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

unreason

Two of the top US general medical journals have just published articles which somehow smell of the promotion of quackery. A relatively long comment on alternative medicine, entitled THE FUTURE OF INTEGRATIVE MEDICINE appeared in THE AMERICAN JOURNAL OF MEDICINE and another one entitled PERSPECTIVES ON COMPLEMENTARY AND ALTERNATIVE MEDICINE RESEARCH in THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. As this sort of thing does not happen that often, it is perhaps worth having a closer look at these publications. The JAMA-article has already been analysed skilfully by Orac, so I will not criticise it further. In the following text, the passages which are in italics are direct quotes from the AJM-article, while the interceptions in normal print are my comments on it.

…a field of unconventional medicine has evolved that has been known by a progression of names: holistic medicine, complementary and alternative medicine, and now integrative medicine. These are NOT synonyms, and there are many more names which have been forgotten, e.g. fringe, unorthodox, natural medicine It is hoped that the perspectives offered by integrative medicine will eventually transform mainstream medicine by improving patient outcomes, reducing costs, improving safety, and increasing patient satisfaction. Am I the only one to feel this sentence is a platitude?

Integrative medicine has been defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.” There is, in fact, no accepted definition; the most remarkable bit in this one is perhaps the term “informed by evidence” which, as we will see shortly, is by no means the same as “evidence-based”, the accepted term and principle in medicine.

The most obvious differences between integrative and conventional medicine are its practitioners, who offer longer consultations and emphasize minimally invasive therapies, such as mind-body approaches, nutrition, prevention, and lifestyle changes, and focus on healing and wellness. Come again! Is that supposed to mean that conventional doctors do not employ “minimally invasive therapies or prevention or nutrition etc.”? In addition to conventional therapies, they may recommend alternatives, such as acupuncture, dietary supplements, and botanicals. BINGO! The difference between integrative and conventional physicians is quite simply that the former put an emphasis on unproven treatments; evidence my foot! This is just quackery by a different name. The doctor-patient relationship emphasizes joint decision-making by the patient and the physician. Yes, that may be true, but it does so in any type of good health care. To imply that the doctor-patient relationship and joint decision-making is an invention of integrative medicine is utter nonsense. 

More and more patients seek integrative medicine practitioners. By 2007, approximately 40% of adult Americans and 12% of children were using some form of alternative therapies compared with 33% in 1991.

The number of US hospitals offering integrative therapies, such as acupuncture, massage therapy, therapeutic touch, and guided imagery, has increased from 8% in 1998 to 42% in 2010.Many academic cancer centers offer these integrative practices as part of a full spectrum of care. Other hospitals offer programs in integrative women’s health, cardiology, and pain management. But why? I think the authors forgot to mention that the main reason here is to make money.

Despite the increasing number of patients seeking alternative therapies, until recently, many of these skills were not routinely offered in medical schools or graduate medical education. Yet they are critical competencies and essential to stemming the tide of chronic diseases threatening to overwhelm both our health care and our financial systems. Essential? Really? Most alternative therapies are, in fact, unproven or disproven! Further, conventional medical journals rarely contained articles about alternative therapies until 1998 when the Journal of the American Medical Association and its affiliated journals published more than 60 articles on the theme of complementary and alternative medicine.

The National Institutes of Health established an office in 1994 and a National Center for Complementary and Alternative Medicine in 1998. Because many alternative therapies date back thousands of years, their efficacy has not been tested in randomized clinical trials. The reasons for the lack of research may be complex but they have very little to do with the long history of the modalities in question. The National Center for Complementary and Alternative Medicine provides the funds to conduct appropriate trials of these therapies. The NCCAM- funded studies have been criticised over and over again and most scientists find them not at all “appropriate”. They also have funded education research and programs in both conventional medical nursing schools and complementary and alternative medicine professional schools. Outcomes of these studies are being published in the conventional medical literature. Not exactly true! Much of it is published in journals of alternative medicine. Also, the authors forgot to mention that none of the studies of NCCAM have ever convincingly shown an alternative treatment to work.

Integrative medicine began to have an impact on medical education when 8 medical school deans met in 1999 to discuss complementary and alternative medicine. This meeting led to the establishment of the Consortium of Academic Health Centers for Integrative Medicine, composed initially of 11 academic centers. By 2012, this group had grown to 54 medical and health profession schools in the United States, Canada, and Mexico that have established integrative medicine programs. The consortium’s first international research conference on integrative medicine was held in 2006, with subsequent research conferences being held in 2009 and 2012. Three conferences? Big deal! I have hosted 14 research conferences in Exeter in as many years. I think, the authors are here blowing up a mouse to look like an elephant.

Multiple academic integrative medicine programs across the country have been supported by National Institutes of Health funding and private contributions, including the Bravewell Collaborative that was founded in 2002 by a group of philanthropists. The goal of the Bravewell Collaborative is “to transform the culture of healthcare by advancing the adoption of Integrative Medicine.” It foremost was an organisation of apologists of alternative medicine and quackery. A high water mark also occurred in 2009 when the Institute of Medicine held a Summit on Integrative Medicine led by Dr Ralph Snyderman. 

There is clear evidence that integrative medicine is becoming part of current mainstream medicine. Really? I would like to see it. Increasing numbers of fellowships in integrative medicine are being offered in our academic health centers. In 2013, there are fellowships in integrative medicine in 13 medical schools. In 2000, the University of Arizona established a 1000-hour online fellowship that has been completed by more than 1000 physicians, nurse practitioners, and physician assistants. This online fellowship makes it possible for fellows to continue their clinical practice during their fellowship. I see, this is supposed to be the evidence?

A 200-hour curriculum for Integrative Medicine in Residency has been developed and is now in place in 30 family practice and 2 internal medicine residencies. The curriculum includes many of the topics that are not covered in the medical school curriculum, such as nutrition, mind–body therapies, nutritional and botanical supplements, alternative therapies (eg, acupuncture, massage, and chiropractic), and lifestyle medicine. It is not true that conventional medical schools do not teach about nutrition, psychology etc. Not all might, however, teach overt quackery. A similar curriculum for pediatric residencies is being developed. The eventual goal is to include integrative medicine skills and competencies in all residency programs.

Conclusions 

Integrative medicine now has a broad presence in medical education, having evolved because of public demand, student and resident interest, increased research, institutional support, and novel educational programs. Now on the horizon is a more pluralistic, pragmatic approach to medicine that is patient-centered, that offers the broadest range of potential therapies, and that advocates not only the holistic treatment of disease but also prevention, health, and wellness.

Is it not an insult to conventional medicine to imply it is not pluralistic, pragmatic, patient-centred, that it does not offer a broad range of therapies, holism and prevention? This article displays much of what is wrong with the mind-set of the apologists of alternative medicine. The more I think about it, the more I feel that it is a bonanza of fallacies, follies and attempts to white-wash quackery. But I would be interested in how my readers see it.

What is a competent homeopath? This intriguing question was addressed in a recent article by researchers from the Department of Public Health, School of Health and Related Research, University of Sheffield, UK, and the Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway. Non-homeopaths would probably argue that either a clinician is competent or he/she is a homeopath; being a competent homeopath seems like a contradiction in terms. So, is is interesting to see what these authors had to say on the subject.

They started by pointing out that homeopathy is unregulated in most European countries, it is therefore not clear, in their view, what it means to be a “competent homeopath”. To clarify this issue, they decided to conduct a small survey investigating homeopathy-educators’ views on what a “competent homeopath” might be and what homeopaths might require in their education. They did a qualitative study based on grounded theory methodology involving telephone interviews with 17 homeopathy-educators from different schools in 10 European countries. The main questions asked were “What do you think is necessary in order to educate and train a competent homeopath?” and “How would you define a competent homeopath?

The results indicate that the homeopathy-educators defined a “competent homeopath” as a professional who, through his/her knowledge and skills together with an awareness of his/her bounds of competence, is able to help his/her patients in the best way possible. This is achieved through the processes of study and self-development, and is supported by a set of basic resources. Becoming and being a “competent homeopath” is underpinned by a set of basic attitudes. These attitudes include course providers and teachers being student-centred, and students and homeopaths being patient-centred. Openness on the part of students is important to learn and develop themselves, on the part of homeopaths when treating patients, and for teachers when working with students. Practitioners have a responsibility towards their patients and themselves, course providers and teachers have responsibility for providing students with effective and appropriate teaching and learning opportunities, and students have responsibility for their own learning and development (in order to avoid confusion or misinterpretation, I have copied this section almost verbatim from the abstract).

The authors consider that, according to homeopathy-educators’ understanding, basic resources and processes contribute to the development of a competent homeopath, who possesses certain knowledge and skills, all underpinned by a set of basic attitudes. And they conclude that this study proposes a substantive theory to answer what homeopathy educators believe a competent homeopath is and what it takes to be educated and trained to become one. The model suggests that certain basic resources and educational and self-developmental processes contribute to developing knowledge and skills necessary to be competent homeopaths. It also pinpoints underlying attitudes needed in the education as well as the clinical practice of competent homeopaths.

I find two things particularly striking in this text which I have copied almost unchanged from the abstract of the original paper (the full text is hardly more illuminating).

Firstly, these statements tell me virtually nothing that is specific to homeopathy. In my view, they are merely a bonanza of platitudes without much real meaning. We could substitute almost any other health care profession for “homeopath”, and the text would still be applicable in a very general and politically correct sort of way. I see nothing here that is specific to homeopathy.

Secondly, according to the findings of this survey, a “competent homeopath” does not seem to have much need for evidence. With virtually every other health care profession I know, one would expect a very strong emphasis on the need for the competent clinician to abide by the rules of evidence-based medicine. Not so in homeopathy!

Why? The answer seems obvious: if a clinician practices evidence-based medicine, he/she cannot possibly practice homeopathy – the evidence shows that homeopathy is a placebo-therapy. So, here we have it: a competent homeopath has to be a contradiction in terms because either someone practices homeopathy or he/she practices evidence-based medicine. Doing both at the same time is simply not possible.

S.O. Hansson from the Royal Institute of Technology, Stockholm, Sweden recently published an interesting comment on the law regulating the labelling of homeopathic products. In it he points out that, in the European Union (EU), all pre-packaged food products must contain a list of ingredients and their quantities. The list should be “accurate, clear and easy to understand for the consumer.” Similar requirements apply to pharmaceutical drugs and products – with one notable exception: homeopathic preparations.

For such products, the ingredients need not be disclosed on the label, which should instead specify “the scientific name of the stock or stocks followed by the degree of dilution.” The degree of homeopathic dilutions is, in turn, given in an understandable jargon, such as “C60”, which actually describes a dilution of 1:10120.

The point Hansson is trying to make is that very few health care professionals and even fewer consumers would understand such abbreviations and jargon. This means that, manufacturers of homeopathic products are legally permitted to hide the fact from their customers that their remedies typically contain no active ingredient at all. Considering that homeopathic products are typically bought ‘over the counter’ (OTC), i.e. without interference from a health care professional, just like food products, the exemption seems most surprising.

The most OTC homeopathic remedies are in the “C30” potency; this signifies a dilution of 1: 1 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000. The likelihood that any potency higher than “C12” might contain a single molecule of active ingredient is very close to zero. In order to comprehend the degree of dilution in homeopathy more fully, a visual approach might be best: for it to have a reasonable chance to contain just one single molecule of active ingredient, a homeopathic pill in a “C30” potency would need to have a diameter roughly equal to the distance between the earth and the sun. Homeopathy is truly impossible to swallow.

If homeopathic manufacturers were obliged to provide a description that is “accurate, clear and easy to understand for the consumer”, it would need to state that any dilution beyond “C12” contains no active molecule. It seems clear that such accurate, clear and understandable information would discourage most consumers to spend their hard-earned money for such nonsense. It seems thus to be obvious that the EU exemption of homeopathic remedies from honest labelling protects the interests of the homeopathic industry.

But surely, this is deeply wrong. Regulations in health care are not supposed to protect commercial interests, they should protect the consumer. In my view, it is time to change such profoundly misguided EU-regulation – in the interest of honesty, single standards, transparency and foremost in the interest of the patient and the consumer.

A cult can be defined not just in a religious context, but also as a” usually nonscientific method or regimen claimed by its originator to have exclusive or exceptional power in curing a particular disease.” After ~20 years of researching this area, I have come to suspect that much of alternative medicine resembles a cult – a bold statement, so I better explain.

One characteristic of a cult is the unquestioning commitment of its members to the bizarre ideas of their iconic leader. This, I think, chimes with several forms alternative medicine. Homeopaths, for instance, very rarely question the implausible doctrines of Hahnemann who, to them, is some sort of a semi-god. Similarly, few chiropractors doubt even the most ridiculous assumptions of their founding father, D D Palmer who, despite of having been a somewhat pathetic figure, is uncritically worshipped. By definition, a cult-leader is idealised and thus not accountable to anyone; he (yes, it is almost invariably a male person) cannot be proven wrong by logic arguments nor by scientific facts. He is quite simply immune to any form of scrutiny. Those who dare to disagree with his dogma are expelled, punished, defamed or all of the above.

Cults tend to brain-wash their members into unconditional submission and belief. Likewise, fanatics of alternative medicine tend to be brain-washed, i.e. systematically misinformed to the extend that reality becomes invisible. They unquestioningly believe in what they have been told, in what they have read in their cult-texts, and in what they have learnt from their cult-peers. The effects of this phenomenon can be dramatic: the powers of discrimination of the cult-member are reduced, critical questions are discouraged, and no amount of evidence can dissuade the cult-member from abandoning even the most indefensible concepts. Internal criticism is thus by definition non-existent.

Like religious cults, many forms of alternative medicine promote an elitist concept. Cult-members become convinced of their superiority, based not on rational considerations but on irrational beliefs. This phenomenon has a range of consequences. It leads to the isolation of the cult-member from the rest of the world. By definition, critics of the cult do not belong to the elite; they are viewed as not being able to comprehend the subtleties of the issues at hand and are thus ignored or not taken seriously. For cult-members, external criticism is thus non-existent or invalid.

Cult-members tend to be on a mission, and so are many enthusiasts of alternative medicine. They use any conceivable means to recruit new converts. For instance, they try to convince family, friends and acquaintances of their belief in their particular alternative therapy at every conceivable occasion. They also try to operate on a political level to popularize their cult. They cherry pick data, often argue emotionally rather than rationally, and ignore all arguments which contradict their belief system.

Cult-members, in their isolation from society, tend to be assume that there is little worthy of their consideration outside the cult. Similarly, enthusiasts of alternative medicine tend to think that their treatment is the only true method of healing. Therapies, concepts and facts which are not cult-approved are systematically defamed. An example is the notion of BIG PHARMA which is employed regularly in alternative medicine. No reasonable person assumes that the pharmaceutical industry smells of roses. However, the exaggerated and systematic denunciation of this industry and its achievements is a characteristic of virtually all branches of alternative medicine. Such behaviour usually tells us more about the accuser than the accused.

There are many other parallels between a  cult and alternative medicine, I am sure. In my view, the most striking one must be the fact that any spark of cognitive dissonance in the cult-victim is being extinguished by highly effective and incessant flow of misinformation which often amounts to a form of brain-washing.

Even after all these years of full-time research into alternative medicine and uncounted exchanges with enthusiasts involved in this sector, I find the logic that is often applied in this field bewildering and the unproductiveness of the dialogue disturbing.

To explain what I mean, it be might best to publish a (fictitious, perhaps slightly exaggerated) debate between a critical thinker or scientist (S) and an uncritical proponent (P) of one particular form of alternative medicine.

P: Did you see this interesting study demonstrating that treatment X is now widely accepted, even by highly critical GPs at the cutting edge of health care?

S: This was a survey, not a ‘study’, and I never found the average GP “highly critical”. Surveys of this nature are fairly useless and they “demonstrate” nothing of real value.

P: Whatever, but it showed that GPs accept treatment X. This can only mean that they realise how safe and effective it is.

S: Not necessarily, GPs might just give in to consumer demand, or the sample was cleverly selected, or the question was asked in a leading manner, etc.

P: Hardly, because there is plenty of good evidence for treatment X.

S: Really? Show me.

P: There is this study here which proves that treatment X works and is risk-free.

S: The study was far too small to demonstrate safety, and it is wide open to multiple sources of bias. Therefore it does not conclusively show efficacy either.

P: You just say this because you don’t like its result! You have a closed mind!

In any case, it was merely an example! There are plenty more positive studies; do your research properly before you talk such nonsense.

S: I did do some research and I found a recent, high quality systematic review that arrived at a negative conclusion about the value of treatment X.

P: That review was done by sceptics who clearly have an axe to grind. It is based on studies which do not account for the intrinsic subtleties of treatment X. Therefore they are unfair tests of treatment X. These trials don’t really count at all. Every insider knows that! The fact that you cite it merely confirms that you do not understand what you are talking about.

S: It seems to me, that you like scientific evidence only when it confirms your belief. This, I am afraid, is what quacks tend to do!

P: I strongly object to being insulted in this way.

S: I did not insult you, I merely made a statement of fact.

P: If you like facts, you have to see that one needs to have sufficient expertise in treatment X in order to apply it properly and effectively. This important fact is neglected in all of those trials that report negative results; and that’s why they are negative. Simple! I really don’t understand why you are too stupid to understand this. Such studies do not show that treatment X is ineffective, but they demonstrate that the investigators were incompetent or hired with the remit to discredit treatment X.

S: I would have thought they are negative because they minimised bias and the danger of generating a false positive result.

P: No, by minimising bias, as you put it, these trials eliminated the factors that are important elements of treatment X.

S: Such as the placebo-effect?

P: That’s what you call it because you irrationally believe in reductionist science.

S: Science requires no belief, I think you are the believer here.

P: The fact is that scientists of your ilk negate all factors related to human interactions. Patients are no machines, you know, they need compassion; we clinicians know that because we work at the coal face of health care. Scientists in their ivory towers have no idea about patient care and just want science for science sake. This is not how you help patients. Show some compassion man!

S: I do know about the importance of compassion and care, but here we are discussing an entirely different topic, namely tests the efficacy or effectiveness of treatments, not patient-care. Let’s focus on one issue at a time.

P: You cannot separate things in this way. We have to take a holistic view. Patients are whole individuals, and you cannot do them justice by running artificial experiments. Every patient is different; clinical trials fail to account for this fact and are therefore fairly irrelevant to us and to our patients. Real life is very different from your imagined little experiments, you know.

S: These are platitudes that are nonsensical in this context and do not contribute anything meaningful to the present discussion. You do not seem to understand the methodology or purpose of a clinical trial.

P: That is typical! Whenever you run out of arguments, you try to change the subject or throw a few insults at me.

S: Not at all, I thought we were talking about clinical trials evaluating the effectiveness of treatment X.

P: That’s right; and they do show that it is effective, provided you consider those which are truly well-done by experts who know about treatment X and believe in it.

S: Not true. Only if you cherry-pick the data will you be able to produce an overall positive result for treatment X.

P: In any case, the real world results of clinical practice show very clearly that it works. It would not have survived for so long, if it didn’t. Nobody can deny that, and nobody should claim that silly little trials done in artificial circumstances are more meaningful than a wealth of experience.

S: Experience has little to do with reliable evidence.

P: To deny the value of experience is just stupid and clearly puts you in the wrong. I have shown you plenty of reliable evidence but you just ignore everything I say that does not go along with your narrow-minded notions about science; science is not the only way of knowing or comprehending things! Stop being obsessed with science.

S: No, you show me rubbish data and have little understanding of science, I am afraid.

P: Here we go again! I have had about enough of that and your blinkered arguments. We are going in circles because you are ignorant and arrogant. I have tried my best to show you the light, but your mind is closed. I offer true insight and you pay me back with insults. You and your cronies are in the pocket of BIG PHARMA. You are cynical, heartless and not interested in the wellbeing of patients. Next you will tell me to vaccinate my kids!

S: I think this is a waste of time.

P: Precisely! Everyone who has followed this debate will see very clearly that you are obsessed with reductionist science and incapable of considering the suffering of whole individuals. You want to deny patients a treatment that  really helps them simply because you do not understand how treatment X works. Shame on you!!!

Reiki is a form of  healing which rests on the assumption that some form “energy” determines our health. In this context, I tend to put energy in inverted commas because it is not the energy a physicist might have in mind. It is a much more mystical entity, a form of vitality that is supposed to be essential for life and keep us going. Nobody has been able to define or quantify this “energy”, it defies scientific measurement and is biologically implausible. These circumstances render Reiki one of the least plausible therapies in the tool kit of alternative medicine.

Reiki-healers (they prefer to be called “masters”) would channel “energy” into his or her patient which, in turn, is thought to stimulate the healing process of whatever condition is being treated. In the eyes of those who believe in this sort of thing, Reiki is therefore a true panacea: it can heal everything.

The clinical evidence for or against Reiki is fairly clear – as one would expect after realising how ‘far out’ its underlying concepts are. Numerous studies are available, but most are of very poor quality. Their results tend to suggest that patients experience benefit after having Reiki but they rarely exclude the possibility that this is due to placebo or other non-specific effects. Those that are rigorous show quite clearly that Reiki is a placebo. Our own review therefore concluded that “the evidence is insufficient to suggest that Reiki is an effective treatment for any condition… the value of Reiki remains unproven.”

Since the publication of our article, a number of new investigations have become available. In a brand-new study, for instance, the researchers wanted to explore a Reiki therapy-training program for the care-givers of paediatric patients. A series of Reiki training classes were offered by a Reiki-master. At the completion of the program, interviews were conducted to elicit participant’s feedback regarding its effectiveness.

Seventeen families agreed to participate and 65% of them attended three Reiki training sessions. They reported that Reiki had benefited their child by improving their comfort (76%), providing relaxation (88%) and pain relief (41%). All caregivers thought that becoming an active participant in their child’s care was a major gain. The authors of this investigation conclude that “a hospital-based Reiki training program for caregivers of hospitalized pediatric patients is feasible and can positively impact patients and their families. More rigorous research regarding the benefits of Reiki in the pediatric population is needed.

Trials like this one abound in the parallel world of “energy” medicine. In my view, such investigations do untold damage: they convince uncritical thinkers that “energy” healing is a rational and effective approach – so much so that even the military is beginning to use it.

The flaws in trials as the one above are too obvious to mention. Like most studies in this area, this new investigation proves nothing except the fact that poor quality research will mislead those who believe in its findings.

Some might say, so what? If a patient experiences benefit from a bogus yet harmless therapy, why not? I would strongly disagree with this increasingly popular view. Reiki and similarly bizarre forms of “energy” healing are well capable of causing harm.

Some fanatics might use these placebo-treatments as a true alternative to effective therapies. This would mean that the condition at hand remains untreated which, in a worst case scenario, might even lead to the death of patients. More important, in my view, is an entirely different risk: making people believe in mystic “energies” undermines rationality in a much more general sense. If this happens, the harm to society would be incalculable and extends far beyond health care.

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.

TYPES OF HOMEOPATHY

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.

CURRENT TYPES OF HOMEOPATHS

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.

WOULD HAHNEMANN APPROVE?

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.

CONCLUSION

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.

The most common pronouncement regarding alternative medicine that I have heard over the years from consumers, health care professionals or decision makers with a liking of alternative medicine goes as follows: “I don’t care how it works, as long as it helps.”

At first glance, this argument seems reasonable, logic and correct; it would be foolish, perhaps even unethical, to reject an effective treatment simply because we fail to understand how its effectiveness comes about – this would not be pragmatic and it is not what we do in medicine: aspirin, for instance, was used and helped many patients long before we understood how it worked. However, once we consider the way this notion is regularly used to defend the use of unproven therapies, we see that, in this context, it is fallacious – in fact, if we dissect it carefully, we find that it  crams three large fallacies in one tiny sentence.

The first thing we notice is that the argument combines two fundamentally different issues which really should be separate  1) the mechanism of action of a therapy and 2) its clinical effectiveness. The matter gets clearer, if we discuss it not in the abstract, but in relation to a concrete example: BACH FLOWER REMEDIES (BFRs). I could have selected many other alternative therapies but BFRs seem fine, particularly as they have so far received no mention on this blog.

Similar to homeopathic preparations, BFRs are so dilute that they do not contain any active ingredients to speak of (they differ from homeopathic preparations, however, in that they do not follow the ‘like cures like’ principle). Several clinical trials of BFRs have been published; collectively, their results show very clearly that the clinical effects of BFRs do not differ from those of placebo. (This does not stop manufacturers selling and consumers buying them; in fact, BFRs are a thriving business.)

The principles backing up BFRs are scientifically implausible, and even BFR-practitioners would probably admit that they have no scientifically defensible idea how their remedies work. Scientists might add that a mechanism of action of such highly dilute remedies is not just unknown but unknowable; there is no way to explain how they work without re-writing several laws of nature.

The overall situation is thus quite clear: BFRs are not effective and there is no plausible mechanism of action.Yet it is hard to deny that many patients feel better after having consulted a BFR-practitioner (or after self-medicating BFRs), and those satisfied customers often insist: “I don’t care how BFRs work, as long as they help me.”

As previously discussed, symptoms can improve for a range of reasons which are related to any specific therapeutic effect: the natural history of the condition, regression towards the mean, placebo-effects etc. Only rigorously controlled trials can tell us whether the therapy or other factors caused the clinical outcome; our perception alone cannot identify cause and effect.

The fact that thousands of patients swear by BFRs, does therefore not constitute proof for their efficacy. The explanation of the apparently different impressions from experience and the results of clinical trials is therefore simple: the empathetic encounter with a therapist and/or a placebo-effect and/or the natural history of the condition are perceived as helpful, while the BFRs are pure placebos.

Back to the notion “I don’t care how this therapy works, as long as it helps” – it turns out to be based on at least three misunderstandings all tightly woven together.

Firstly, it was not the treatment itself that helped, but something else (see above). To imply that the treatment worked is therefore a fallacy.

Secondly, the reference to an unknown mechanism of action is aimed at misleading the opponent: it distracts  from the first fallacy (“the treatment is effective”) by super-imposing a second fallacy (that there might be a mechanism of action). Crucially it attempts to wrong-foot the opponent by implying: “you reject something useful simply because you cannot explain it; this is poor logic and even worse ethics – shame on you!”.

BFR-enthusiasts are bound to see all this quite differently. They will probably claim that a placebo-effect is also a plausible mechanism. “Surely” they might say “this means that BFRs are useful and should be widely employed”.

In proclaiming this, they turn the double-fallacy into a triple fallacy. What they forget is that we do not need a placebo to generate placebo-effects. An effective treatment administered with time, compassion and empathy will, of course, also generate a placebo-effect – what is more, it would generate a specific therapeutic effect on top of it. Thus the BFR are quite useless in comparison. There is rarely a good justification for using placebos in clinical routine.

In conclusion, the often-used and seemingly reasonable sentence “I don’t care how it works, as long as it is helpful  turns out to be a package of fallacies when used to support the use of unproven treatments.

On the last day of the year, is time to contemplate the achievements and failures of the past 12 months and think about the future. For me, it is also the moment to once again place my tongue in my cheek, empathise with my opponents and think of what they might hope for in the coming year.

Here is a brief yet somewhat ambitious expose of what I came up with: the charlatan’s wish list for 2013.

1 Let the Daily Mail and similar publications continue to promote uncritical thinking and bogus claims for alternative medicine.

2 Make sure that politicians remain blissfully ignorant of all matters related to science.

3 Let the anecdote continue to reign over evidence, for instance, in the popular press.

4 Regulate alternative practitioners such that they benefit from the added status without any obligation to abide by the generally accepted rules of evidence-based practice.

5 Prevent the closure of more homeopathic hospitals.

6 Ensure that the public continues to be mislead about nonsensical scams such as “integrated medicine”.

7 Increase the influence of Prince Charles in the realm of health care.

8 Give Royal status to the ‘College of Medicine’.

9 Appoint Dr Michael Dixon, chair of the ‘NHS-Alliance’ and the above-named “college”, as advisor to the government.

10 Introduce more post-modern thinking into health care; after all, there is more than one way of knowing!

11 Defame all those terrible sceptics who always doubt our claims.

12 Cherish double standards in medicine; they are essential for our survival!

13 Make sure researchers of alternative medicine use science not for testing but for proving the value of alternative therapies.

14 Continue to allow promotion of alternative medicine to masquerade as research.

15 Ensure that all our celebrity clients tell every journalist how young they look thanks to alternative medicine.

16 Let ‘Duchy’s Original detox Tincture’ become a financial success – Charles needs the added income for promoting quackery.

17 Open more woo-institutes in academia to spread the gospel of belief-based medicine.

18 Prevent anyone from finding out that many of us break even the most fundamental rules of medical ethics in our daily practice.

I am aware that the list is probably not nearly complete, and I invite everyone to add items of importance. Happy New Year!

 

 

Let me briefly pick up the issue about ad hominem attacks mentioned at the end of my last post.

One of the most striking feature of the debates about alternative medicine is, in my experience, the fact that, whenever the defenders of the indefensible ran out of rational arguments, personal attacks are rarely far. Personal or ad hominem attacks are fallacious arguments directly directed at a named individual which serve as substitutes for that individual’s arguments. In football terminology, they play the player instead of the ball.

After many years of being at the receiving end of this phenomenon, I have grown to be amused by it, not just amused, I have slowly started to appreciate it. Strange? Let me explain.

Initially, I have to admit, I was annoyed, sometimes livid when someone hurled a personal attack in my direction. At one stage, I even investigated whether my university did not have the obligation to legally protect me in such situations. Predictably, the answer was negative.

Later I considered on one or two occasions taking legal action myself. However, after just a minimum of reflection, I dismissed the idea: it is bad enough that the British Chiropractic Association sued my friend and co-author Simon Singh for libel, but under no circumstances did I want to display a similarly deplorable behaviour.

Eventually, I realised that an ad hominem attack often is an important signal indicating that the attacker is wrong, very wrong indeed. It is nothing else than an open admission by “the other side” that they have no more reasonable arguments, that they are resorting to unreasonable notions, and that they have lost not just the plot but also the debate. In other words, being personally attacked in this way is a compliment and an unfailing sign of victory – and, if that is so, we should be proud of every single ad hominem attack we get after a well-reasoned debate.

Even on this relatively young blog, we have already seen signs of such victories; most notably a chiropractor recently conceded defeat after a perfectly reasonable debate on the safety of spinal manipulation by stating that “Ernst is an infamous medical demagogue who speaks nonsense“. Yet this little outburst of chiropractic self-humiliation is nothing compared to plethora of similar statements elsewhere on the internet. The following list is the result of just ~10 minutes of searching; I took the liberty of copying a short quote from each site but enthusiasts will find much more revealing stuff, I’m sure.

http://harald-walach.de/2012/12/18/mausetot-durch-homoeopathie-edzard-ernst-und-der-grosse-killer-nix/

“…whether he [Ernst] has only written or also read them [the reviews he has published], is a matter of dispute between experts…”

http://www.truthwillout.co.uk/2010/03/the-trials-of-edzard-ernst/

“…he’s really just another dull academic who knows nothing about it.   The fact that someone decided he could have a title that makes it sound like he’s knowledgable [sic] is irrelevant, he remains a nobody in the field of complementary therapy, his own university don’t even seem to like him, just about everything he says is negative and no ordinary member of the public I’ve ever mentioned him to has heard of him at all, so although he’s beloved by a few hacks and a small platoon of cynics, the rest of the world could not give a toss.”

http://avilian.co.uk/2012/02/edzard-ernst-exposed-as-a-fraud-and-a-liar/

“Edzard Ernst Exposed as a Fraud and a Liar”

http://www.naturalmatters.net/news-view.asp?news=4136

“Edzard Ernst, Britains self proclaimed “first Professor of Complementary Medicine” is finding himself with a lack of funding and his unit is facing closure.

He is blaming his clash with Prince Charles, but why Professor Ernst thinks anyone wants to fund someone who claims to be a professor of CAM, yet spends all his time debunking CAM we will never know. Its a rather strange scenario we feel!”

http://www.homeopathytoday.org/tag/edzard-ernst/

“From time to time you may see news reports about “an expert” named Edzard Ernst who regularly offers commentary about the value of homeopathic medicine. Ignore any such references he makes on the subject. He has never received even an introductory education on the subject of homeopathy”

http://www.chiropracticlive.com/why-should-anyone-believe-what-professor-edzard-ernst-says-after-he-put-his-name-to-a-bbc-programme-he-now-describes-as-deception/

“Why should anyone believe what Professor Edzard Ernst says, after he put his name to a BBC programme, he now describes as “deception”.”

http://johnbenneth.wordpress.com/2010/11/28/i-challenge-edzard-ernst-and-the-evil-empire-at-exeter/

“EDZARD ERNST and the Evil Empire at Exeter”

http://theunhivedmind.com/wordpress2/?p=816

“Edzard Ernst, is not a credible source of information about the effectiveness of homeopathy”

http://community.wddty.com/blogs/adverse_reactions/archive/2007/10/05/Herbicide.aspx

“Prof Edzard Ernst (family motto: ‘I have not come to praise alternative medicine, I have come to bury it’) who has hardly said a good word for alternative medicine in all the years he has held the recently-created Complementary Medicine chair at Exter [sic]University. ”

http://campaignfortruth.com/Eclub/120107/CTM%20-%20confusedaboutalternativemedicine.htm

“the pharma-friendly gold standard that Ernst and his colleagues seem to worship”

http://www.chiropractorsforfairjournalism.info/The_Medical_GoodFellas.html

Edzard Ernst of the Medical School at the University of Exeter wrote his infamous 2010 study from England, “Deaths After Chiropractic: A Review Of Published Cases,” that once again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles

It is hard to deny that these statements are amusing. But by far my favourite personal attacker is a German chap called Claus Fritzsche. He runs a website which, at one stage, seemed almost entirely dedicated to telling lies about me; and, what is best of all, he even took money for these efforts from several homeopathic manufacturers. Surely, apart from perhaps the Nobel Prize, this must be the nicest recognition, the sweetest feast of victory and greatest compliment any scientist might ever wish for.

So, ad hominem attackers of all ages, types, nationalities and persuasions, please keep them coming. I am unlikely to sue for libel; on the contrary, I will celebrate them for what they truly are: they are compliments for me, victories for reason and admissions of defeat for you.

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