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The Ethics of Homeopathy Jim McVeagh Apr 22

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Dr Shaun Holt is no stranger to controversy, having last year laid into the Chiropractors. Now he, along with a number of other researchers, have written a letter to the New Zealand Medical Journal saying:

Practicing homeopathy or endorsing it by referring patients is not consistent with the ethical or regulatory requirements of practising medicine

This is unlikely to endear him to the many hundreds of GPs who use, or advocate the use of, homeopathic remedies! It certainly annoyed Susanna Shelton, co-president of the New Zealand Council of Homeopaths, who claims “homeopathy had been safely practised around the world for 200 years”. However, Shaun was not talking about the “safety” of homeopathy, but about the utility of it. If it does not work, it’s safety is a moot issue.

Shaun’s point is that it could be considered unethical to advocate a treatment that has no evidence backing it’s usefulness, particularly in the light of the Medical Council’s latest directive on alternative therapies which clearly states:

Doctors must inform patients on the nature of alternative treatments they offered, the extent to which they were consistent with conventional theories of medicine, whether they had the support of the majority of doctors, and their likely effectiveness according to peer-reviewed medical publications.

Unfortunately for proponents of homeopathy, a recent review of all the Cochrane evidenced-based reviews on homeopathy was less than enthusiastic. The article (found here) concludes:

The most reliable evidence – that produced by Cochrane reviews – fails to demonstrate that homeopathic medicines have effects beyond placebo.

Indeed, a quick trip through some of the latest issues of reputable journals such as Homeopathy, Journal of Alternative and Complementary Medicine and Evidenced Based Complementary and Alternative Medicine, reveals much waffle and little in the way of real science. Even the odd randomised trials are usually poorly done and use very small numbers of patients. The larger, better done trials invariably fail to show significant results. All in all, it is hard not to draw the conclusion that homeopathy is dependent chiefly upon the placebo effect.

Readers of this blog will know that I have a soft spot for the placebo effect. I believe it can be a very useful tool in medicine, provided that the doctor/patient relationship is robust enough to survive the eventual discovery that the medication is question is bogus. However, the basic problem with homeopathy is that it is all bogus and the placebo effect cannot be used blindly with every patient but has to be used sparingly and carefully when appropriate. I therefore tend to agree with Shaun that it is difficult to approve of the wholesale use of homeopathy in a doctor’s practice.

Supporters of homeopathy usually point out that it is harmless and relatively cheap and that it does have anecdotal benefits, though it is usually uncertain whether these benefits are derived from the holistic and detailed manner of the consultation or the “medicine” itself. Unfortunately, homeopathy has a number of undesirable effects that far outweigh its nebulous gains.

  • There is a substantial risk that patients may not seek conventional care in life or limb threatening situations. Shaun makes this very point in the Herald article. The situation is made more dangerous by the fact that homeopathy practitioners have a distinct aversion to “allopathic” medicine and tend to avoid referring back to conventional doctors.
  • Scarce resources are wasted on homeopathy. While the first point is well-known, it is not really appreciated that valuable resources are being wasted in terms of doctor’s time, patient’s money and manufacturing equipment, to name a few. This is not as acute a problem in New Zealand (where few public health resources are spent on homeopathy) as it is in the US, where there are entire hospitals and clinics dedicated to the subject.
  • Support for science-based medicine is weakened. It is quite likely that some commentators will get quite hot under the collar telling me all the faults of conventional medicine. Some of these criticisms may be justified but a great many will be based on an antipathy toward scientific medicine that is wholly unjustified. The vaccine debate would be an excellent example of this effect, but homeopathy provides good fodder for some of the more flakey responses to medicine.
  • Support for genuine complementary therapies may be weakened. There are some alternative therapies such as acupuncture and meditation, that produce verifiable, evidence-based results. Yet these therapies run the risk of being dismissed by doctors and patients being bombarded by ludicrous claims from myriad other complimentary “therapies”, including Homeopathy. (source: Smith K. Against Homeopathy – A Utilitarian Perspective. Bioethics – epub)

The conclusion is therefore inescapable that homeopathy is not a harmless thing that slightly flakey patients go for. It is not a valid therapeutic modality that doctors can use. It is a deeply anti-scientific subject of dubious merit that subtly undermines every that medicine stands for. Doctors who use it should seriously consider the ethics of their stance.

PS: You can find a poster size version of the wonderfully rude graphic right here.

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Lactose Intolerant Jim McVeagh Feb 11

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The recent stunt by the New Zealand Skeptics Society might be very amusing, but it fails to add much to the debate on homeopathy. The skeptics swallow large amounts of homeopathic remedy to attempt to show its overall uselessness. Unfortunately, this demonstration is no more significant than an atheist demanding that God strikes him dead with a thunderbolt to prove his existence and then claiming that proves God does not exist, because he survived. I suspect it does little more than ignite acrimonious debates and certainly proves nothing at all. One hopes that none of the skeptics involved were diabetic – ingesting that much lactose (the principle ingredient) might push them into a coma.

There is no real scientific theory to explain the “effects” of homeopathy above and beyond the obvious one of placebo effect. I recall reading an article in New Scientist (that I can no longer locate) which described an elegant experiment that demonstrated that protein molecules being created by DNA, folded themselves into their normal shapes much faster than simple molecular attraction would allow, suggesting that, perhaps, water maintains a memory of the shape of the protein molecule; helping the long strand fold into its working shape. This is a far cry, of course, from suggesting that water maintains the memory of the shape of arnica after a 30C dilution. It also ignores the fact that the single glass of water you use to swallow the arnica would contain billions of other different “memories”. It also gives no insight into how that “shape” (should it exist) can alleviate symptoms caused by entirely different molecules.

The lack of a coherent scientific theoretical basis does not necessarily invalidate homeopathy. The claim “we have no idea how this works, but it does work” is not an unreasonable one (we can call it awaiting a scientific theory), if one can prove a reproducible effect. This is the essential problem with homeopathy. Occasional RCTs may show an effect above and beyond the placebo effect, but this effect is not reproducible in subsequent trials, particularly trials with larger numbers of subjects and more rigorous designs. The net result is that, when analysed together, homeopathic trials demonstrate only placebo effect and a little observer bias. Shiang et al’s meta-analysis Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy (Lancet 2005; 366: 726—32) showed that, once they were controlled for observer bias, homeopathic trials demonstrated only an effect similar to placebo, whereas comparative conventional medicine trials produced an effect far above the placebo effect. I have not seen a convincing homeopathic rebuttal to this study, though several have been attempted.

I have several colleagues who use homeopathic remedies on a regular basis in their practice. I have no particular objection to this. I occasionally deliberately use a placebo to help a patient overcome a problem that is clearly volitional rather than pathological. Some would charge that this is unethical and an abuse of the patient’s right to choose. I say that is politically correct nonsense.

I do, however, have a problem with the pharmacies selling these remedies over the counter. As far as I am concerned, they may as well be charging for magic water. Homeopathy proper requires a great deal of input from the practitioner to determine the symptoms and settle upon an individualised regime. Buying an over-the-counter homeopathic medicine for “allergies” is simply purest quackery, regardless of what you may think of homeopathy itself.

I also have grave doubts about practicing homeopathists with little or no medical training. These people are not skilled enough to recognise an illness that requires conventional medication urgently. In fact, their very suspicions about the nature of “allopathic medicines” may make them resistant to referring a patient on to their general practitioner. This disadvantaging of patient occurs far more often than you would like to think. Fortunately serious harm or death is rare.

Complementary medicine needs to follow the rules of proper scientific enquiry – develop a theory, test it, reject it for another. Instead, most CAM studies consist of anecdotal series or poorly design small trails that serve little purpose than to fool a lay person. I am not a skeptic about homeopathy – I am prepared to view it with an open mind, But that does not mean I will uncritically accept anything thrown at me.

Show me some real science. I will be listening.

Additional

Peter Cresswell provides some amusing and interesting links on this issue.

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