Edzard Ernst


Fairly early on during my time at Exeter, I had felt that it would be relevant, interesting and important to familiarise general practitioners with alternative medicine. At the time, we decided that we would start to run regular courses specifically for these health care professionals. Back in the mid 1990s, this was a remarkable thing to do, so much so that we even published our experience after the first such event. Recently I came across the article that resulted from this endeavour; here is an except from the abstract:

The delegates started with a positive but questioning attitude toward complementary medicine (CM) and acknowledged that they gained useful information, leading to increased confidence in discussing CM with patients. The course to a large extent met their needs and expectations. Benefits and draw-backs of integrating CM within general practice were explored. The main advantage of CM, apart from the potential intrinsic value of the techniques themselves, was identified as the time to establish a good therapeutic relationship with the patient. The particular concerns about CM that were expressed by the doctors included poor dialogue with CM practitioners, doubts about competence, and lack of readily identifiable and recognized qualifications. The risk of holding out unrealistic hope of cure was their greatest concern, however, especially if patients were thereby denied an effective orthodox treatment.

What strikes me as particularly remarkable is the fact that, even then, so many doubts were voiced by our GPs about alternative practitioners, their therapeutic claims and their doubtful medical competence. It was then that it occured to me for the first time that these therapists might systematically misinform their patients. This suspicion was strengthened on numerous occasions in the years to come; but it was not until much later that we decided to look into this subject (which is rather difficult to research) more systematically. What we found shocked us. Here are the conclusions of some of our investigations:

The most popular websites on complementary and alternative medicine for cancer offer information of extremely variable quality. Many endorse unproven therapies and some are outright dangerous. The link to the article is here.

Some complementary and alternative medicine (CAM) providers have a negative attitude towards immunisation and means of changing this should be considered. The link is here.

Advice about herbal medicine is readily available over the Internet. The advice offered is misleading at best and dangerous at worst. Potential Internet users should be made aware of these problems and ways of minimizing the risk should be found. The link is here.

The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue. The link is here.

In another study, we found that advice given by alternative practitioners to diabetic patients had the potential to kill them. A similarly scary conclusion emerged when we evaluated the advice chiropractors provide to asthma patients. Other research found that anthroposophic doctors often advise against measles vaccinations and are thus causing measles outbreaks.

The totality of this evidence, I believe, begs the question: DO ALTERNATIVE PRACTITIONERS SYSTEMATICALLY MISINFORM THEIR PATIENTS? I look forward to a lively discussion of it.

Yesterday, I received a letter from the editor-in-chief of the journal ‘Homeopathy‘ informing me that I have been struck off the editorial board of his publication. As the letter is not marked confidential, I feel that I can reproduce parts of it here:

Dear Professor Ernst,

This is to inform you that you have been removed from the Editorial Board of Homeopathy.  The reason for this is the statement you published on your blog on Holocaust Memorial Day 2013 in which you smeared homeopathy and other forms of complementary medicine with a ‘guilt by association’ argument, associating them with the Nazis.

I should declare a personal interest….[Fisher goes on to tell a story which is personal and which I therefore omit]…  I mention this only because it highlights the absurdity of guilt by association arguments.


Peter Fisher Editor-in-Chief, Homeopathy

I do agree with Dr Fisher that guilt by association is absurd. However, I disagree with the notion that I used this fallacy in my post the full text of which be found here. After re-reading it several times, I still do not see that it employs a ‘guilt by association argument’. It merely recounts historical facts which are not well-known and therefore worth mentioning. Importantly, the post consits in essence of quotes from my previous publications on the subject. My motives for writing it could not have been clearer and are emphacised in the last paragraph:

So, why bring all of this up today? Is it not time that we let grass grow over these most disturbing events? I think not! For many years, I actively researched this area (you can find many of my articles on Medline) because I am convinced that the unprecedented horrors of Nazi medicine need to be told and re-told – not just on HOLOCAUST MEMORIAL DAY, but continually. This, I hope, will minimize the risk of such incredible abuses ever happening again.

Perhaps a comparison might make it a little clearer why, in my opinion, Fisher’s is so utterly bizarre. Imagine an eminent researcher in the area of psychiatry who has been on the editorial board of a journal in his area for many years and contributed numerous articles to this journal. He then decides to research and subsequently write about the infamous Nazi past of German psychiatry. As a result, he is fired from his editorial board position because the editor feels that he has smeared the reputation of psychiatry.

I think most observers might find this odd and unjustified. Such a thing would not happen, I think, in a field with a mature research-culture. That it did happen in homeopathy might be interpreted as a reflection of the fact that homeopathy lacks such a culture.

So how precisely can we explain my dismissal? My article and my motives for writing it could have been thoroughly misunderstood – in my view, this is unlikely because I explained my motives in some detail both in the article and in the comments that follow the article. Here is my last of several posts clarifying my motives:

i am sorry that some have misunderstood the message of this blog and the reason why i wrote it.
i did certainly not want to engage in the GUILTY BY ASSOCIATION fallacy.
here is the truth:
i have had a research interest in nazi medicine and published about it.
in the course of these activities, i discovered that, contrary to what most people seem to assumue, alt med was involved as well. so i published this too many years ago.
this blog was simply and purely aimed at re-telling this story because it deserves to be re-told, in my view.
i regret that some people have read things into it which i did not intend.

Another explanation could be that Dr Fisher, who also is the Queen’s homeopath, lacks sufficient skills of critical thinking to understand the article and its purpose. Alternatively, he has been waiting for an occasion to fire me ever since I became more openly critical of homeopathy about five years ago.

Whatever the explanation, I think it is regrettable that the journal ‘Homeopathy’ has now lost the only editorial board member who had the ability to openly and repeatedly display a critical attitude about homeopathy – remember: without a critical attitude progress is unlikely!

Samuel Hahnemann, a German physician who was frustrated with the ‘heroic’ medicine of his time, invented homeopathy about 200 years ago. Since then, his followers have applied what we might call ‘selective dogmatism’ to his invention: they have religiously adhered to certain aspects, been considerably more liberal in other respects and abandoned some concepts altogether. It is therefore not unreasonable, I think, to ask what the ‘father of homeopathy’ – if he were still with us – might think of homeopathy as it is being practised today.


We tend to consider homeopathy to be one single therapy or school of thought, but this is not quite true. There a numerous forms of homeopathy, including the following:

Auto-isopathy (treatment with remedies made from patients’ own body substances)

Classical homeopathy (doctrine based on strict Hahnemannian principles)

Clinical homeopathy (non-individualised treatment based mainly on guiding symptoms; e.g. arnica for bruises)

Complex homeopathy (treatment with combination remedies)

Homotoxicology (treatment based on Reckeweg’s concepts of detoxification)

Isopathy (use of remedies made from the causative agent, e.g. a specific allergen for an allergy)

Pluralistic homeopathy (use of more than one remedy at once)

The list could be extended, and we could discuss the characteristics as well as the pros and cons of each variant. But this would be rather futile and intensely boring; suffice to say that, from all we know about Hahnemann’s views and temper, he would have strongly condemned even the slightest deviation from the strict rules of his doctrine.


So, what about the different ways in which homeopathy (whatever version we might select) is practised by Hahnemann’s disciples today? The way I see it, four different and fairly distinct types of homeopaths currently exist.

The purist homeopath

Samuel Hahnemann himself clearly was a purist. He was adamant that his detailed instructions must be followed to the letter. Amongst other things, this means that homeopathy must be seen as the only true medicine; mixing homeopathy with any other type of medicine is, according to its founder, strictly forbidden; Hahnemann was very explicit that this would weaken or even abolish its effects. Today’s purist homeopaths therefore follow these instructions religiously and employ homeopathy as the sole and only therapeutic option for any symptom or disease.

The liberal homeopath

Purist-homeopaths still do exist today, but they seem to be in the minority. Most homeopathic doctors mix homeopathic with conventional medicines, and most non-doctor homeopaths (they prefer the term ‘professional homeopaths’) accept or at least acknowledge that a mixed approach might often be necessary or preferable. In the words of Hahnemann, these homeopaths are ‘half-homeopaths’ who have ‘betrayed’ his gospel. He would most certainly disown them and point out that this type of approach is doomed to failure and cannot possibly work.

The occasional homeopath

In several countries – Germany is a good example – many doctors use homeopathy on just relatively rare occasions. We might speculate why this is so; my personal impression is that this group of clinicians do not really believe in the effectiveness of homeopathy at all. They employ it because some patients ask for it, or because they want to use a legally defensible and harmless placebo. There can be no doubt, Hahnemann would have not approved of this approach at all. Quite to the contrary, he would have been furious, called them ‘traitors’ or worse and insisted that this is nothing more than a placebo-therapy.

The DIY-homeopath

DIY-homeopaths is my term for patients and consumers who have no training in homeopathy but buy homeopathic remedies over the counter and self-administer them without consulting a trained homeopath. They might see it being recommended for a certain health problem and give it a try. If their symptoms subsequently disappear, they are likely to misinterpret this phenomenon and become convinced that homeopathy is effective. This group seems to be by far the largest of all types of homeopaths.


What would Hahnemann, if we could ask him today, make of all this? I think he would be fuming with anger (from all we know, he was a rather short-tempered man and had no patience with ‘traitors’).

The DIY-homeopaths obviously break every rule in his book: without a long and complicated consultation, it would not be possible to identify the correct, individualised remedy. What follows is simple: according to Hahnemann’s teachings, all these millions of people across the globe are treating themselves with pure placebos. Ironically, this is where most scientists would agree Hahnemann’s verdict!

Hahnemann would certainly direct equal scorn towards the occasional homeopaths who do not even believe in homeopathy. To Hahnemann, belief in his doctrine was essential and the use of his remedies as mere placebos would have been insulting, utterly unacceptable and destined to therapeutic failure.

We do know from Hahnemann’s mouth what he thought of those clinicians he himself called “half-homeopaths”. In his view, they were ‘traitors’ who did not even deserve to be called true homeopaths. There can be no question about the fact that he would have judged their practice as a useless and ineffective abomination.

This leaves us with the purist-homeopath. This relatively small group of dogmatists turns out to be the only one which Hahnemann might have actually approved of. They tend to strictly adhere to (almost) every of the numerous therapeutic instruction he ever put to paper. Like Hahnemann, they believe that homeopathy is the only efficacious medicine and, like Hahnemann, they use it as a true alternative to ‘allopathy’, the derogatory term Hahnemann coined for conventional medicine.


If this analysis is correct, we are today faced with the situation where homeopathy is used by many people worldwide but, according to the teachings of homeopathy’s founder, it is currently badly misused – so much so that, according to Hahnemann’s most clearly and repeatedly expressed views, it cannot possibly result in clinical benefit. Considering that most of today’s homeopaths would insist that the words of Hahnemann as pure gospel, this situation is most bizarre and ironic indeed. It becomes even more ironic when we realise that the only group of clinicians who employ homeopathy in the ‘correct’ way is also the one which is the most serious danger to public health.

There probably is no area in health care that produces more surveys than alternative medicine. I estimate that about 500 surveys are published every year; this amounts to about two every working day which is substantially more than the number of clinical trials in this field.

I have long been critical of this ‘survey-mania’. The reason is simple: most of these articles are of such poor quality that they tell us nothing of value.

The vast majority of these surveys attempts to evaluate the prevalence of use of alternative medicine, and it is this type of investigation that I intend to discuss here.

For a typical prevalence survey, a team of enthusiastic researchers might put together a few questions and design a questionnaire to find out what percentage of a group of individuals have tried alternative medicine in the past. Subsequently, the investigators might get one or two hundred responses. They then calculate simple descriptive statistics and demonstrate that xy% (let’s assume it is 45%) use alternative medicine. This finding eventually gets published in one of the many alternative medicine journals, and everyone is happy – well, almost everybody.

How can I be such a spoil-sport and claim that this result tells us nothing of value? At the very minimum, some might argue, it shows that enthusiasts of alternative medicine are interested in and capable of conducting research. I beg to differ: this is not research, it is pseudo-research which ignores most of the principles of survey-design.

The typical alternative medicine prevalence survey has none of the features that would render it a scientific investigation:

1) It lacks an accepted definition of what is being surveyed. There is no generally accepted definition of alternative medicine, and even if the researchers address specific therapies, they run into huge problems. Take prayer, for instance – some see this as alternative medicine, while others would, of course, argue that it is a religious pursuit. Or take herbal medicine – many consumers confuse it with homeopathy, some might think that drinking tea is herbal medicine, while others would probably disagree.

2) The questionnaires used for such surveys are almost never validated. Essentially, this means that we cannot be sure they evaluate what we think they evaluate. We all know that the way we formulate a question can determine the answer. There are many potential sources of bias here, and they are rarely taken into consideration.

3) Enthusiastic researchers of alternative medicine usually use a  small convenience sample of participants for their surveys. This means they ask a few people who happen to be around to fill their questionnaire. As a consequence, there is no way the survey is representative of the population in question.

4) The typical survey has a low response rate; sometimes the response rate is not even provided or remains unknown even to the investigators. This means we do not know how the majority of patients/consumers who received but did not fill the questionnaire would have answered. Often there is good reason to suspect that those who have a certain attitude did respond, while those with a different opinion did not. This self-selection process is likely to produce misleading findings.

And why I am so sure about all of theses limitations? To my embarrassment, I know about them not least because I have made most these mistakes myself at some time in my career. You might also ask why this is important: what’s the harm in publishing a few flimsy surveys?

In my view, these investigations are regrettably counter-productive because:

they tend to grossly over-estimate the popularity of alternative medicine,

they distract money, manpower and attention from the truly important research questions in this field,

they give a false impression of a buoyant research activity,

and their results are constantly misused.

The last point is probably the most important one. The argument that is all too often spun around such survey data goes roughly as follows: a large percentage of the population uses alternative medicine; people pay out of their own pocket for these treatments; they are satisfied with them (if not, they would not pay for them). BUT THIS IS GROSSLY UNFAIR! Why should only those individuals who are rich enough to afford alternative medicine benefit from it? ALTERNATIVE MEDICINE SHOULD BE MADE AVAILABLE FOR ALL.

I rest my case.

The developed world is in the middle of a major obesity epidemic. It is predicted to cause millions of premature deaths and billions of dollars, money that would be badly needed elsewhere. The well-known method of eating less and moving more is most efficacious but sadly not very effective, that is to say people do not easily adopt and adhere to it. This is why many experts are searching for a treatment that works and is acceptable to all or at least most patients.

Entrepreneurs of alternative medicine have long jumped on this band waggon. They have learnt that the regulations are lax or non-existent, that consumers are keen to believe anything they tell them and that the opportunities to make a fast buck are thus enormous. Today, they are offering an endless array of treatments which are cleverly marketed, for instance via the Internet.

Since many years, my research team are involved in a programme of assessing the alternative slimming aids mostly through systematic reviews and occasionally also through conducting our own clinical trials. Our published analyses include the following treatments:

Phaseolus vulgaris

Supplements containing conjugated linoleic acid

Green tea

Garcinia extracts

Calcium supplements

Chromium picolinate

Guar gum



There are, of course, many more but, for most, no evidence exist at all. The treatments listed above have all been submitted to clinical trials. The results show invariably that the outcomes were not convincingly positive: either there were too few data, or there were too many flaws in the studies, or the weight reduction achieved was too small to be clinically relevant.

Our latest systematic review is a good example; its aim was to evaluate the evidence from randomized controlled trials (RCTs) involving the use of the African Bush Mango, Irvingia gabonensis, for body weight reduction in obese and overweight individuals. Three RCTs were identified, and all had major methodological flaws. All RCTs reported statistically significant reductions in body weight and waist circumference favoring I. gabonensis over placebo. They also suggested positive effects of I. gabonensis on blood lipids. Adverse events included headache and insomnia. Despite these apparently positive findings, our conclusions had to be cautious: “Due to the paucity and poor reporting quality of the RCTs, the effect of I. gabonensis on body weight and related parameters are unproven. Therefore, I. gabonensis cannot be recommended as a weight loss aid. Future research in this area should be more rigorous and better reported.”

People who want to loose weight are often extremely desperate and ready to try anything. They are thus easy victims of the irresponsible promises that are being made on the Internet and elsewhere. Despite the overwhelmingly evidence to the contrary, consumers are led to believe that alternative slimming aids are effective. What is more, they are also misled to assume they are risks-free. This latter assumption is false too: apart from the harm done to the patient’s bank account, many alternative slimming aids are associated with side-effects which, in some cases, are  serious and can even include death.

The conclusion from all this is short and simple: alternative slimming aids are bogus.

When I retired a few months ago, I began to sort out hundreds of old files and, in the course of doing so, I stumbled across my inauguration lecture given at Exeter in late 1993. Because so many people have been puzzled, bewildered or annoyed by my post, my attitude, my remit, my writings, my errors, my perceived lack of support for CM or my alleged inconsistencies, I have now decided to reproduce the most important sections of this publication here (unfortunately, the article is not available on line but I will send a PDF to anyone who asks for it). For clarity, the original text is in italics; where i needed to add something, I put it in square brackets so that there can be no misunderstandings.

… there are some common denominators [for all different types of CM]: an all encompassing theory (sometimes more a philosophy than a theory) the view of health as a balance of forces within the body and healing as the restoration of this balance, the holistic approach, and the emphasis on each individual’s own responsibility for health. It is noteworthy that the latter two characteristics are, of course, an integral part of (good) orthodox medicine.

…[CM] often lacks an adequate theoretical basis, its diagnoses are usually not in line with science, and it has failed to demonstrate clinical effectiveness convincingly. CM may thus be defined as those branches of the art and science of health care that are not in accordance with current medical thought, scientific knowledge or university teaching…

… no one doubts that today’s modern, orthodox medicine is more successful than any of its predecessors in diagnosing, treating and preventing disease. Yet the public chooses complementary medicine in vast numbers. Why? There must be many reasons, ranging from dissatisfaction with high-tech medicine to a fascination with mysticism, from grabbing ‘the last straw’ to looking for more empathy, to falling victim to the Barnum-Effect or the Health Information Fatigue Phenomenon. Whatever the reasons are (and no doubt they need to be researched in much more detail), they represent a severe criticism to the content and style of today’s medicine. Orthodoxy might be well advised to try and learn a lesson from the apparent success and obvious popularity of CM…

CM also accepts more and more its own limitations, the fact that it may also do harm and the urgent need for much more scientific proof – a remarkable change considering that the scientific method was formerly said to be nothing short of naive reductionism representing an over-simplified mechanistic philosophy, which does injustice to the complexities of the human being.

… the medical establishment is gradually becoming more open-minded and prepared to look into the matter seriously. It realises that it must abandon old prejudice and differentiate between various approaches – maybe not everything in CM is bad after all! A wry and useful classification is the schematic listing of CM in 3 categories: the frankly fraudulent, the foolishly harmless, and the possibly useful. It is clear that only rigorous research will be able to differentiate one from the other.

…why do we need controlled trials, some proponents of CM would argue, when everyday experience shows us that our treatments work? The answer is disarmingly simple: clinical experience can be totally and repeatedly misleading. Medical history abounds with examples. Blood-letting, the panacea of the middle-ages, killed probably more people than it ever helped. Yet clinicians thought to witness its benefit for centuries. Every time in the past, present and future, when a patient’s cure is solely attributed to a treatment, two important factors are neglected: the natural history of the disease, and the placebo effect. There is only one way to be sure, and that is to conduct randomised controlled trials. The notion that they are not feasible, desirable or conclusive is blatantly wrong; not to believe in controlled trials is not to care about the effectiveness of one’s doings and to adopt a quasi-religious attitude towards medicine.

I find some of the points I made back in 1993 remarkable. To be honest, I could not stop smiling when I re-read my text after almost 20 years. Rather than discussing the messages of my own lecture, I will leave the critical assessment of these points to the probably lively comment section that will follow this post. In closing, I do, however, want to briefly highlight two aspects.

1) Many CM proponents have attacked me because they feel that I am too critical and  some even assume that I am in the pockets of BIG PHARMA and got the Exeter job under false pretences. The University of Exeter should have employed an outspoken champion of CM, they argue. I think my inaugural lecture shows beyond any doubt that they always knew who they were getting and it suggests that, at least initially (before Prince Charles intervened), they wanted me because universities need scientists, not promoters.

2) Since 1993, about 10 000 articles have been published on the subject of CM (my estimate), and yet we do not seem to have advanced all that much. The title “changing attitudes” might thus have been more than a little optimistic on my part!

Whenever I have the occasion to discuss with  practitioners of alternative medicine the pros and cons of their methods, I hear sooner or later the argument “WE TREAT THE ROOT CAUSES OF DISEASE !!!” This remark emerges regularly regardless of the type of treatment the practitioner uses, and regardless of what disease we might have been talking about.

The statement is regularly pronounced with such deep conviction (and almost audible exclamation marks) that I am inclined to conclude these practitioners fully and wholeheartedly believe it. The implication usually is that, in conventional medicine, we only treat the symptoms of our patients. Quite often, this latter notion is not just gently implied but also forcefully expressed.

I have often wondered where this assumption and the fierce conviction with which it is expressed come from. The answer, I have come to conclude after many years of having such debates, is quite simple: it is being taught over and over again during the practitioners’ training, and it constitutes a central message of most ‘textbooks’ for the aspiring alternative practitioner.

It is not difficult to find the actual origin of all this. The notion that alternative practitioners treat the root causes is clearly based on the practitioners’ understanding of aetiology. If a traditional acupuncturist, for instance, becomes convinced that all disease is the expression of an imbalance of life-forces, and that needling acupuncture points will re-balance these forces thus restoring health, he must automatically assume that he is treating the root causes of any condition. If a chiropractor believes that all diseases  are due to ‘subluxations’ of the spine, it must seem logical to him that spinal ‘adjustment’ is synonymous with treating the root cause of whatever complaint his patient is suffering from. If a Bowen therapist is convinced that “the Bowen Technique aims to balance the whole person, not just the symptoms“, he is bound to be equally sure that “practically any problem can potentially be addressed” by this intervention.

Let us assume for a minute that all these practitioners are correct in believing that their interventions are causal treatments, i.e. therapies directed against the cause of a disease. Successful treatment of any root cause can only mean that the therapy in question completely  heals the problem at hand. If we abolish the cause of a disease, we would expect the disease to disappear for good.


I have contemplated it frequently and discussed it often with practitioners but, so far, I have not identified a single one.  I have no problem naming diseases which conventional medicine can cure – but, in alternative medicine, I only draw blanks. Even those alternative therapies which might be effective are not causal but symptomatic by nature. Honestly, I have not yet come across a single alternative treatment for which there is compelling evidence proving that it can produce more than symptom-relief.

But, of course, I might be wrong, over-critical, blind, bought by the pharmaeutical industry, dishonest or stupid. So, the purpose of this post is to clarify this issue once and for all. I herewith invite practitioners to name a disease for which there is sound evidence proving that it can be cured by their therapy.

A few weeks ago, The College of Chiropractors, a Company Limited by guarantee, was given a royal charter. A royal charter is a formal document issued by a monarch, granting a right or power to an individual or an corporate body. They are used to establish significant organisations such as cities or universities.

This is how the event was protrayed by chiropractors [link disabled by admin due to possible malware]:

Rarely granted, a Royal Charter signals permanence and stability and, in the College of Chiropractors’ case, a clear indication to others of the leadership value and innovative approach the College brings to the development of the chiropractic profession. The Royal Charter essentially formalises the College’s position as a unique, apolitical, consultative body, recognising its role in promoting high practice standards and certifying quality and thus securing public confidence.

For those of us who are not familiar with the College, here is how they describe themselves and their history:

On the advice of a senior medical figure, an organisational model similar to that of a Medical Royal College was devised. Thus, the College of Chiropractors was conceived during 1997 and incorporated in 1998 as an independent body to develop, encourage and maintain the highest possible standards of chiropractic practice for the benefit of patients.

Over the next couple of years the embryonic ‘College’ grew with a regional faculty infrastructure, the mainstay of the organisation, becoming firmly established in order to foster education locally. As an independent body, separate from any of the political groups, members were able to share information and expertise from all areas of the profession. Following its incorporation in October 1998, the College of Chiropractors was formally launched on 28th April 1999 at the King’s Fund.

The College is now an academic membership organisation with almost 3000 members worldwide, and the following objectives:

  • to promote the art, science and practice of chiropractic;
  • to improve and maintain standards in the practice of chiropractic for the benefit of the public;
  • to promote awareness and understanding of chiropractic amongst medical practitioners and other healthcare professionals and the public;
  • to educate and train practitioners in the art, science and practice of chiropractic;
  • to advance the study of and research in chiropractic.

From my perspective, this begs numerous questions; here are just some of them:

1) Have UK chiropractors truly been promoting “high practice standards and certifying quality and thus securing public confidence”?

I would argue that they have been doing the opposite. They made bogus therapeutic claims by the hundreds on their websites, and when Simon Singh had the courage to make this public, they sued him for libel. Call me old-fashioned, but I fail to see how this maintains “the highest possible standards of chiropractic practice for the benefit of patients” nor how this might “promote the art, science and practice of chiropractic.”

2) Is it truly for the benefit of the people that so many chiropractors deny the considerable risks of spinal manipulation?

I would have thought that this is a serious disservice to the people and the health of the nation and believe it reflects an irresponsible disregard of the precautionary principle in health care.

3) How can we accord the high aims of the College with the fact that UK chiropractors demonstrably violate fundamental rules of medical ethics, e.g. informed consent, and that their professional bodies must be aware of this fact, yet have so far failed to do anything about it?

I think there is a discrepancy here that needs explaining.

4) Does the College truly “advance the study of and research in chiropractic?”

We have shown that UK research into chiropractic has not increased but decreased since statutory regulation. This leads me to suspect that regulation is being abused as a means of gaining recognition and not as a mechanism to protect the public.

Considering all this, I find that the status of the other Royal Colleges has been de-valued by the ascent of this organisation. And I ask myself WHAT NEXT? A COLLEGE OF WINDOW SALES-MEN, perhaps? Or would this giving a bad name to the poor window-salesmen?

Several months ago, my co-workers and I once again re-visited the contentious issue of acupuncture’s safety. We published several articles on the topic none of which, I am afraid to say, was much appreciated by the slightly myopic world of acupuncture. The paper which created overt outrage and prompted an unprecedented amount of hate-mail was the one on deaths after acupuncture. This publication reported that around 90 fatalities associated with acupuncture had been documented in the medical literature.

The responses from acupuncturists ranged from disbelief to overt hostility. Acupuncturists the world over seemed to agree that there was something profoundly wrong with me personally and with my research; they all knew that acupuncture was entirely safe and that I was maliciously incorrect and merely out to destroy their livelihood.

So, am I alarmist or am I just doing my duty in reporting important facts? Two new articles might go some way towards answering this intriguing question.

The first is a review by Chinese acupuncturists who summarised all the adverse events published in the Chinese literature, a task which my article may have done only partially. The authors found 1038 cases of serious adverse events, including 35 fatalities. The most frequent non-fatal adverse events were syncope (468 cases), pneumothorax (307 cases), and subarachnoid hemorrhage (64 cases). To put this into context, we ought to know that the Chinese literature is hopelessly biased in favour of acupuncture. Thus the level of under-reporting can be assumed to be even larger than in English language publications.

The second new article is by a Swedish surgeon who aimed at systematically reviewing the literature specifically on vascular injuries caused by acupuncture. His literature searches found 31 such cases; the majority of these patients developed symptoms in direct connection with the acupuncture treatment. Three patients died, two from pericardial tamponade and one from an aortoduodenal fistula. There were 7 more tamponades, 8 pseudoaneurysms, two with ischemia, two with venous thrombosis, one with compartment syndrome and 7 with bleeding (5 in the central nervous system). The two patients with ischemia suffered lasting sequeleae.

The answer to the question asked above seems thus simple: the Chinese authors, the Swedish surgeon (none of whom I know personally or have collaborated with) and I are entirely correct and merely report the truth. And the truth is that acupuncture can cause severe complications through any of the following mechanisms:

1) puncturing the lungs resulting in a pneumothorax,

2) puncturing the heart causing a cardiac tamponade,

3) puncturing blood vessels causing haemorrhage,

4) injuring other vital structures in the body,

5) introducing bacteria or viruses resulting in infections.

Any of these complications can be severe and might, in dramatic cases, even lead to the death of the patient.

But we have to have the right perspective! These are extremely rare events! Most other treatments used in medicine are much much more risky! To keep banging on about such exotic events is not helpful! I can hear the acupuncture world shout in unison.

True, these are almost certainly rare events – but we have no good idea how rare they are. There is no adverse event reporting scheme in acupuncture, and the published cases are surely only the tip of the ice-berg. True, most other medical treatments carry much greater risks! And true, we need to have the right perspective in all of this!

So let’s put this in a reasonable perspective: with most other treatments, we know how effective they are. We can thus estimate whether the risks outweigh the benefit, and if we find that they do, we should (and usually do) stop using them. I am not at all sure that we can perform similar assessments in the case of acupuncture.

Clinical trials of acupuncture can be quite challenging. In particular, it is often difficult to make sure that any observed outcome is truly due to the treatment and not caused by some other factor(s). How tricky this can be, shows a recently published study.

A new RCT has all (well, almost all) the features of a rigorous study. It tested the effects of acupuncture in patients suffering from hay fever. The German investigators recruited 46 specialized physicians in 6 hospital clinics and 32 private outpatient clinics. In total, 422 patients with IgE sensitization to birch and grass pollen were randomized into three groups: 1) acupuncture plus rescue medication (RM) (n= 212), 2) sham acupuncture plus RM (n= 102), or 3) RM alone (n= 108). Twelve acupuncture sessions were provided in groups 1 and 2 over 8 weeks. The outcome measures included changes in the Rhinitis Quality of Life Questionnaire (RQLQ) overall score and the RM score (RMs) from baseline to weeks 7, 8 and 16 in the first year as well as week 8 in the second year after randomization.

Compared with sham acupuncture and with RM, acupuncture was associated with improvement in RQLQ score and RMS. There were no differences after 16 weeks in the first year. After the 8-week follow-up phase in the second year, small improvements favoring real acupuncture over  sham were noted.

Based on these results, the authors concluded that “acupuncture led to statistically significant improvements in disease-specific quality of life and antihistamine use measures after 8 weeks of treatment compared with sham acupuncture and with RM alone, but the improvements may not be clinically significant.

The popular media were full of claims that this study proves the efficacy of acupuncture. However, I am not at all convinced that this conclusion is not hopelessly over-optimistic.

It might not have been the acupuncture itself that led to the observed improvements; they could well have been caused by several factors unrelated to the treatment itself. To understand my concern, we need to look closer at the actual interventions employed by the investigators.

The real acupuncture was done on acupuncture points thought to be indicated for hay fever. The needling was performed as one would normally do it, and the acupuncturists were asked to treat the patients in  group 1 in such a way that they were likely to experience the famous ‘de-qi’ feeling.

The sham acupuncture, by contrast, was performed on non-acupuncture points; acupuncturists were asked to use shallow needling only and they were instructed to try not to produce ‘de-qi’.

This means that the following factors in combination or alone could have caused [and in my view probably did cause] the observed differences in outcomes between the acupuncture and the sham group:

1) verbal or non-verbal communication between the acupuncturists and the patient [previous trials have shown this factor to be of crucial importance]

2) the visibly less deep needling in the sham-group

3) the lack of ‘de-qi’ experience in the sham-group.

Sham-treatments in clinical trials serve the purpose of a placebo. They are thus meant to be indistinguishable from the verum. If that is not the case [as in the present study], the trial cannot be accepted as being patient-blind. If a trial is not patient-blind, the expectations of patients will most certainly influence the results.

Therefore I believe that the marginal differences noted in this study were not due to the effects of acupuncture per se, but were an artifact caused through de-blinding of the patients. De facto, neither the patients nor the acupuncturists were blinded in this study.

If that is true, the effects were not just not clinically relevant, as noted by the authors, they also had nothing to do with acupuncture. In other words, acupuncture is not of proven efficacy for this condition – a verdict which is also supported by our systematic review of the subject which concluded that “the evidence for the effectiveness of acupuncture for the symptomatic treatment or prevention of allergic rhinitis is mixed. The results for seasonal allergic rhinitis failed to show specific effects of acupuncture…”

Once again, we have before us a study which looks impressive at first glance. At closer scrutiny, we find, however, that it had important design flaws which led to false positive results and conclusions. In my view, it would have been the responsibility of the authors to discuss these limitations in full detail and to draw conclusions that take them into account. Moreover, it would have been the duty of the peer-reviewers and journal editors to pick up on these points. Instead the editors even commissioned an accompanying editorial which displays an exemplary lack of critical thinking.

Having failed to do any of this, they are in my opinion all guilty of misleading the world media who reported extensively and often uncritically on this new study thus misleading us all. Sadly, the losers in this bonanza of incompetence are the many hay fever sufferers who will now be trying (and paying for) useless treatments.

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