We used to call it ‘alternative medicine’ (on this blog, I still do so, because I believe it is a term as good or bad as any other and it is the one that is easily recognised); later some opted for ‘complementary medicine’; since about 15 years a new term is en vogue: INTEGRATED MEDICINE (IM).
Supporters of IM are adamant that IM is not synonymous with the other terms. But how is IM actually defined?
One of IM’s most prominent defenders is, of course Prince Charles. In his 2006 address to the WHO, he explained: “We need to harness the best of modern science and technology, but not at the expense of losing the best of what complementary approaches have to offer. That is integrated health – it really is that simple.”
Perhaps a bit too simple?
There are several more academic definitions, and it seems that, over the years, IM-fans have been busy moving the goal post quite a bit. The original principle of ‘THE BEST OF BOTH WORLDS’ has been modified considerably.
- IM is a “comprehensive, primary care system that emphasizes wellness and healing of the whole person…” [Arch Intern Med. 2002;162:133-140]
- IM “views patients as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment.” [BMJ. 2001; 322:119-120]
During my preparations for my lecture at the 16th European Sceptics Congress in London last week (which was on the subject of IM), I came across a brand-new (September 2015) definition. It can be found on the website of the COLLEGE OF MEDICINE This Michael Dixon-led organisation can be seen as the successor of Charles’ ill-fated FOUNDATION FOR INTEGRATED HEALTH; it was originally to be called COLLEGE FOR INTEGRATED MEDICINE. We can therefore assume that they know best what IM truly is or aspires to be. The definition goes as follows:
IM is a holistic, evidence-based approach which makes intelligent use of all available therapeutic choices to achieve optimal health and resilience for our patients.
This may sound good to many who are not bothered or unable to think critically. It oozes political correctness and might therefore even impress some politicians. But, on closer scrutiny, it turns out to be little more than offensive nonsense. I feel compelled to publish a short analysis of it. I will do this by highlighting and criticising the important implications of this definition one by one.
1) IM is holistic
Holism has always been at the core of any type of good health care. To state that IM is holistic misleads people into believing that conventional medicine is not holistic. It also pretends that medicine might become more holistic through the addition of some alternative modalities. Yet I cannot imagine anything less holistic than diagnosing patients by merely looking at their iris (iridology) or assuming all disease stems from subluxations of the spine (chiropractic), for example. This argument is a straw-man, if there ever was one.
2) IM is evidence-based
This assumption is simply not true. If we look what is being used under the banner of IM, we find no end of treatments that are not supported by good evidence, as well as several for which the evidence is squarely negative.
3) IM is intelligent
If it were not such a serious matter, one could laugh out loud about this claim. Is the implication here that conventional medicine is not intelligent?
4) IM uses all available therapeutic choices
This is the crucial element of this definition which allows IM-proponents to employ anything they like. Do they seriously believe that patients should have ALL AVAILABLE treatments? I had thought that responsible health care is about applying the most effective therapies for the condition at hand.
5) IM aims at achieving optimal health
Another straw-man; it implies that conventional health care professionals do not want to restore their patients to optimal health.
In my lecture, which was not about this definition but about IM in general, I drew the following six conclusions:
- Proponents of IM mislead us with their very own, nonsensical terminology and definitions.
- They promote two main principles: use of quackery + holism.
- Holism is at the heart of all good medicine; IM is at best an unnecessary distraction.
- Using holism to promote quackery is dishonest and counter-productive.
- The integration of quackery will render healthcare not better but worse.
- IM flies in the face of common sense and medical ethics; it is a disservice to patients.
One of the questions that I hear regularly is: ‘What happened to your research unit at Exeter?’ Therefore it might be a good idea to put the full, shameful story on this blog.
After the complaint by Prince Charles’ secretary to my Vice Chancellor alleging that I had breached confidentiality over the Smallwood report, my University conducted a 13 months investigation into my actions. At the end of it, I was declared innocent as charged (it should have been clear from a 10 minute discussion that I had done nothing wrong: I had not disclosed any information from the report, and even if I had, it would have been a matter of public interest and medical ethics to blow the whistle. However, the Vice Chancellor never once bothered to talk to me.). Subsequently, all support that I had once enjoyed broke down, my staff’s contracts were terminated, and I eventually had to take early retirement (full details of this part of the story can be found in ‘A SCIENTIST IN WONDERLAND’).
A few months later, a new dean was appointed at my medical school. The new man seemed to have a lot more understanding for my situation than his predecessor. Provided that I accept to go into early retirement, he offered to re-employ me for one year (half time) to help him find a successor for my position.
I did accept because, above everything, I wanted to prevent the closure of my unit. We then developed criteria for advertising the post and conducted two rounds of advertisements. Several candidates applied but none them seemed suited in our view. Eventually we did find several experts who were promising; one even came to Exeter from abroad and had detailed talks with the dean and several other people.
However, Exeter was unwilling to equip my potential successor with any funds to speak of. The suggestion was to appoint the new chair with the onus to raise all the necessary funds himself. This is a proposition that no well-qualified academic at the professorial level can possibly find attractive. Consequently, the candidates all declined.
Meanwhile, there had been an initiative by several altruistic UK public figures and friends to raise funds for the new chair and thus save my unit from closure. Sadly, however, these activities did not generate in the necessary cash. When my year of half-time re-employment had expired, I left Exeter and my unit disappeared for good.
To the present day, I am not at all sure what the true intentions of Exeter had been during this final stage.
- Was I offered re-employment simply to keep me sweet?
- Did they fear that I would otherwise sue them or cause a public scandal?
- Did they truly believe they could find a suitable successor?
- If so, why did they not put up the money?
I do not expect to ever find conclusive answers for any of these questions. However, I do know what, in an ideal world, should have become of my unit. If it had been for me to decide, I would have equipped the chair with the necessary core funds and appointed an ethicist with a documented interest in alternative medicine as the new professor. I see two main reasons for this perhaps less than obvious choice:
- In my experience, Exeter would greatly benefit from an ethicist to give them guidance on a range of matters.
- After two decades of being involved in alternative medicine research, I have become convinced that this field foremost needs the input of a critical ethicist.
In case either of these last two statements puzzles you, I recommend you read ‘A SCIENTIST IN WONDERLAND’.
The last time I had contact with Dr Fisher was when he fired me from the editorial board of his journal ‘Homeopathy’. He did that by sending me the following letter:
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 did not expect to have any more dealings with him after this rather unpleasant encounter. But, as it turns out, I recently did have a further encounter.
When the BMJ invited me to write a debate article about the question whether homeopathy should continue to be available on the NHS, I accepted (with some reservations, I hasten to add). At the time, I did not know who would do the ‘other side’ of this debate. It turned out to be Peter Fisher, and our two articles have just been published.
As one would expect from a good journal, the articles were both peer reviewed. One of the peer-reviewers of my piece was most scathing of it essentially claiming that it was entirely worthless. Feeling that this was a bit harsh and very impolite, I was keen to see who this reviewer had been; it was none other than Andrew Vickers. This is remarkable because Vickers had not only published several homeopathic papers with Fisher, but also had been in the employment of the ‘Royal London Homeopathic Hospital’ under Fisher. To the best of my knowledge, his conflicts of interested had not been disclosed. I did point that out to the BMJ, but they seemed to think nothing of it.
Anyway, I was pleased to eventually (the whole procedure took many months) see the articles published, but at the same time somewhat irritated by Fisher’s piece. It contained plenty of misleading information that the peer-reviewers obviously had failed to correct. Here is a small sample from Fishers piece:
… recent overviews have had more favourable conclusions, including a health technology assessment commissioned by the Swiss federal government that concluded that homeopathy is “probably” effective for upper respiratory tract infections and allergies.
Readers interested in the clinical evidence can access the CORE-HOM database of clinical research in homeopathy free of charge (www.carstens-stiftung.de/core-hom). It includes 1117 clinical trials of homeopathy, of which about 300 are randomised controlled trials.
In the podcast that accompanies the articles Fisher insists that, on this database, there are well over 300 RCT, and I had to admit that this was new to me. Keen to learn more, I registered with the database and had a look. What I found startled me. True, the database does claim that almost 500 RCTs are available, but just a very superficial scrutiny of these studies reveals that
- some are not truly randomised,
- some are not even clinical trials,
- the list includes dual publications, re-analyses of already published studies as well as aborted trials,
- many have never been peer-reviewed,
- many are not double-blind,
- many are not placebo controlled,
- the majority are of poor methodological quality.
As to the other thing mentioned in the above excerpt from Fisher’s article, the famous ‘health technology assessment commissioned by the Swiss federal government’, I can refer my readers to a blog post by J W Nienhuys which probably says it all, if not, there is plenty more criticism of this report available on the Internet.
My conclusion from all this?
THE QUEEN’S HOMEOPATH USES ARGUMENTS THAT SEEM JUST AS BOGUS AS HOMEOPATHY ITSELF.
The following episode gives just one of many examples of attempts by my Exeter peers to sabotage my scientific, moral and ethical standards. The players in this scene are:
- Prof John Tooke, at the time dean of my medical school,
- Dr Michael Dixon, GP in Devon,
- Nelson’s homeopathic pharmacy, known from my previous post,
- Mr Simon Mills, former director of the Centre for Complementary Health Studies, University of Exeter,
- Prince Charles, future king of England.
By the year 2000, I began to experience unnecessary unpleasantness at Exeter on a more and more regular basis. This passage from my book describes the key moment when it became clear to me that something profoundly wrong was going on:
The watershed came in 2003, when I saw an announcement published in the newsletter of the Prince of Wales’ Foundation for Integrated Health:
“The Peninsula Medical School aims to become the UK’s first medical school to include integrated medicine at postgraduate level. The school also plans to extend the current range and depth of programmes offered by including healthcare ethics and legislation. Professor John Tooke, dean of the Peninsula Medical School, said: “The inclusion of integrated medicine is a patient driven development. Increasingly the public is turning to the medical profession for information about complementary medicines. This programme will play an important role in developing critical understanding of a wide range of therapies”.
When I stumbled on this announcement, I was truly puzzled. Tooke is obviously planning a new course for me, I thought, but why has he not told me about it? When I enquired, Tooke informed me that the medical school was indeed preparing to offer a postgraduate “Pathway in Integrated Health”; this exciting new innovation had been initiated by Dr Michael Dixon, a general practitioner who, after working in collabora-tion with my unit for several years, had become one of the UK’s most outspoken proponents of spiritual healing and other similarly dubious forms of alternative medicine. For this reason, Dixon was apparently very well regarded by Prince Charles.
A few days after I had received this amazing news, Dixon arrived at my office and explained, with visible embarrassment, that Prince Charles had expressed his desire to him personally to establish such a course at Exeter. His Royal Highness had already facilitated its funding which, in fact, came from “Nelsons”, one of the UK’s largest manufacturers of homeopathic remedies. The day-to-day running of the course was to be put into the hands of the ex-director of the Centre for Complementary Health Studies (CCHS), the very unit that, almost a decade earlier, I had struggled—and eventually even paid—to be separated from because of its overtly anti-scientific agenda. The whole thing had been in the planning for many months. I was, it seemed, the last to know—but now that I had learnt about it, Dixon and Tooke leaned on me with all their might to persuade me to contribute to this course by giving a few lectures.
I could no more comply with this request than fly. Apart from anything else, anyone who had read my papers would have known that I was opposed in principle to the concept of “Integrated Health”. As I saw it, “integrating” quackery with genuine, science-based medicine was nothing less than a profound betrayal of the ethical basis of medical practice. By putting its imprimatur on this course, and by offering it under the auspices of a mainstream medical school, my institution would be encouraging the dangerously erroneous idea of equivalence—i.e. the notion that alternative and mainstream medicine were merely two parallel but equally valid and effective methods of treating illness.
To add insult to injury, the course was to be run by someone who I had good reason to reject and sponsored by a major manufacturer of homeopathic remedies. In all conscience, the latter circumstance seemed to me to be the last straw. Study after study carried out by my unit had found homeopathy to be not only conceptually absurd but also therapeutically worthless. To all intents and purposes, the discussion about the value of homeopathy was closed. Even a former director of the Royal London Homeopathic Hospital had concluded in his book that “homeopathy has not been proved to work… the great majority… of the improvement that patients experience is due to non-specific causes”. If we did not take a stand on this issue, we might as well give up and go home. Consequently, I politely but firmly declined the offer of participating in this course.
By now numerous other incidents of a similar nature had poisoned the atmosphere at my own medical school and university so much that both my work and my health were suffering. How had it come to this? Why was even the most obvious and demonstrable truth being turned upside down so that it could be used against me? Why were my peers seemingly bent on constraining me and making life increasingly difficult for me?
It has been reported that Belgium has just officially recognised homeopathy. The government had given the green light already in July last year, but the Royal Decree has only now become official. This means that, from now on, Belgian doctors, dentists and midwives can only call themselves homeopaths, if they have attended recognised courses in homeopathy and are officially certified. While much of the new regulation is as yet unclear (at least to me), it seems that, in future, only doctors, dentists and midwives are allowed to practice homeopathy, according to one source.
However, the new law also seems to provide that those clinicians with a Bachelor degree in health care who have already been practicing as homeopaths can continue their activities under a temporary measure.
Moreover, the official recognition as a homeopath does not automatically imply that the services will be refunded from a health insurance.
It is said that, in general, homeopaths are happy with the new regulation; they are delighted to have been up-graded in this way and argue that the changes will result in higher quality standards: “This is a very important step and it can only be to the benefit of the patients’ safety. Patients will know whether or not they are dealing with someone who correctly applies homeopathic medicine”, Leon Schepers of the Unio Homeopathica Belgica was quoted saying.
The delight of homeopaths is in sharp contrast to the dismay of rational thinkers. The NHMRC recently assessed the effectiveness of homeopathy. The evaluation is both comprehensive and independent; it concluded that “the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.” In other words, homeopathic remedies are implausible, over-priced placebos.
Granting an official status to homeopaths cannot possibly benefit patients. On the contrary, it will only render health care less effective and charlatans more assertive.
Can anyone think of celebrities promoting conventional treatments? Jane Fonda advertising blood pressure control? Brad Pit advocating early intervention after stroke? Boris Johnson making sure that diabetics check their metabolic control? Angelina Jollie suggesting that we all immunise our kids? Well, I cannot – not many anyway. But I certainly could list numerous VIPs doing their very best to promote quackery and anti-vaccination propaganda.
We may smile about such vain attempts to catch the lime-light, but the influence of celebrities on consumers’ behaviour might be huge and detrimental. It is difficult to estimate, and I am not aware of much reliable research data in this area. But my instinct tells me that, in the realm of alternative medicine, the ‘celebrity-factor’ is a very strong determinant of alternative medicine usage, and one that significantly contributes to the ‘sea of misinformation’ in this area.
With one of our research projects at Exeter, we wanted to identify reports on celebrities’ use of alternative medicine. We searched our department’s extensive data files, the Internet via the Google search engine, and the UK popular press via LexisNexis using the search terms “celebrity”, “alternative medicine” and “complementary medicine”. We considered articles published during 2005 and 2006 for inclusion in our study.
Using this strategy, we identified 38 celebrities using a wide range of alternative medicine interventions. Homeopathy, acupuncture and Ayurveda were the most popular modalities. The conclusion we drew from this investigation was that there may be many reasons why consumers use alternative medicine, and wanting to imitate their idols is one of them.
Some pro-alternative sites even boast with the fact that celebrities use quackery: Oprah is into it; so are Madonna, Uma and Gwyneth. No, it’s not a club for high-profile women with unique names. It’s alternative medicine. As ABC News describes, alternative medicine remains an option outside of “standard care” practices that physicians employ. But it has had a sweeping effect on the country, and celebrities have played a role in its popularity.
This, I think, indicates that celebrities are being used as a marketing tool for the alternative medicine industry. Both seem to feed of each other: the industry turns the celebrity endorsements into profit, and the celebrities turn the interest of the press into the all-important fame needed for remaining a celebrity. If a star displays her shapely back in a low-cut dress, nobody bats an eyelash; if, however, her back is covered with marks from today’s cupping-therapy, the press goes crazy – and, as a consequence, cupping therapy experiences a boost. The fact that there is no good evidence for this treatment becomes entirely irrelevant, and so is the fact that thousands of people will hence forward waste their money on ineffective treatments, some of them possibly even losing valuable time for curing a life-threatening disease.
Who wants such a pedestrian thing as evidence? We are in the realm of the high-fliers who cannot be bothered with such trivialities – unless, of course, they are really ill, in which case they will not consult their local quack but use the best conventional medicine on offer. Has anyone heard of a member of the Royal family being rushed to a homeopathic hospital when acutely ill?
In my experience, a VIP’s conviction in promoting quackery is inversely correlated to his expertise and intelligence. Prince Charles seems to want the entire British nation to be force-fed on quackery – anything from Gerson diet to homeopathy. He knows virtually nothing about medicine, but makes up for this deficit through a strong and quasi-religious belief in quackery. Scientists tend to laugh about his quest and might say with a slightly pitiful smile “but he is full of good will!”. Yet I am not sure that it is all that funny, nor am I convinced that good will is enough. Misleading the public about matters of health care is not amusing. And good will and conviction render quacks not less but more dangerous.
Even though I have not yet posted a single article on this subject, it already proved to be a most controversial subject in the comments section. A new analysis of the evidence has just been published, and, in view of the news just out of a Royal Charter for the UK College of Chiropractors, it is time to dedicate some real attention to this important issue.
The analysis comes in the form of a systematic review authored by an international team of chiropractors (we should not fear therefore that the authors have an “anti-chiro bias”). Their declared aim was “to determine whether conclusive evidence of a strong association [between neck manipulation and vascular accidents] exists”. The authors make it clear that they only considered case-control studies and omitted all other articles.
They found 4 such publications all of which had methodological limitations. Two studies were of acceptable quality, and one of these studies seemed to show an association between neck manipulation and stroke, while the other one did not. The authors’ conclusion is ambivalent: “Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but it is also lacking for no association”.
The 4 case-control studies, their strength and weaknesses are, of course, well-known and have been discussed several times before. It was also known that the totality of these data fail to provide a clear picture. I would therefore argue that, in such a situation, we need to include further evidence in an attempt to advance the discussion.
Generally speaking, whenever we assess therapeutic safety, we must not ignore case-reports. One might be next to meaningless but collectively they can provide strong indicators of risk. In drug research, for instance, they send invaluable signals about potential problems and many drugs have been withdrawn from the market purely on the basis of case-reports. If we include case-reports in an analysis of the risks of neck manipulations, the evidence generated by the existing case-control studies appears in a very different light. There are virtually hundreds of cases where neck manipulations have seriously injured patients, and many have suffered permanent neurological deficits or worse. Whenever causation is validated by experts who are not chiropractors and thus not burdened with a professional bias, investigators find that most of the criteria for a causal relationship are fulfilled.
While the omission of case-reports in the new review is regrettable, I find many of the staements of the authors helpful and commendable, particularly considering that they are chiropractors. They seem to be aware that, when there is genuine uncertainty, we ought to err on the safe side [the precautionary principle]. Crucially, they comment on the practical implications of our existing knowledge: “Considering this uncertainty, informed consent is warranted for cervical spinal manipulative therapy that advises patients of a possible increase in the risk of a rare form of stroke…” A little later, in their discussion they write: “As the possibility of an association between cervical spinal manipulative therapy and vascular accidents cannot be ruled out, practitioners of cervical spinal manipulative therapy are obliged to take all reasonable steps that aim to minimise the potential risk of stroke. There is evidence that cervical rotation places greater stresses on vertebral arteries than other movements such as lateral flexion, and so it would seem wise to avoid techniques that involve full rotation of the head.”
At this point it is, I think, important to note that UK chiropractors tend not to obtain informed consent from their patients. This is, of course, a grave breach of medical ethics. It becomes even graver, when we consider that the GCC seems to do nothing about it, even though it has been known for many years.
Is this profession really worthy of a Royal Charter? This and the other question raised here require some serious consideration and discussion which, no doubt, will follow this short post.