Every time I think I can take a break from homeopathy, something pulls me back to the topic. Today it’s an unbelievably poorly reasoned defense of homeopathy, in, of all places, the British Medical Journal. Glasgow-based general practitioner Des Spence writes,
It was an intentional overdose. To prove a point I poured about 30 tiny tablets into my mouth and crunched them down. Because scientifically, I do not believe that these homeopathic pills have any active ingredient.
Today, homeopathy is medicine’s whipping boy, repeatedly and systematically beaten to the ground. Yet despite explaining that the tablets are just placebos, homeopathy always gets up to take another beating. Some homeopathy is funded by the NHS, through general practice, and in the few homeopathic hospitals. This fact enrages the growling commissars of evidenced based medicine who want homeopathy purged from the NHS.
“Growling commissars of evidenced based medicine”? Perhaps he’s referring to health professionals (like me) that believe that health interventions and treatments should be evaluated based on a single, scientific standard. And that publicly-funded health systems, like the National Health Service (NHS), should fund what works. Treatments that are not medicine, but are are vitalistic belief systems without evidence of efficacy, don’t make the cut. Homeopathy was invented in the 1800’s and rejects established facts about biochemistry, physics, and pharmacology. If homeopathy works, then medicine as we practice it, could not work. Spence’s comment implies acceptance of one of the triumphs of homeopathy and alternative medicine marketing, that demanding all interventions should meet the same safety and efficacy standards is inappropriate.
So does homeopathy work? This depends what you measure. Does it cure infection, degenerative conditions, and cancer? It most certainly does not. And if any such claims are made they must be vigorously denounced. But homeopathy is most commonly used for medically unexplained symptoms in patients dismissed as neurotic; the so called “worried well.” These patients have passed from specialist to specialist, enduring repeated invasive and needless negative investigations. Or homeopathy is used in addition to, but not instead of, conventional treatments.
To which I would add: [citation required] Any search for “homeopathic vaccinations” should clear up any uncertainty about what homeopathy’s promoters believe homeopathy can treat. This 2010 BBC documentary found homeopathic vaccinations being offered in Scotland. Or you can look at the hundreds of cases of harm documented at “What’s the harm” where homeopathy was substituted for real medical advice. Even if only a fraction of homeopathy is being used to treat serious medical conditions to the exclusion of real medicine, the consequences can be catastrophic. Granting legitimacy to the use of sugar pills for any condition gives an unwarranted and dangerous imprimatur of credibility to the overall practice.
The homeopathic doctors I know are caring people, disillusioned with the crudeness of conventional medicine, not your typical aggressive alpha medical type. They are not in the pay of big pharma, whose drugs potentially kill 100 000 people a year in the United States alone.1 They listen, spend time, and offer some explanation for the unexplainable—and their patients like them. The effect of homeopathy is the positive effect of a therapeutic relationship that is reassuring, accepting, and supportive. Society should never underestimate the healing effect of a kind word or the value of a holistic approach. These consultations genuinely improve wellbeing. Homeopathic pills are placebos, but the placebo response is great, maybe even as high as 80%.
Here is where Spence really starts building a giant straw man. Homeopaths are “caring”. Conventional medicine, on the other hand is “crude”? I’ll tell that to my patients alive because of organ transplants and immunosupressant drugs. Or the patients with HIV who are alive today and watched their friends die before effective medications were developed. Or the children cured of acute lymphoblastic leukemia with chemotherapy. Medicine has its risks and benefits, but it delivers the goods. In comparison, I’m curious why homeopathy isn’t considered “crude” when actual remedies include such absurdities as “Stonehenge”, “Berlin Wall”, “Air Cabin Pollution”, and “Photocopying Powder”. There isn’t a single reproducible example of homeopathy effectively treating anything, ever. How could it? The treatments are inert.
Spence also believes us to all be in the pay of Big Pharma, giving out drugs that kills. That a medical doctor is making this statement is unbelievable. Again I’ll add, [citation required]. 100,000 killed per year? Spence offers the infamous Death by Medicine gambit to further poison the well of conventional medicine. Not only are health professionals on the take, we’re killing our patients, too! Dr. Spence must not treat any of his patients with anticoagulant medications like warfarin. After all, anticoagulants probably kill more people than any other drug, owing to bleeding risk. So why do we use them? Because millions get deep vein thrombosis, and hundreds of thousands die from blood clots. Warfarin can prevent this, but it can cause fatal bleeding, too. Drug use decision-making involves a consideration of risk and benefits of treatments. Listing the harms, like deaths from medicine, without also quantifying the benefits leads to ridiculous statements – like the one Spence makes here.
Spence paints a picture of homeopathy being some sort of benign practice free of corporate interests. The facts say otherwise. Boiron, one of the largest homeopathy manufacturers sells €523M (2011) worth of magic beans per year. Natural products manufacturers are multi-million dollar businesses, with $2.5 billion in revenue concentrated just in the top seven companies. And we can argue about the quality of Pharma’s research, but they’re spending 15-20% of revenue on R&D, while homeopathy manufacturers can barely achieve a tenth of that.
Finally, Spence refers to the placebo effect. Unfortunately, while placebos may offer subjective improvements, systematic reviews show that placebo interventions offer no clinically significant benefits. Even if we accept subjective reports of improvement as desirable, how do we achieve them with homeopathy? Spence says the homeopath “offer some explanation for the unexplainable”. Here we come to the crux of homeopathy. In order for homeopathy to have offer any placebo effect at all, patients must be deceived of the scientific facts that homeopathy has no medicinal effects. This is a highly paternalistic position for any health professional to take – in a era of shared decision-making, withholding relevant information from a patient is not only unethical, it’s dishonest. Further, ethicist Dr. Chris Macdonald has commented that health professionals have an ethical obligation to not just be honest with customers about homeopathy, but to be candid about it. It’s not ethically acceptable to offer homeopathy without disclosing information about its lack of effects. And without that disclosure, we should not expect any placebo effects.
There is no hard evidence for homeopathy. But likewise the more you understand of research evidence the more you understand it is mere modern marketing quackery. There may be some dangerous homeopathic charlatans, but there are plenty in mainstream medicine too. We need to accept that patients will still use homeopathy, and having access to it through the NHS means it is regulated and safe. As for the cost to the NHS, this is roughly the same as a single week of antidepressants,2 3 medications that are little better than placebo.4 Modern medicine has real capacity to do harm but often minimal good; homeopathy has minimal capacity to do harm but real capacity to do good. Homeopathy is an easy target; we would be better to focus on the failings of conventional medicine. Homeopathy is bad science but good medicine.
Here Dr. Spence appears to give up completely on real medicine, describing research evidence as “marketing quackery”. Again, [citation required]. I gather Spence is including research from bodies like the National Institutes of Health, the biggest research funder in the world. And while it’s true that there are problems in medical research, particularly with the conduct and reporting pharmaceutical-industry sponsored trials, characterizing all research, even Pharma research, as “quackery” is demonstrably false. In contrast, there’s no research at all to suggest homeopathy has any medicinal effects, it seems Spence prefers nothing to something – and the NHS should fund it. As I noted above, considering homeopathy from an ethical perspective illustrates that any use at all results in disutility, wasting finite health care dollars, and redirecting patients away from valid treatments. So there is little if any capacity for it to “do good.” Spence sums up with a tu quoque argument, essentially saying that “hey, modern medicine is bad, so we shouldn’t be concerned if there’s a little bit of deception about sugar pills.”
Spence concludes that homeopathy is “good medicine”. Given the deception inherent to homeopathy, that’s a curious conclusion to make. The only way to improve medicine and patient care, which I do believe Dr. Spence wants to do, is to scrutinize what we do, offer what works, and fix what’s wrong. Adding fake treatments into the mix won’t improve the practice of medicine. No matter how you spin it, homeopathy is incompatible with a science-based practice standard. Using homeopathy in a health system cannot be ethically justified – so health professionals should strongly advocate advocate against the allocation of limited health resources to these treatments. We owe our patients the ethical responsibility to tell them that homeopathy is no alternative to real medicine.