Defender of Science-Based Medicine Sued

When you first started seeking the facts about “alternative” medicine, where did you turn? For me, it was Quackwatch. Before there were blogs or podcasts, there was Quackwatch. It’s been around since 1996, which is prehistoric by internet standards. Quackwatch is an enormous site: if there’s a dubious health intervention, there’s a pretty good chance that Quackwatch has a page about it. I’ve linked to it repeatedly on this blog, as I consider it to be a credible source of information.

Unfortunately, taking an evidence-based approach to medicine, and putting that evidence in the public eye, puts you at all kinds of risks. From personal smears, to unfounded allegations of conflicts of interest, to legal threats, advocates for pseudoscience do whatever they can when they cannot refute the facts. And that’s what’s happening to the founder of Quackwatch: Dr. Stephen Barrett is being sued by a laboratory called Doctor’s Data. Continue reading

Homeopathy and Consumer Protection

Editor’s Note: It’s World Homeopathy Awareness Week.

Today’s guest post is from Dr. Chris MacDonald, PhD. Dr. MacDonald is Associate Professor, Department of Philosophy, Saint Mary’s University, and a Nonresident Senior Fellow at Duke University’s Kenan Institute for Ethics. Dr. MacDonald blogs at the Business Ethics Blog.

What should we think about homeopathy, from the point of view of Business Ethics? We can begin by asking the same questions about homeopathy as we would ask about any other product. Those questions fall under two main headings:

  1. Is it generally ethically OK to sell this product? Is it a product that should be on the market at all?
  2. If it’s generally ok to sell this product, what are the obligations of companies selling them? Are there any ethical limits on how or to whom they are marketed?

In a free society, there’s a general presumption in favour of free commerce. If Party A has a product and says to Party B, “Hey, you might like this,” and if Party B says, “Hey, I think I’d like some of that, here’s some money!” then they should generally be free to make the transaction. But there are limits. Some things cannot ethically be bought or sold (children or votes, for example). Other things can be sold, but only under special circumstances (cigarettes and alcohol, for example). And more generally, there is a very broad requirement that all transactions must be carried out without force, fraud, or deception.

Now, discussions over alternative therapies like homeopathy tend to be combative, rather than constructive, particularly on the Internet. That’s unfortunate, because a lot is at stake. Finding ways to have a constructive discussion is essential, but few make that effort. But there is common ground in the debate, and we should make good use of it. Both sides of the debate agree, for example — indeed they ethically have to agree — on the importance of consumer protection, though they may disagree on the right way of achieving it. Health is complex, and important, and the average consumer typically needs to be able to turn to experts to get good advice. There are plenty of unscrupulous individuals and companies out there willing to try to make a fast buck by preying on the gullible or the uninformed. Anyone who truly cares about health has to recognize that that’s a serious problem.

So, let’s look at homeopathy through the lens of consumer protection. Most generally, consumer protection means, first, making sure that products are safe (or “safe enough”, since almost all products carry at least some risk), and, secondly, making sure that products do what the manufacturer or seller says they’ll do.

Although I happen believe that homeopathy (like most other alternative therapies) does not in fact work, I want to have a constructive discussion about consumer protection with those who think it does. So I’m going to assume, for the sake of argument, two things that many skeptics are likely to deny.

  1. First, I’m going to assume that homeopaths (and supporters) genuinely believe in the power of homeopathy. That is, I’m going to assume that most homeopaths are not outright frauds. (Actually, that’s not just for the sake of argument. I strongly believe that to be a justified assumption. I strongly suspect that the vast majority of homeopaths and homeopathic pharmacies are 100% well-intentioned, and seek only to promote the health of their patients and customers.)
  2. Secondly, I’m even going to assume — again for the sake of constructive argument — that homeopathy works. I’ll assume that the anecdotes of homeopaths and their patients confirms the positive effects that Randomized Controlled Trials have thus far been unable to detect.

Next, given these assumptions, I’m going to pose two questions for homeopaths to answer, questions that I would likewise pose to any other kind of reputable business, especially any other reputable business in the field of health.

  1. How do we detect phoney homeopathic preparations? In order to protect consumers, we need to be able to detect fake remedies — fake versions (sold by counterfeiters) that are really just inert look-alike copies of genuine remedies. In an age of international trade and Internet-based pharmacies, phoney pills are a big problem. So, is there any way to test a homeopathic preparation to verify that it is genuine? If I buy homeopathic tablets, is there any test that can be done to see if they’re real or counterfeit? If authorities suspect a criminal organization of selling fake homeopathic tablets, how can they tell the difference between the criminal organization’s tablets and those manufactured by an honest homeopathic pharmacy?
  2. What advice would you give a potential patient/customer who is trying to choose among various alternative therapies? How should a potential customer/patient choose between homeopathy, Therapeutic Touch, acupuncture, Angel Therapy, and so on? In other words, how can consumers know that they’re about to buy something good, rather than something bogus? “Trust me” won’t do as an answer. Trust, in itself, is neither a good nor a bad thing; what we value is justified trust. What is it that justifies consumers in trusting you, rather than someone else? “Try it” also isn’t a good answer. When health is on the line, we shouldn’t have to experiment on ourselves. We should have some assurance ahead of time. Consumers deserve that. One alternative, of course, is to deny that this is an important question at all, by claiming that literally all alternative therapies work. But that would make little sense. There surely are fraudsters out there, offering stuff they know can’t work. And even ignoring outright fraud, the homeopathic philosophy claims to have identified the true nature of disease; other philosophies, it seems then, must have it wrong. Which ones? Consumers deserve your input on this important issue.

These are questions I expect any reputable business to be able to answer. They are also questions to which I have not yet heard homeopaths give good answers. (In fact, I asked a version of the 2nd question on my blog, with depressing results.) I’m honestly interested to hear any an answer.

In the end, what I’m really looking for here are reasonably generalizable standards of consumer protection across various categories of health products. What standard of evidence and safety should be applied to products offered for sale, quite generally? If homeopathic preparations are not expected to stand up to the rigours of Randomized Controlled Trials, why, in all fairness, should the products of the major pharmaceutical companies be forced to meet that standard? Surely Merck and GlaxoSmithKline would love to avoid having to jump through those hoops. Surely Big Pharma would love to be able to give vague answers to my questions above. But we don’t let them. And we’re right not to let them. The question is, can the Homeopathic industry demonstrate its commitment to ethics by giving clear answers, too?

Singh vs. the BCA: A Libel Reform Update

I’ve blogged in the past about the case of Simon Singh who has been sued by the British Chiropractic Association (BCA) for making the following statement:

The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

Rather than refute Simon’s comments with evidence to substantiate their claims, the BCA decided to sue. When organizations seek to supress debate and discussion about science by using legal means, it causes “libel chill”, where speech is suppressed by fear of legal action. Singh’s case is the impetus to a campaign for libel reform in the United Kingdom, where libel laws are horrendous, putting the onus and the costs solely on the defendant. An initial ruling went against Singh, and he appealed. Yesterday’s ruling was in his favour, and will allow Singh to use a “fair comment” defence in his arguments.

What was very encouraging for Singh, and for all who comment on the legitimacy and credibility of scientific matters, was the following comment from the Court:

’34. We would respectfully adopt what Judge Easterbrook, now Chief Judge of the US Seventh Circuit Court of Appeals, said in a libel action over a scientific controversy, Underwager v Salter 22 Fed. 3d 730 (1994):

“[Plaintiffs] cannot, by simply filing suit and crying ‘character assassination!’, silence those who hold divergent views, no matter how adverse those views may be to plaintiffs’ interests. Scientific controversies must be settled by the methods of science rather than by the methods of litigation. … More papers, more discussion, better data, and more satisfactory models – not larger awards of damages – mark the path towards superior understanding of the world around us.”‘

You might be asking – What does this case have to do with Science-Based Pharmacy? Quite a bit. It’s essential for health professionals to have the freedom to comment openly about the scientific evidence supporting any drug, treatment or health intervention. Criticizing data (or the lack of data) is fair comment.  Data and evidence should determine which treatments are deemed credible – not legal threats to silence critics.

It’s too early to declare victory, as Singh points out himself  in today’s Guardian column. The BCA could still appeal. But this entire saga has been such a public relations disaster for chiropractors worldwide. As press coverage has grown, so has the scientific and mainstream scrutiny of chiropractic. And it hasn’t been positive.

The battle for free speech and fair comment continues. Sign the petition at www.libelreform.org.

For more comment and discussion on yesterday’s ruling: Kim at Skeptic North; Orac at Respectful Insolence; Jack of Kent.

British MPs Tell Gov’t: Stop Funding Homeopathy

In a clear statement on the absurdity of public funding and regulation of homeopathy, British MPs instructed government to stop paying for homeopathy, shut down homeopathic hospitals, cease all homeopathy clinical trials, and to crack down on homeopathic efficacy claims.

Committee chairman Phil Willis MP said; “We were seeking to determine whether the Government’s policies on homeopathy are evidence based on current evidence. They are not.”

Homeopathy doesn’t work. It can’t work. If it did, physics, biochemistry and pharmacology as pharmacists know it would be false. Yet this elaborate placebo system persists, supported in part by the pharmacy profession, which seems comfortable selling products with no active ingredients and no evidence of efficacy.

I have blogged previously about the British inquiry into homeopathy, the public relations disaster for Boots the Chemist (selling their own store brand of homeopathy), and the effectiveness of the “10-23” protesters, who staged a mass homeopathic overdose, where, not surprisingly, nothing untoward happened to anyone.

The final report from the British inquiry has been released. It scrutinized government policies on homeopathy, and gives direction to the National Health Service.  But the recommendations apply to any country (like Canada) that legitimizes homeopathy. Continue reading

Pharmacies Targeted in Mass Homeopathy Overdose

Hundreds of protesters will gather outside Boots pharmacies on January 30 to swallow entire bottles of  homeopathic remedies and embarrass a profession that sells them in the absence of any evidence of efficacy.

A few weeks ago, I blogged about the 10:23 protest which was gathering momentum in the United Kingdom. Recall that in late 2009, a senior executive from Alliance Boots, a UK pharmacy chain, admitted that there is no clinical evidence to support homeopathic products, yet Boots sells these products strictly because of consumer demand.

Homeopathy is an elaborate placebo system of “remedies” with no active ingredients.  Based on the absurd notion of “like cures like”, proponents of homeopathy believe that any substance can be an effective remedy if it’s diluted enough: raccoon fur, the sunlight reflecting off Saturn, even pieces of the Berlin Wall are all part of the homeopathic pharmacopeia.  And when I say dilute, I mean dilute. The 30C “potency” is common – it’s a ratio of 10-60.  You would have to give two billion doses per second, to six billion people, for 4 billion years, to deliver a single molecule of the original material. That’s dilute. Continue reading

Libel Reform: Canada vs. the U.K.

Libel chill is an huge concern for advocates of science-based pharmacy and science-based medicine.  It is critically important that there be an open and public debate about the science and evidence informing personal decisions about our health, as well as decisions affecting how we direct resources in our health care system. Unfortunately, some groups seeks to quash debate, rather than engaging in a discussion of evidence. Without the freedom to make open, critical comments about science and the scientific process, we give free reign to those that promote pseudoscience or seek to subvert the scientific process.

As I’ve previously blogged, Simon Singh is currently being sued by the British Chiropractic Association for libel. The British Chiropractic Association could have provided evidence to refute Singh’s comments. But it did not, and turned to legal means to silence criticism of its practices. He is appealing an initial court ruling, and is leading a campaign to reform English libel law.  See his recent update here:

“It has been 18 months since I was sued for libel after publishing my article on chiropractic. I am continuing to fight my case and am prepared to defend my article for another 18 months or more if necessary. The ongoing libel case has been distracting, draining and frustrating, but it has always been heartening to receive so much support, particularly from people who realise that English libel laws need to be reformed in order to allow robust discussion of matters of public interest. Over twenty thousand people signed the statement to Keep Libel Laws out of Science, but now we need you to sign up again and add your name to the new statement.

The new statement is necessary because the campaign for libel reform is stepping up a gear and will be working on much broader base. Sense About Science has joined forces with Index on Censorship and English PEN and their goal is to reach 100,000 or more signatories in order to help politicians appreciate the level of public support for libel reform. We have already met several leading figures from all three main parties and they have all showed signs of interest. Now, however, we need a final push in order to persuade them to commit to libel reform.

Finally, I would like to make three points. First, I will stress again – please take the time to reinforce your support for libel reform by signing up at www.libelreform.org. Second, please spread the word by blogging, twittering, Facebooking and emailing in order to encourage friends, family and colleagues to sign up. Third, for those supporters who live overseas, please also add your name to the petition and encourage others to do the same; unfortunately and embarrassingly, English libel laws impact writers in the rest of the world, but now you can help change those laws by showing your support for libel reform. While I fight in my own libel battle, I hope that you will fight the bigger battle of libel reform.”

English libel law is an international problem, because you can be sued for libel English court for statements you make in Canada, if it appears in print in the UK. And not only are the defence costs prohibitive, the onus is on the defendant to prove they didn’t libel. Consequently, these laws have an impact all over the world. The Libel Reform Campaign is asking for signatures from people all over the world, to illustrate how absurd these laws are. Please consider adding your signature today.

Happily, the news is much much better in Canada for bloggers, skeptics, and advocates for science. Continue reading

Two more picks for your library

Here’s two other great references that I neglected to mention in my last post. Both would make great gifts as well…

An Apple a Day – This book on nutrition is written by Joe Schwarcz, Director of McGill University’s Office for Science and Society. It covers the gamut of nutritional questions that come up. From tomatoes and lycopene, to flax, to oats and soluble fibre, to artificial sweeteners, fluoride, organic food, acrylamide and hormones in meat. He also examines (and dismisses) alt-health nostrums such as detox and alkali diets.  Each chapter is about 6 pages, so Schwarcz gets right to the point, summarizes the science, and then makes some bottom-line recommendations. It’s all done in an easy-to-read and accessible style. My only complaint is that while Schwartz does mention the sources of most of his data, he does not use formal citations, which would help a reader verify his conclusions. Overall, Schwarcz’s approach is cautious and pragmatic and appears consistent with the science.  As a general reference, for a non-health-professional (or health professional) curious about food controversies, you probably can’t do better than this book. And check out the Office for Science and Society’s web page, where they debunk the idea that homeopathy can be useful for the flu.

They Might Be Giants – Here Comes Science (CD/DVD) – This fantastic CD/DVD combo is highly recommended for any parent – and even if you don’t have kids, it’s a great package. TMBG is an alternative rock band that’s been together since the 1980s. Once they started having kids, they started producing some family-friendly music. And with Here Comes Science, they hit it out of the park. If you want your kids to get excited about science, this is a great start. Check out a few of their videos below – from singing about the periodic table, to the scientific method (Put it to the Test).  But the title track pretty much says it all, and sums up nicely the underlying theme of Science-Based Pharmacy: Science is Real. Continue reading

Homeopathy in UK Pharmacies: PR Disaster

Look at the headlines:

Boots: Homeopathic Remedies Please Customers Rather Than Cure

Distrust me, I’m a Pharmacist (registration required):

So why are so many nonsensical products available from Boots, our trusted family chemist? Has Boots become UK’s largest purveyor of placebos? Are pharmacists shopkeepers, only out to make a profit, or healthcare professionals keen to improve public health?

The NHS should not waste our cash on homeopathy:

Placebos, including homeopathy, don’t work as well as the therapies that have been tested against them and been found to be significantly more effective. The NHS has a fixed budget each year: if £4 million is spent on homeopathy, it means that £4 million is not available for more clinically effective treatments.

And check out this open letter to Boots from Merseyside Skeptics.

The Boots brand is synonymous with health care in the United Kingdom. Your website speaks proudly about your role as a health care provider and your commitment to deliver exceptional patient care. For many people, you are their first resource for medical advice; and their chosen dispensary for prescription and non-prescription medicines. The British public trusts Boots.

However, in evidence given recently to the Commons Science and Technology Committee, you admitted that you do not believe homeopathy to be efficacious. Despite this, homeopathic products are offered for sale in Boots pharmacies – many of them bearing the trusted Boots brand.

Not only is this two-hundred-year-old pseudo-therapy implausible, it is scientifically absurd. The purported mechanisms of action fly in the face of our understanding of chemistry, physics, pharmacology and physiology. As you are aware, the best and most rigorous scientific research concludes that homeopathy offers no therapeutic effect beyond placebo, but you continue to sell these products regardless because “customers believe they work”. Is this the standard you set for yourselves?

The majority of people do not have the time or inclination to check whether the scientific literature supports the claims of efficacy made by products such as homeopathy. We trust brands such as Boots to check the facts for us, to provide sound medical advice that is in our interest and supply only those products with a demonstrable medical benefit.

We don’t expect to find products on the shelf at our local pharmacy which do not work.

Not only are these products ineffective, they can also be dangerous. Patients may delay seeking proper medical assistance because they believe homeopathy can treat their condition. Until recently, the Boots website even went so far as to tell patients that “after taking a homeopathic medicine your symptoms may become slightly worse,” and that this is “a sign that the body’s natural energies have started to counteract the illness”. Advice such as this directly encourages patients to wait before seeking real medical attention, even when their condition deteriorates.

We call upon Boots to withdraw all homeopathic products from your shelves. You should not be involved in the sale of ineffective products, because your customers trust you to do what is right for their health. Surely you agree that your commitment to excellent patient care is better served by supplying only those products whose claims can be substantiated by rigorous scientific research? Or do you really believe that Boots should be in the business of selling placebos to the sick and the injured?

The support lent by Boots to this quack therapy contributes directly to its acceptance as a valid medical treatment by the British public, acceptance it does not warrant and support it does not deserve. Please do the right thing, and remove this bogus therapy from your shelves.

I would not be surprised to see pharmacists bumped off the top of the “Most Trusted” professional list, as a result of press like this.

Are pharmacists going to take responsibility for their own profession, advocate for science-based pharmacy, and stop selling homeopathy? Or will we be complacent, until we’re called out for allowing placebos to sit on pharmacy shelves?

 

 

Recommended Skeptical References

I’m a voracious reader, and I thought I’d share some of my favorite books over the past year that have challenged, inspired, or enriched me. Whether you’re a health professional or not, I strongly recommend you put these on your reading list. They’ve helped me a lot in refining my philosophy about pharmacy practice, and improving my skeptical viewpoint.

The Demon-Haunted World – Science as a Candle in the Dark – If you read only one book on this list, make it this one.  It is Carl Sagan’s challenge to us to fight pseudoscience. The book describes the scientific method as an awe-inspiring method of discovery.  It will encourage a skeptical and critical mindset, and challenge you to think carefully about your own assumptions. Some of the book is spent discussing logical fallacies, which has helped me improve my criticism skills.

On Being Certain This is a great book that deals the feeling of certainty that we have about things. Written by a neurologist, the book makes a convincing argument that “certainty” is a mental sensation, and not evidence of fact. In fact, Burton argues that it’s actually independent of active reasoning. Certainty, he concludes, is actually not biologically possible. We must use science as a method to evaluate data according to its likelihood of being correct.  An enjoyable and challenging read. Here’s a review at Science-Based Medicine.

Snake Oil Science This book does a fantastic job of explaining the rise of alternative medicine, as well as how health professionals are challenged to avoid making logical inferences. But the finest section of the book deals with the placebo effect – it’s the best explanation I’ve ever read. The book concludes with a dissection of systematic review of alt-med, and illustrates what high-quality systematic reviews really say about various complementary and alternative practices. Highly recommended. Here’s a review at Science-Based Medicine.

Autism’s False Prophets Until dealing with H1N1 this year, I had no idea about the level of antivaccination sentiment in Canada. And the “manufactroversy” about vaccines and autism baffled me.  I watched Orac battle the antivaxxers almost daily, but didn’t have a good sense of how this irrational and dangerous cult became established. For a succinct summary of how different organization and individuals have mislead the autism community, and established the modern antivaccination movement,  this book is a fantastic resource. Having read this book, you’ll understand the history of the antivax movement, and have a better understanding of their tactics. I believe it should be mandatory reading for every pharmacist. I also highly recommend you also read Amy Wallace’s recent article in Wired magazine, where Offit is profiled in the article “An Epidemic of Fear”.

Fooled by Randomness This book, by Nassim Nicholas Taleb, deals with luck and chance: How we understand it, and how it shapes our decision-making. Taleb, a mathematical trader “obsessed with uncertainty”, is a natural skeptic. The book focuses on different type of what he calls “thinking deficits” and makes a persuasive case for how we favour the visible and the personal, and minimize or ignore the abstract. It’s why one anecdote can convince someone of the value of an intervention ( like “homeopathy worked for me“) despite persuasive evidence that it’s placebo.

Trick or Treatment -Written by Edzard Ernst, a professor of complementary medicine, and Simon Singh, an author and science journalist now infamous for being sued by the British Chiropractic Association, this book doesn’t pull any punches. “The Undeniable Facts About Alternative Medicine” is the subtitle. It’s a fantastic read. The book opens with a review of the scientific method with some interesting historical facts. The book then dedicates a chapter each to acupuncture, homeopathy, chiropractic, and herbal medicine. The book concludes with a discussion of placebo therapies and their place in patient care. The appendix includes one-page summaries of dozens of alternative health modalities, with a short summary of their effectiveness. Highly recommended for everyone. Here’s another review from Science-Based Medicine.

How We Know What Isn’t So Why do people believe in the absurd, like homeopathy, despite all evidence? This book will help answer that question. Another good overview of critical thinking, this book outlines how human reason is fallible, and what to do about it.  While the books is over 15 years old, it’s still completely relevant. This book will likely force you to consider your own thought processes and beliefs -it did for me.

Why People Believe Weird Things – This book by skeptic Michael Shermer, looks at alien abduction, Creationism, psychics, recovered memories, Holocaust, and more. He explores why even well-educated people can hold beliefs that seem utterly baffling to others.

 

 

Those are my recommendations for anyone interested in pseudoscience, skepticism, and critical thinking. If you have any related books you’d recommend as a must-read, please list them in the comments. I’m compiling my “to read” list for 2010.

Homeopathy in Pharmacies: Scrutiny in the UK

It looks terrible on pharmacists and pharmacy practice: Homeopathy, on pharmacy shelves.  In front of Members of Parliament, the  Professional Standards Director for Boots, a huge British pharmacy chain, made the following admission last week:

There is certainly a consumer demand for these products. I have no evidence to suggest they are efficacious. It is about consumer choice for us and a large number of our customers believe they are efficacious.

Ugh. Profits before ethical patient care. Foreshadowing for Canadian pharmacies?

In the United Kingdom, the parliamentary science and technology met last week to evaluate the strength of evidence that supports the MHRA’s decision (their version of Health Canada) to license homeopathic products for sale, and allow claims to be attached to these products without evidence that they work. Pointed questions were directed at Boots and their decision to sell homeopathy in pharmacies.

The hearing are well worth reading through.  And the media response has been scathing. “However they sugar it, you’re swallowing a delusion” says The Times:

Boots sees no reason to stop selling a line of products of no proven value when there are still consumers (gullible mugs) prepared to buy it.

Ben Goldacre both spoke at the hearings, and then wrote about it later, in an article entitled Homeopathy and the nocebo effect:

There were comedy highlights, as you might expect from any serious inquiry into an industry where sugar pills have healing powers conferred upon them by being shaken with one drop of the ingredient which has been diluted so extremely that it equates to one molecule of the substance in a sphere of water whose diameter is roughly the distance from the Earth to the sun.

The man from Boots said he had no evidence that homeopathy pills worked, but he sold them because people wanted to buy them. The man from the pill manufacturers’ association said negative trials about homeopathy were often small, with an average of 65 people, and “all statisticians” agreed you need 500 people for a proper trial. Not only is it untrue that you necessarily need this many people ; he then cited, in his favour, a positive homeopathy trial with just 25 patients in it.

The Telegraph also weighed in,  with an article entitled: Boots: We sell homeopathic remedies because they sell, not because they work.

With homeopathy creeping into many Canadian pharmacies, as well as pharmacy continuing education programs, that headline may yet appear in Canada. Stay tuned.