MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

“Edzard and his ilk are not really serious about honoring the Hippocratic tradiiton of “First, do no harm,” and even then, they will spin what seemingly good responses to homeopathic treatment as a placebo.”

This comment came recently from our good friend Dana Ullman, and it made me think again about homeopathy and the ‘first do no harm’ principle.

  • The first thing to note is that the Hippocratic oath does not contain this sentence.
  • And the second thing to stress is that clinicians are doing harm regularly. The ‘first do no harm’ principle has long been understood to mean that clinicians should always take care that their actions generate more benefit than harm.

As we discussed all this in more detail before, I do not intend to dwell on it. Today, I rather consider three exemplary scenarios in order to investigate how the principle of doing more good than harm applies to homeopathy (or indeed any other form of so-called alternative medicine (SCAM)).

SCENARIO 1:

PATIENT WITH A SELF-LIMITING CONDITION

Let’s assume our patient has a cold and consults her physician who prescribes a homeopathic remedy. One could argue that no harm is done in such a situation. The treatment will not help beyond a placebo effect, but the cold will disappear in just a few days, and the patient will not suffer any side effects. This attitude is common but it disregards the following potential harms:

  1. The cost for the treatment.
  2. The possibility that our patient suffered for several days needlessly from cold symptoms that might be treatable.
  3. The possibility of our patient getting the erroneous impression that homeopathy is an effective therapy (because the cold did go away quickly) and therefore opts to use it for future, more serious illnesses.

What if the physician only prescribed homeopathy because the patient asked him to do so? Strictly speaking, the above-named issues still apply in this situation. The ethical thing would have been to inform the patient what the best evidence tells us (namely that homeopathy is a placebo therapy), provide assurance about the nature of the condition, and prescribe effective treatments as needed.

And what if the physician does all of these things and, in addition, prescribes homeopathy because the patient wants it? In this case, the possibility of harms 1 and 3 does still apply.

SCENARIO 2

PATIENT WITH A CHRONIC CONDITION

Consider a patient suffering from arthritis who consults her physician who prescribes homeopathic remedies as the sole therapy. In such a situation, the following harms apply:

  1. The cost for the treatment.
  2. The possibility that our patient suffers needlessly from symptoms that are treatable. As the symptoms can be serious, this would often amount to medical negligence.

What if the physician only prescribed homeopathy because the patient asked him to do so and the patient refuses conventional therapies? In such cases, it is the physician’s ethical duty to inform the patient about the best evidence as it pertains to homeopathy and conventional treatments for her condition. Failure to do so would amount to negligence. The patient is then free to decide, of course. But so is the physician; nobody can force him/her to prescribe ineffective treatments. If no consensus can be reached, the patient might have to change physician.

And what if the physician does inform the patient adequately but also prescribes homeopathy because the patient wants it? In this case, the possibility of harms 1 and 3 does still apply.

SCENARIO 3

PATIENT WITH A LIFE-THREATENING CONDITION

Consider a young man with testicular cancer who consults his doctor who prescribes homeopathic remedies as the sole therapy. In such a situation, the physician is grossly negligent and could be struck off because of negligence.

What if the physician prescribed homeopathy because the patient asked him to do so and refuses conventional therapies? In such a case, it is the ethical duty of the physician to inform the patient about the best evidence as it pertains to homeopathy and to the conventional treatment for his cancer. Failure to do so would amount to negligence. The patient is then free to decide, of course. But so is the physician; nobody can force him to prescribe ineffective treatments. If no consensus can be reached between the physician and the patient, the patient might have to change physician.

And what if the physician does inform the patient adequately makes sure he receives effective oncological treatments, but also prescribes homeopathy because the patient insists on it? In this case, the possibility of harms 1 and 3 does still apply.

These scenarios are, of course, rather schematic and, in everyday practice, many other factors might need considering. They nevertheless show that the ‘do more good than harm’ principle does not support homeopathy (or any other ineffective SCAM). In other words, the practice of homeopathy is not ethical.

But what if someone (like Dana Ullman) strongly believes in the effectiveness of homeopathy? In this case, he or she is not acting according to the best available evidence – and that, of course, is also unethical.

 

27 Responses to ‘First do no harm’ and homeopathy

  • Straw man argument again.

    First, I’ve never said that “First, do no harm” is a part of the “Hippocratic oath,” but it is without doubt the most famous statement from Hippocrates. Surely, you are NOT question whether Hippocrates never said this.

    Clinicians who has been properly and adequately trained in homeopathy, as verified by any of the specialty status boards of homeopathy worldwide observe daily medical miracles from homeopathic treatment…and that is why there is a significant body of clinical evidence for its efficacy, despite your repeated Trumpian (and fake news) proclaimations to the contrary.

    It is every patient’s right to seek the health and medical care he or she wishes…and it is every clinician’s right to provide the health and medical care he or she deemed to be appropriate with informed consent.

    Sadly and strangely in your world, people should be forced to receive some type of “state-approved” treatment by clinicians who are similarly forced to provide such treatment. You live in a dystopian world. My sincere condolences.

    • Oh, Dana, you are priceless!
      1. I do not claim that you said the sentence comes from the oath.
      2. “medical miracles from homeopathy”? yes, they must be miracles indeed, because homeopathy itself does not work. so, thanks for confirming!
      3. “It is every patient’s right to seek the health and medical care he or she wishes”. did not dispute it.
      4. “it is every clinician’s right to provide the health and medical care he or she deemed to be appropriate with informed consent.” I am not sure that this is correct, and I know that most homeopaths do not obtain proper informed consent.
      5. ” in your world, people should be forced to receive some type of “state-approved” treatment by clinicians who are similarly forced to provide such treatment”. where and when did I say something remotely like this?
      6. “My sincere condolences.” I am not sure you know what sincerity means.

    • “it is every clinician’s right to provide the health and medical care he or she deemed to be appropriate with informed consent”

      So if a clinician deems a substandard or ineffective treatment (or just outright fraud) appropriate, then they have the right to perform that “care” just as long as they can convince the patient to agree to it? Wow.

      If a “CONmed” practitioner does that with a “CONmed” product, both Prof Ernst and you would—rightly—scream in fury about the appalling patient abuse that’s being perpetrated under the guise of “care”. (One of the big complaints we have with conventional medicine is medical boards and other regulators who fail to take action against incompetent or abusive practitioners, despite the trail of damaged and dead patients they leave in their wake. More regulation is better, when mistakes are measured in lives.)

      Whereas you AltMedders happily roll out the red carpet when it’s one of your own doing the same. After all, how can you possibly not obtain “informed consent” when requesting it of fellow believers whose standard of evidence is, like yours, “what I really REALLY want to be True” and “nah-nah-nah can’t hear you” to everything that doesn’t fit those mutually agreed beliefs. When neither practitioner nor patient is willing to contemplate even the possibility of being wrong, how can you lose†?

      This is why you’re a Religion, not a science. Declaring that before you practise would be informed consent.

      † Some may ultimately, indirectly lose—up to and including their lives. But that’s not on you as practitioners; that’s on them as patients for not committing hard enough. AltMed never fails its patients; only patients fail AltMed.

      • So, for instance, during the 1918-19 flu pandemic, JAMA and the Surgeon General recommended 25 aspirin tablets per day to suppress the fever. Aspirin went off-patent in 1917, enabling it to be a cheap drug.

        Any MD who would recommend this protocol in 2021 would have his or her medical license revoked…and yet, the AMA hasn’t apologized for providing care that led to the death of hundreds of thousands and millions of people.

        https://academic.oup.com/cid/article/49/9/1405/301441

        How many more examples do we need from every decade of serious dangers from “well accepted” medical science?

        • your example is > 100 years old and very ill-chosen.
          more importantly, what does it have to do with homeopathy being unethical?

        • You cited “straw man” further up the thread, Dana. And used the phrase incorrectly. Logical fallacies are something else you plainly do not understand.

          If you want an example of what a Straw Man argument is, look at the post you’ve just made.

          Oh and the phrase “primum non nocere” is believed to date from the 17th century. Not Hippocrates.

          Your relationship with facts and the truth remains as tenuous as ever, Dana. Run along, now.

          • Oh and the phrase “primum non nocere” is believed to date from the 17th century. Not Hippocrates.

            The fact that it’s in Latin should have been a bit of a giveaway.

        • “AMA hasn’t apologized for providing care that led to the death of … millions of people”

          Stop us if you’re heard this before: [citation most definitely required].

          Or, did you intentionally miss the bit that says: “The hypothesis presented herein”?

          There’s a lot of “ifs” and “maybes” in that paper, and rightly so, because it’s dealing with a lot of historical uncertainty in its search for an improved explanation of a tiny part of our world. There may be something to the hypothesis it presents; there may not. As the paper itself notes, aspirin’s toxicity profile was not properly understood until the 1960s; thus 1918 doctors prescribing high-dose aspirin to Spanish flu victims were operating in good faith based on the (very incomplete) information available at the time, without the luxury of either time or hindsight that you and I now have. As an initial hypothesis, it is highly speculative and only minimally evidenced; the start of an enquiry, not its end. There’s no way form hard conclusions without first obtaining a large number of historical medical records in order to determine exactly which patients took high-dose aspirin and which did not, in order to compare their outcomes (after minimizing the confounders as best it can). Therefore it does not, again noting:

          To determine the proportion of virus-induced pathology, subsequent bacterial infection, and overall 1918 pandemic mortality attributable to salicylate, experimental models and analysis of primary consecutive individual treatment and pathology records are needed.

          Seeing as the original paper was published in 2009, I did a quick rummage to see if there was a followup study (a positive result from which would’ve been big news indeed), but nothing leaped out. Thus I suspect, as with many hypotheses, either no-one was interested in doing the work to [dis]prove it, or they quickly got a negative result. Thus it remains what it is: speculation.

          And yet, you showed no such caveats or hesitation when confidently declaring that the AMA “killed millions”; why is that, do you think?

          ..

          That was a rhetorical question, of course. I’ve already got the answer, because I understand the difference between science and religion, and how to tell which is which by their words and behaviors:

          Science is wrong, knows that it’s wrong, and works its ass off to become less wrong over time.

          Whereas religion is Right, knows that it’s Right, and endlessly strives to prove its Rightness by whatever means available.

          To wit: science-based medicine already knows it is flawed, and openly admits this fact every time it abandons one of its old, established practices (bloodletting, high-dose aspirin, ubiquitous radical mastectomy, lobotomy, and so on) in favor of something [usually] newer and [usually] better. Your repetitive restating of this information after medicine already stated it first impresses no-one but yourself.

          The irony is, such amateur mud-flinging misdirection only proves just how barren your own cupboard is; for if you did possess convincing evidence of AltMed’s efficacy then you would have presented that instead. Like the proverbial lawyer with neither truth nor law on his side, you loudly pound the table. Which may make for good performance art, and no doubt wins you some sales, but science it is not.

          You’re a preacher man, dude. Get over yourself, and embrace the fact already.

          “Quacks citing problems in pharma make me laugh. FLAWS IN AIRCRAFT DESIGN DO NOT PROVE THE EXISTENCE OF MAGIC CARPETS.” – Dr Ben Goldacre

    • @Dana Ullman

      Clinicians who has been properly and adequately trained in homeopathy …

      Ah, yes, just like my stepdaughter when she was six years old, concocting a witch brew together with her friends, by mixing and mashing up more or less arbitrary ingredients, just as long as they were characterized by ‘flatness’ …

      … observe daily medical miracles from homeopathic treatment …

      Yes, just like my stepdaughter when she was six years old, when she and her friends ‘treated’ me with said concoctions, instantly resulting in all sorts of hilarious symptoms such as speaking in tongues (mostly Italian) and making wild gestures … with the end result that I agreed to make them pizza instead of broccoli … YESS! Success!
      I can still see those smiling faces when their magic really worked! Wonderful days …

      • Literally dozens of surveys about WHO uses homeopathic medicines have consistently found that the more educated a person is, the more likely they use homeopathic medicines. It is completely understandable therefore that you, Richard Rasker, do not use homeopathic medicines. No surprise there.

        • Dana: every time you have been shown to be absurdly wrong you do us a great favour by issuing a stupid insult thus demonstrating that you have no arguments.
          THANK YOU!

        • You, Dana, are very highly educated.

          Which shows us that education and intelligence are two very different things.

        • @Dana Ullman

          the more educated a person is, the more likely they use homeopathic medicines.

          Well, then India must be absolutely teeming with geniuses …

          Anyway, you are partly correct: people with lower education are usually smart enough to know that for health problems, they should rely on the judgment of actual experts – real doctors, that is. Also, people with a lower education tend to have less money, so they can’t afford to waste money on quackery(*).

          Then there are people with a higher education (academic/scientific): they are usually smart enough to know exactly what homeopathy is, and as a result, these people also will never use it. So this contradicts your claim already.

          The sweet spot (for homeopaths, that is) is found in the group of people with just enough education to make them erroneously believe that they can critically assess all sorts of things outside their own field of expertise, and also with just enough money to be able to spend a few hundred bucks on useless frippery every now and then without it hurting too much.
          And yes, these are people with a ‘higher’ education, but NOT in any scientific or academic field, but usually in arts or management or the likes. These are people who are often found on Mount Stupid. And not surprisingly, this is also where most homeopaths and other quacks reside.

          It is completely understandable therefore that you, Richard Rasker, do not use homeopathic medicines.

          Well, yes, of course. I studied homeopathy quite extensively, and I’m pretty certain that I know rather more about it than you do – and the most important thing I learned is that it is foolish quackery, propagated by rather dim yet hugely arrogant people. QED.

          *: In most western countries, healthcare is a matter of public funding, so consulting a real doctor is essentially free(**), whereas homeopaths usually charge between $80 and $200 per visit.

          **: Of course real doctors don’t work for free, but they still charge considerably less than homeopaths. E.g. our Dutch GP’s earn $12 for a 20-minute consultation.

        • “the more educated a person is, the more likely they use homeopathic medicines.”

          The more educated a person is, the better job he or she is likely to have, and therefore the more disposable income, to be spent on self-indulgent consulations with CAM practitioners.

          • Reformulating Voltaire for the modern day:

            “The art of homeopathy consists of fluffing the patient’s ego while real medicine cures the disease.”

            It’s an effective prescription for needy neurotics with overweight wallets.

          • Yes. This year I’ve read a slew of autobiographical books by GPs and consultants. One of the GPs (I can’t be bothered trawling through Kindle downlaods to find which one) made a similar observation, after recounting a consultation with a patient who said she was going to then consult her homeopath. He noted (words to the effect) that this kind of thing pertains to the comfortably-off middle classes who can afford to indulge themselves.

          • The more educated a person is, the better job he or she is likely to have, and therefore the more disposable income, to be spent on self-indulgent consulations with CAM practitioners.

            Professor Ernst has noted a correlation between spending on CAM and BMW sales figures (see Medico-Legal Journal (2006) Vol. 74 Part 2, pp56-68).

        • iirc, most of those surveys suggest middle class women with an arts degree are over represented.

          I’m not sure if the UK Facebook groups I monitor are representative, but they do reflect this. Additiionally, one thing they reveal is often unwarranted anxiety about their own and their children’s health. Health literacy is generally very low. The homeopaths who turn up on these groups offer poor and sometimes risky health “advice” and stoke up fears about doctors and medical treatments.

          It goes without saying that anti-vaccination is common and there is a lot of sharing of Covid related disinformation.

    • First, I’ve never said that “First, do no harm” is a part of the “Hippocratic oath,” but it is without doubt the most famous statement from Hippocrates.

      Your comments complaining that medical doctors fail to follow an instruction to “do no harm” imply that homeopathic remedies “do no harm”. How do you know this?

      Surely, you are NOT question whether Hippocrates never said this.

      I assume the double negative is unintentional. The nearest thing in Hippocrates’ writings seems to be “The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.” Note the implied trade-off between risk and benefit.

      See, for example, here: https://www.health.harvard.edu/blog/first-do-no-harm-201510138421

    • Mr Ullman, it would be very helpful to me if you would name the laboratory that can distinguish between homeopathic water and non-homeopathic water. You said that it is “no problem” to name it, and that those who (like me) doubt that it can be done, are “liars or fools”. Eleventh time of asking…..

    • …and it is every clinician’s right to provide the health and medical care he or she deemed to be appropriate with informed consent.

      No. It’s a duty to offer the best possible treatment. In certain cases, there may be a number of treatment options, each with a a different risk/benefit profile and the clinician has a duty to discuss those with the patient.

      A clinician is normally defined as a doctor having direct contact with patients rather than being involved with theoretical or laboratory studies. Many SCAM practitioners are not medically qualified and in some jurisdictions they make up the majority. Lay SCAMsters often operate in a regulatory and ethical vacuum, which is less true with doctors, although jurisdictions do vary in their approach and level of tolerance/indifference.

      Lay SCAMsters often struggle with concepts such as scope of practice and practicing within limits of competence.

  • So Edzard Ernst complains about everything. It is questionable how in 2016 you have already published about seven books, a prodigious production for such a short time. However, I have been examining your books and I do not know whether to laugh or cry, many of them are the copy of one another, do you know that this is very serious Ernst? There’s even a chapter of yours in an Oxford medical book:

    “The results of about a dozen subsequent systematic reviews generally fail to demonstrate effects beyond pla-
    cebo. Therefore, the best evidence available to date fails to suggest efficacy”

    Strange that you don’t quote any of those “dozen references.” Do book editors allow you to make unsubstantiated claims? isn’t that a contradiction to what you say about your blog? What about your last book?

    “Many simply report test-tube experiments which tell us nothing about homeopathy’s clinical value”

    Obviously these types of experiments have no clinical value, but they do have plausubility.

    Another example: “While these results seem encouraging, there are numerous concerns about
    this study. Firstly, the article has no methods section”

    You must be kidding Ernst, Frass’s article does have a methods section, well actually the section is called material and methods. Springer didn’t check your book?

    Your other book of “150 modalities” is to die of laughter, in the case of agrohomeopathy you only wrote one page, I repeat, one page. And for that you say that” there is no reliable evidence ” quoting the article by Jäger et al. that doesn’t say what you’re saying, but that plant models are suitable for investigating homeopathy.

    • oh, dear!
      I don’t complain! not even about your stupid rant. I try to present the best available evidence.
      “It is questionable how in 2016 you have already published about seven books, a prodigious production for such a short time.”
      SHORT TIME? In 2016, I had been researching SCAM for ~ 25 years!
      “Your other book of “150 modalities” is to die of laughter, in the case of agrohomeopathy you only wrote one page, I repeat, one page.”
      Have you not noticed that the principle of the book is to explain each modality in just 7 points?

  • Most studies do show improvement with homeopathy…

    Review
    Eur J Health Econ . 2014 Mar;15(2):157-74.
    doi: 10.1007/s10198-013-0462-7. Epub 2013 Feb 10.
    Economic evaluations of homeopathy: a review
    Petter Viksveen 1 , Zofia Dymitr, Steven Simoens
    Affiliations
    • DOI: 10.1007/s10198-013-0462-7
    Abstract
    Context: Economic evaluations of commonly used complementary and alternative medicine (CAM) therapies such as homeopathy are needed to contribute to the evidence base on which policy makers, clinicians, health-care payers, as well as patients base their health-care decisions in an era of constrained resources.
    Objectives: To review and assess existing economic evaluations of homeopathy.
    Methods: Literature search was made to retrieve relevant publications using AMED, the Cochrane Library, CRD (DARE, NHS EED, HTA), EMBASE, MEDLINE, and the journal Homeopathy (former British Homoeopathic Journal). A hand search of relevant publications was carried out. Homeopathy researchers were contacted. Identified publications were independently assessed by two authors.
    Results: Fifteen relevant articles reported on 14 economic evaluations of homeopathy. Thirteen studies reported numbers of patients: a total of 3,500 patients received homeopathic treatment (median 97, interquartile range 48-268), and 10 studies reported on control group participants (median 57, IQR 40-362). Eight out of 14 studies found improvements in patients’ health together with cost savings. Four studies found that improvements in homeopathy patients were at least as good as in control group patients, at comparable costs. Two studies found improvements similar to conventional treatment, but at higher costs. Studies were highly heterogeneous and had several methodological weaknesses.
    Conclusions: Although the identified evidence of the costs and potential benefits of homeopathy seemed promising, studies were highly heterogeneous and had several methodological weaknesses. It is therefore not possible to draw firm conclusions based on existing economic evaluations of homeopathy. Recommendations for future research are presented.

  • “I swear by Hahnemann, the great physician, and all the gods and goddesses making them my witness that I will fulfill according to my ability and Judgment this Oath till the last minute of my life.”

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