QED Tickets: On Sale Now!

In a recent Pulse magazine article professor of complementary medicine Edzard Ernst praised the founder of homeopathy, Samuel Hahnemann.

“In my view, Samuel Hahnemann, the German doctor who invented homeopathy about 200 years ago, is a man who should be celebrated.”

Can this be true? Surely one of the most respected proponents of evidence based medicine cannot be advocating homeopathy as a treatment.

In his article he cites the hammering homeopathy has received over the last year including the House of Commons select committee’s damning report, the BMA describing homeopathy as “witchcraft”, and my particular favourite – comedians taking the “homeopathic mickey” (sadly 10.23′s not insignificant role doesn’t get a mention).

Fortunately normal service resumes further in the article – to quote Prof Ernst:

“His primary achievement is not to have developed homeopathy. His true achievement is that, in the course of doing this, he has shown us how important non-specific effects – often also called the ‘art’ of medicine – are in terms of getting patients better. To put it bluntly, Hahnemann has taught us that patients can improve even when we give them nothing but placebos.”

This somewhat conciliatory line is admirable, but I think also provides the crack which has allowed homeopathy to be practiced for so many years as an NHS treatment. Most doctors either haven’t been aware of the implausibility of homeopathy, or have been happy for other practitioners to provide placebos to patients, in the knowledge that there is some perceived benefit. Homeopathy is often given for intractable problems, where EBM doesn’t always provide sufficient benefit. As Prof Ernst says, the act of being empathic and providing sufficient time is often enough to make the patient feel better.

I agree with the professor on the benefits of offering empathy and time, but I don’t believe this is the entirety of what homeopathy offers. Firstly it requires a degree of dishonesty on the part of the clinician who either is consciously giving a placebo treatment, or is deluding himself that there is efficacy in the homeopathic treatment. There is also a degree of collusion between practitioner and patient, where both may be aware of the lie, but have to go through the ritual, in order for the placebo effect to work. This ritual extends to the ridiculous dilution and succussion process.

The degree of self delusion is apparent in the responses to Prof Ernst’s post. One homeopath writes:

“a medical system that has spread to all continents of the world through little more than word of mouth- ie the recommendation of satisfied patients- to the point where it is now the second most widely used medical system in the world’ I think these … qualifications speak for themselves for it is a ludicrous supposition that homoeopathy could have gained such widespread approval on the strength of nothing more than the placebo effect.”

No need for evidence here then, just lay on the self delusion with a trowel. Further on he states:

“I believe it is part of the code of ethics of doctors in this country that they do not publicly decry fellow professionals. The fact that some junior members of the BMA broke their own code in order to criticise fellow doctors who have undergone full professional training then undertaken further training in order to become members of the Faculty of Homoeopaths should be deplored and is certainly evidence of a lowering of professional standards.”

This last point is especially sad, as the junior doctors were not criticising specific homeopathic doctors, but the entire implausible tenet that they depend on.

Hats off then to Hahnemann for helping to expose the placebo effect, which through double blinded placebo controlled trials can be dialled out of the equation. The short term gains achieved by being dishonest with patients cannot be helpful in the long run. Despite time constraints, I would hope that doctors would always provide empathy and sufficient time required to deal with their patients. Providing an explanation of their condition, and being honest about what can (or cannot) be done to help them is much more laudable, empowering and ultimately more beneficial.

The other day, I read Marsh’s latest post ‘Real Medicine: I Wonder’ with interest – as (hopefully!) one of the “good doctors” he wrote of, I would like to report all is well within the NHS. Unfortunately I can’t. Virtually all the comments on his piece were positive about the use of conventional medicine, but an important point was raised regarding the care of osteoarthritic hip pain. Currently the options for “wear and tear” arthritis are very limited, the options being:

1. do nothing
2. take painkillers
3. hip replacement surgery.

The only definitive treatment is option 3, which for most patients is a life changing procedure. Unfortunately it has a limited lifespan, and in general is only offered to more severely affected patients. As this condition can start in the 50’s or younger, we have the difficult task of informing people that they will have to put up with the pain for many years before surgery will be considered. The problem with evidence based medicine (EBM) is that it leaves lots of gaps, which CAM (complementary and alternative medicine) is more than happy to fill.

On a daily basis, we have to inform patients that their self limiting viral illness/gastroenteritis etc. will not respond to antibiotics. It is so easy to skip the explanation and just dish out the pills, but with the advent of MRSA and other drug resistant nasties, the finger is pointing more and more at “irresponsible GP’s” and their over-prescribing of antibiotics as the cause of this new epidemic. How tempting it would therefore be to prescribe a harmless placebo that might make people feel better, psychologically if not physically. There is however, something inherently dishonest about this approach that would prevent me and most of my colleagues from doing so.

However, a small – but noisy – bunch of GPs DO seem to have followed this route, and regularly post articles and comments in GP magazines. Here are a few quotes (s0urces available on request):

“I have studied homeopathy, scientifically, not in a non-touchy feely way, and have found it to be extremely helpful in areas of medicine where conventional alternatives have not helped. As a GP, I have found homeopathy on occasion to work exceptionally well, and if it does no harm, then why not try it?”

And:

“I couldn’t explain it then and I can’t explain it now. Those who dismiss homeopathy because it does not fit their world view do themselves a disservice, by not attempting to listen to homeopaths or read what they write, unless it is to seek out reasons to toss a few more metaphorical rocks.”

A particular vociferous voice is Andrew Sikorski, a Sussex-based GP and member of the executive council of the Faculty of Homeopaths. He regularly hounds Edzard Ernst and the blogs of Pulse magazine, quoting latin phrases in an impressively self-deluded manner. For example:

“The best EBM would be studying N=1 trials with the particular patient to see what suits their needs best and provides an optimum outcome. Rarely does my patient match the inclusion criteria of a single study, let alone amalgamated studies included in met-analyses. Yet I am heartened by the research which suggests there is an inbuilt healing system within us all and judiciously following Hippocrates’ dictat ‘primo (primum) non nocere’” – Source: Pulse 03/12/09

In other words, in his view, randomised blinded placebo controlled trials are of less value than individual anecdotal evidence. Hippocrates did indeed require that practitioners “first do no harm”, and in his day doing nothing was significantly less harmful than the black magic that was offered at the time. In fact Hippocrates dispelled a lot of the mysticism that dominated health care at the time, and I have no doubt that had he lived today, he would advocate modern evidence based medicine.

There is currently something of a battle going on at government level, fuelled by HRH’s “Foundation for Integrated Health”. Homeopathy has been part of the NHS for many years, with 5 Homeopathy hospitals nationwide, including one in Liverpool. These cost the NHS several million pounds a year to run, and are so established that it is hard to see how they will ever be closed down. The National Institute for Clinical Excellence uses the latest evidence to advocate EBM, and yet we are undermined by the government who are now proposing a “Personal health budget scheme” where patients can choose how NHS money is spent on them, including homeopathy, acupuncture and other alternative treatments. Indeed recent NICE guidelines (normally the bastion of EBM) for back pain are particularly worrying, as the working group included acupuncturists and chiropractors, but no pain management specialists. Not unsurprisingly the guidelines include these alternative therapies.

What’s the harm in CAM? Consider the death in 2000 of a 6 month old baby, whose parents refused conventional medicine in favour of alternative therapies. A leading homeopath was quoted by the BBC:

“Increasingly, with the rise in popularity of complementary medicine these situations are going to arise. Also there is considerable scepticism about some of the aspects of conventional medicine.”

I couldn’t have put it better myself.

As far as the cost is concerned, it was estimated in 2007 that the money spent on homeopathy by the NHS could have saved 600 lives by the prescribing of Herceptin to more breast cancer patients. (Source: Baum, M., et al)

The fact that Prince Charles meets the health secretary on a regular basis, and in the light of the same health secretary’s recent performance in the parliamentary select committee on homeopathy, it would suggest that CAM has more than just a foot in the door. In my view, the Merseyside Skeptics new 10.23 campaign could not have come at a better time. The more public awareness of what is being done in their name (and with their money) the better.

Dr. Selva Rasaiah
10:23

*Update: After feedback, a couple of the facts here have been happily amended to come more into line with current medical procedure*