questioned (as long as the NHS continues to pay for homeopathy?)…

NHS England needs to conduct a review of how it evaluates treatments and take far more notice of the experiences of doctors and patients. Then perhaps we will see a more financially efficient health service, healthier patients and an end to the injustice of healthcare rationing (the author forgot to tell her readers that she is a homeopath – in fact, she did not even once use the word ‘homeopathy’ in her diatribe. Because of her extreme views, she has featured on this blog before. [“homeopathy can be helpful for pretty much any condition”] Dr Day also forgot to declare conflicts of interest in her most recent vituperation [easy mistake to make; I know I am being petty).

 

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If I were a fan of homeopathy and a believer in the magical healing power of shaken water, I would be very worried. While homeopaths put forward such embarrassingly daft arguments, the future of homeopathy looks bleak indeed.

 

 

This is the title of an editorial by Alan Schmukler. You probably remember him; I have featured him before, for instance here, here, and here. This is what was recently on Schmukler’s mind (I have added a few references referring to comments of mine added below):

England’s National Health Service (NHS) is proposing that NHS doctors no longer be permitted to prescribe homeopathic remedies [1]… They claim lack of evidence for effectiveness. Anyone who’s been remotely conscious the last 10 years will see this as a pretext. Homeopathy is practiced by board certified physicians in clinics and hospitals around the world [2]. The massive Swiss review of homeopathy, found it effective, safe and economical, and the Swiss incorporated homeopathy into their national health care system [3]…

The reason given for banning homeopathy and these nutrients is a lie. Why would the NHS ban safe, effective and affordable healing methods? [4] Without these methods, all that is left are prescription drugs. Apparently, someone at the  NHS has an interest in pushing expensive prescription drugs [5], rather than safer and cheaper alternatives. That someone, also wishes to deny people freedom of choice in medicine [6]. I say “someone”, because organizations don’t make decisions, people do. Who is that someone?  In looking for a suspect, we might ask, who is the chief executive of the organization? Who introduced this plan and is promoting it? Who at the NHS has the political clout?  Who was it that recently declared: “Homeopathy is a placebo and a misuse of scarce NHS funds which could better be devoted to treatments that work”.

The quote is from Simon Stevens, NHS England’s chief executive. He got the job in 2014, after ten years as a top executive at UnitedHealth, the largest health insurance company in America. His past work experiences and current activities show that he favors privatization [7]. That would make him an odd choice to run a healthcare system based on socialized medicine. In fact, he has been moving the NHS towards privatization and the corporate, profit based American model. [8] The last thing a privatizer in healthcare would want, are non-proprietary medicines, for which you can’t charge exorbitant fees [9]. Banning homeopathy on the NHS is just one small part of a larger plan to maximize corporate profits by letting corporations own and control the health care system [10].  Before they can do this, they have to eliminate alternative methods of treatment.

Personally, I think Schmukler is wrong – here is why:

1 The current argument is not about what doctors are permitted to do, but about what the NHS should do with our tax money.

2 Argumentum ad populum

3 Oh dear! Anyone who uses this report as evidence must be desperate – see for instance here.

4 Why indeed? Except highly dilute homeopathic remedies are pure placebos.

5 Maybe ‘someone’ merely wants to use effective medications rather than placebos.

6 Freedom of choice is a nonsense, if it is not guided by sound evidence – see here.

7 No, that’s Jeremy Hunt! But in any case privatisation might be more profitable with homeopathy – much higher profit margins without any investment into R&D.

8 No, this is Hunt again!

9 Homeopathic remedies are ideal for making vast profits: no research, no development, no cost for raw material, etc., etc.

10 I am sure Boiron et al would not mind stepping into the gap.

I very much look forward to the next outburst of Alan Schmukler and hope he will manage to think a bit clearer by then.

We have repeatedly discussed the fact that alternative medicine (AM) is by no means free of risks. I find it helpful to divide them into two broad categories:

  1. direct risks of the intervention (such as stroke due to neck manipulation, or cardiac tamponade caused by acupuncture, or liver damage due to a herbal remedy) and
  2. indirect risks usually due to the advice given by AM practitioners.

The latter category is often more important than the former. It includes delay of effective treatment due to treatment with an ineffective or less effective form of AM. It is clear that this will cause patients to suffer unnecessarily.

Several investigations have recently highlighted this important problem, including this study from Singapore which assessed the predictors of AM-use in patients with early inflammatory arthritis (EIA), and its impact on delay to initiation of disease-modifying anti-rheumatic drugs (DMARD). Data were collected prospectively from EIA patients aged ≥ 21 years. Current or prior AM-use was ascertained by face-to-face interviews. Predictors of AM-use and its effect on time to DMARD initiation were determined by multivariate logistic regression and Cox proportional hazards, respectively.

One hundred and eighty patients were included: 83.9% had rheumatoid arthritis, 57% were seropositive. Median (IQR). Chinese race, being non-English speaking,  smoking and high DAS28 were independent predictors of AM-use. AM-users initiated DMARD later (median [IQR] 21.5 [13.1-30.4] vs. 15.6 [9.4-22.7] weeks in non-users, P = 0.005). AM-use and higher DAS28 were associated with a longer delay to DMARD initiation. Race, education level, being non-English speaking, smoking and sero-positivity were not associated.

The authors concluded that healthcare professionals should be aware of the unique challenges in treating patients with EIA in Asia. Healthcare beliefs regarding AM may need to be addressed to reduce treatment delay.

These findings are not dissimilar to results previously discussed, for instance:

The only solution to the problem I can think of would be to educate AM practitioners and the public such that they are aware of the issue and do everything possible to prevent such problems. But this is, of course, easier said than done, and it seems more than just optimistic to hope that such endeavours might be successful. The public is currently  bombarded with misleading information and outright lies about AM (many of my previous post have addressed this problem). And practitioners would have to operate against their own financial interest to prevent these problems from occurring.

This means that treatment delays caused by AM-use and advice from AM practitioners are inevitable…

unless you have a better idea.

If so, please let me know.

 

Guest post by Richard Rawlins MB BS MBA FRCS

Doctors who are registered medical practitioners (RMPs) must comply with the standards of practice set down by the General Medical Council. ‘Homeopathy’ is a specific system of medical care, devised by Dr Samuel Hahnemann in the nineteenth century, and comprises two distinct dimensions: (i) the establishment of a constructive therapeutic relationship between an empathic homeopath and a patient. This may provide benefit due to the non-specific effects of condolence, counselling, and care – and should be a component of the practice of all doctors in any event; (ii) the homeopathically prepared (HP) remedies that are generally prescribed. To avoid confusion, these two dimensions should not be conflated.

HP remedies may be obtained over the counter, prescribed by lay homeopaths and even given out by dentists and nurses on the grounds that “30C homeopathic arnica helps bruising”. The US Federal Trades Commission has stated that “The Commission will carefully scrutinize the net impression of OTC homeopathic advertising or other marketing employing disclosures to ensure that it adequately conveys the extremely limited nature of the health claim being asserted…accordingly, unqualified disease claims made for homeopathic drugs must be substantiated by competent and reliable scientific evidence.” (FTC Policy statement 2017).

Special focus should be brought to bear on the ethical, intellectual and professional obligations of those doctors registered as medical practitioners by the GMC and practicing homeopathy in the UK. Some homeopaths may intend taking advantage of gullible and vulnerable patients. Here I take it that those practitioners who prescribe homeopathic remedies sincerely do believe they have worthwhile effects, but I contend such practice generally fails to comply with ethical and professional standards as set down by the GMC. That is to be deprecated.

Systems to regulate medical practice in the British Isles have been devised since the middle ages. In 1518, Thomas Linacre founded the College of Physicians – based on systems he had seen in Europe. From 1704, the Society of Apothecaries licensed its members to prescribe and dispense medicines, and developed the profession of general practice. In order to protect the public from charlatans, quacks and fraudsters more effectively, the Medical Act of 1858 established formal statutory regulation of doctors by the General Medical Council. Registrants who are not deemed fit to practice may be struck off the register. They can still practice, but not as registered medical practitioners. They can still use the title ‘doctor’ (as can anyone), but not for fraudulent purposes.

Dr Samuel Hahnemann qualified in Saxony in 1781 and was a good doctor, but he became disillusioned with many of the practices and practitioners of his day. He wrote about his fellow doctors: “Precious and fragile human life, so easily destroyed, was frequently placed in jeopardy at the hands of these perverted people, especially since bleedings, emetics, purges, blistering plaster, fontanels, setons, caustics and cauterisations were used.” In 1796 he wrote to a friend, “I renounced the practice of medicine that I might no longer incur the risk of doing injury, and I engaged in chemistry exclusively and in literary occupations.”

Hahnemann went on to develop his own alternative system of health care, which he styled ‘Homoeopathy’. Published as the Organon of the Healing Arts in 1810, Hahnemann set out an idiosyncratic medical system based on identifying ‘remedies’ which in large doses, could produce symptoms comparable to those suffered by the patient. The remedies he prescribed were prepared with serial dilutions so that no active principle remained. Today’s homeopaths hold that a remedy’s ‘vital force’, ‘healing energy’ or ‘memory’ provides therapeutic benefit. That may be the case, but the consensus of informed scientific and medical opinion is that any effects of ‘homeopathy’ are as a result of contextual placebo effects. The remedies themselves cannot and do not have any effect. England’s Chief Medical Officer has described homeopathy’s principles as ‘rubbish’. The government’s Chief Scientific Adviser, Sir Mark Walport has said he would tell ministers, “My view, scientifically, is absolutely clear: homeopathy is nonsense. The most it can have is a placebo effect.” Simon Stevens, CEO of the NHS, when interviewed on Radio 4 said he agrees with Sir Mark – yet failed to explain why he had not included homeopathic remedies in the 2017 list of NHS proscribed medicines. That stance is being reviewed.

The GMC states, “Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected.” Those standards are set down in the GMC’s Good Medical Practice which advises, “Serious or persistent failure to follow this guidance will put your registration at risk.” The GMC standards are coherent with those of the American Medical Association’s Principles of Medical Ethics (2016).

In précis, the most relevant and important GMC standards are:

  • Make the care of your patient your first concern.
  • Give patients the information they want or need in a way they can understand.
  • Be honest and open and act with integrity.
  • Never abuse your patients’ trust in you or the public’s trust in the profession.
  • You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.
  • You must  prescribe drugs or treatment only when you are satisfied that the drugs or treatment serve the patient’s needs.                                                                                                                                             
  • You must provide effective treatments based on the best available evidence.
  • You must be satisfied that you have consent or other valid authority before you carry out any examination, investigation or provide treatment.
  • You must make good use of the resources available to you.

I contend that medical practitioners who prescribe homeopathic remedies regularly fail to meet these standards. They know perfectly well that the best available evidence indicates no support for the assertion that homeopathic remedies ‘serve the patient’s needs’, except as placebos; that the treatments have no specific effects; that the remedies are placebos; and that resources are wasted by expenditure on these ineffective remedies. Medical homeopaths invariably do not give patients this information; they fail to obtain properly informed consent; they do not justify their decisions and actions rationally; and they may be obtaining financial advantage by misrepresentation to insurance companies or the NHS. This is an abuse of the public’s trust in the medical profession.

The issue of informed consent is particularly important. GMC guidance states that, “The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit for the patient. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice. …Before accepting a patient’s consent, you must consider whether they have been given the information they want or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded.”

The GMC states that, “in order to have effective discussions with patients about risk, you must identify the adverse outcomes that may result from the proposed options… risks can take a number of forms, but will usually be: side effects; complications; failure of an intervention to achieve the desired aim.” The risk of wasting money on ineffective remedies, whether NHS or private, and of delaying treatment known to be effective should also be discussed.

Homeopaths acknowledge that after ministration of remedies, some patients experience ‘aggravations’ – a worsening of symptoms, but they advise this is evidence that the remedy is ‘working’. Medical consensus is more likely to suggest ‘aggravations’ are evidence of an underlying psychological component to the patient’s condition. Suggestions that remedies themselves have any effect, good or bad, is misrepresentation and may be fraud. Offering patients sugar pills with a claim the pills have therapeutic effects means lying to them, and is an abuse of trust.

Homeopaths’ system of diagnosis and prescription of remedies requires them to have beliefs for which there is no plausible evidence base. The Oxford Dictionary defines ‘belief’ as “assent to a proposition, statement or fact, especially on the grounds of testimony or authority, or in the absence of proof or conclusive evidence.” It might be acceptable to practice ‘homeopathy’ as a counselling modality, providing the practitioner complies with the GMC standard that, “You must not express your personal beliefs to patients in ways that exploit their vulnerability or are likely to cause them distress.”

Homeopaths are invariably non-compliant in obtaining fully informed consent. Such a failing is an abuse of patients’ trust in the medical profession. Doctors might be determined to be unfit to practice unless they clearly justify their prescriptions, and identify the evidence that supports them. All these issues should also be explored during the doctor’s annual appraisal, without which a registered medical practitioner will not be licensed to practice. Even registration without a licence requires compliance with the standards. Appraisal can be carried out by non-homeopaths, as the issue is not the assessment of the standard of ‘homeopathic practice’, but compliance with GMC standards of good medical practice.

If a medical homeopath wishes to be GMC compliant, they must properly inform patients about contentious issues. I suggest that consent should be obtained along the lines: “I propose prescribing you a remedy comprising sugar pills impregnated with a solution which has been diluted to such an extent that a sphere of water the size of the Earth’s average radius to the Sun would probably contain no more than one molecule of the original substance. Nevertheless, my clinical experience suggests to me that this remedy will improve your condition. You need to understand that colleagues who practise conventional evidence-based scientific medicine regard my belief as implausible and the methods I use as ‘alternative.’ I believe the remedy will help you, but I have no evidence accepted by the majority of doctors that the intervention I propose will achieve the desired effects. I do not believe that taking a homeopathic remedy will delay any other treatment which might reasonably help your condition and I invite you to take this remedy with understanding of the issues I have outlined.” A copy of the consent should be placed in the patient’s records.

Those who defend the right of registered medical practitioners to prescribe HP remedies do so with arguments fatally holed by a myriad of logical fallacies. Some arguments are (with fallacies in parenthesis):

  • “Homeopathy has been used for over two hundred years” (appeal to tradition and argument from ignorance);
  • “It has become very popular and is what patients want (appeal to popularity);
  • “Homeopathy has the capacity to help patients” (red herring, because present consideration is about the value of HP remedies, not relationships);
  • “Remedies are cheap” (red herring);
  • “Homeopathy does not do any harm” (irrelevant and a red herring);
  • “Pharmaceuticals have side effects” (tu quoque and red herring);
  • “The Royal Family use it” (appeal to irrelevant authority);
  • “The remedies enhance the doctor/patient relationship (straw man);
  • “Science does not know everything” (red herring and false dichotomy);
  • “Those who oppose us don’t understand homeopathy” (argumentum ad hominem and ‘poisoning the well’);
  • “I have the evidence of patients’ anecdotes and testimonials” (pseudoscience, confirmation bias and cherry picking);
  • “Homeopathic doctors are caring people” (red herring and straw man);
  • “I’ve got much evidence of  patients taking remedies and getting better” (post hoc ergo propter hoc – ‘after this, therefore because of this’ – confusion of coincidence with causation).

The latter most perverse fallacy is the foundation of homeopathic practice, based on identifying a remedy whereby ‘like cures like’ – a principle based on post hoc fallacy for which there is no scientifically credible evidence.

Unless and until medical homeopaths understand the intellectual environment in which they practice, are prepared to properly inform their patients, and obtain consent for treatment having done so, they should not prescribe homeopathic remedies. Fortunately, there is no evidence that patients who are prescribed HP remedies by empathic GMC registered homeopaths have any different outcomes from those prescribed pure sugar pills – even if they are told they are placebos. However, trust in the medical profession can only be maintained if deceptive practices are set aside and full explanations for proposed interventions are offered. Given the scientific consensus, patients have to face up to the fact that to the highest degree of probability, HP remedies have no value. Regrettably, too many patients and even homeopaths are in denial. Medical homeopaths should continue to serve their patients with care, compassion and intellectual honesty, but if they are to comply with the standards required for GMC registration, they should not prescribe homeopathically prepared remedies.

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