“Treating evidence with contempt”
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2063 (Published 13 October 2008) Cite this as: BMJ 2008;337:a2063
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Self justification drives us all. It is why, whether you are an
alternative practitioner or traditional physician, you will believe that,
since you are a kind and caring person, what you do is in the best
interest of your patient. I recommend everyone to read 'Mistakes were made
(but not by me)' by Carol Tavris and Elliott Aronson. It explains the
response by alternative practitioners, and also all of us who justify what
we are doing, when at times what we do does not have the evidence base to
support it. But we KNOW that it helps our patients!
Competing interests:
None declared
Competing interests: No competing interests
It is not right that Professor Ernst is bullied for providing some
clear-sighted evaluation of CAM. I rely on his assessments to know what
might help and what is not safe for patients to carry on with. Who would
do this if he did not? His work, and those who challenge unsupportable
claims, deserve our support.
Competing interests:
None declared
Competing interests: No competing interests
The last three years have seen a constant stream of articles and
books stating categorically that there is no evidence for homeopathy.
Edzard Ernst is not the only one feeling frustrated and upset by this
sterile and overblown debate, but at least he can comfort himself that he
has helped to set its terms. Those of us who have also read the evidence
but happen not to agree are also feeling frustrated: that our points seem
hard to get across inthe professional and lay media. By contrast, the
wilder and more unpleasant responses of anti-science members of the (non-
medical) homeopathic community are noted and cited with great care by
Goldacre, Ernst and their fellow travellers.
This current period of anti-CAM and anti-homeopathy campaigning began
with the Shand et al paper in 2005 (1). This was intriguingly presented
to the press as the “first” systematic review of homeopathy. The original
study design was useful, but the final analysis was arrived at on
unspecified grounds, comparing unidentified trials and should surely be
treated with caution. These flaws were obvious to anyone who didn’t
assume a-priori, that its findings must be correct. It is surprising to
see self styled defenders of science and objectivity basing categoric
statements on such a foundation, whilst simultaneously ignoring the mixed
findings of the meta-analyses that preceded it. (2, 3, 4, 5, 6)
It can only be a matter of time before detailed analysis of the
problems with the Shand et al study appear in the research literature.
Dare we hope this will lead to at very least a toning down of the rhetoric
that characterises this debate?
There are deep seated problems besetting medicine at present, and
such challenges cannot be met by reverting to simplistic and entrenched
positions on anyone’s part. It can only be hoped that we will soon see a
broadening of the polarising agenda set by Professor Ernst and many of
those who agree with him (many are rapid responders to, or cited in, his
letter). Only when this occurs can we have a fruitful discussion of
placebo, CAM, integrated care, and the challenges of creating and
interpreting evidence relevant to the wide ranging needs of our patients.
1) Shang A, Huwiler-Müntener K, Nartey L, et al. Are the clinical
effects of homeopathy placebo effects? Comparative study of placebo-
controlled trials of homoeopathy and allopathy. Lancet 2005; 366: 726-32.
2) Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of
homoeopathy placebo effects? A meta-analysis of placebo-controlled trials.
Lancet 1997; 350: 834-43
3) Cucherat M, et al. Evidence of clinical efficacy of homeopathy. A meta-
analysis of clinical trials. Eur J Clin Pharmacol 2000; 56: 27-33.
4) Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy.
Br Med J 1991; 302: 316-23
5) Linde K, Melchart D. Randomized controlled trials of individualized
homeopathy: a state-of-the-art review. J Alter Complement Med 1998;4: 371-
88
6) Boissel JP, Cucherat M, Haugh M, Gauthier E. Critical literature review
on the effectiveness of homoeopathy: overview of data from homoeopathic
medicine trials. Homoeopathic Medicine Research Group. Report to the
European Commission. Brussels 1996, 195-210.
A list of reference of papers on homeopathy research can be found at
http://www.trusthomeopathy.org/case/res_toc
Competing interests:
I don't consider practicing both as a GP and as a homeopathic physician to be competing interests, but I declare them anyway!
Competing interests: No competing interests
It seems to me strange that cancer patients who wish to pay for
potentially effective treatments that have not yet been approved by NICE
are charged for their NHS chemotherapy, while cancer patients who wish to
pay for their definitely ineffective complementary treatment are
encouraged to do so and retain their right to NHS chemotherapy.
Competing interests:
None declared
Competing interests: No competing interests
Homeopathy's arch sceptics Colquhoun, Ernst an Singh
and others who cry 'EBM" make their attacks from within a
large glass house. The quality of the evidence base for much of what is
practised daily in the NHS is pretty poor. As the British BMJ Clinical
Evidence so succinctly points out 'of around 2500 treatments covered 13%
are rated as beneficial, 23% likely to be beneficial, 8% as trade off
between benefits and harms, 6% unlikely to be beneficial, 4% likely to be
ineffective or harmful, and 46%, the largest proportion, as unknown
effectiveness' and ' most decisions about treatments still rest on the
individual judgements of clinicians and patients.'
(http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp)
The NHS homeopathic hospital treatment centres that Colquhoun, Ernst
an Singh are so desperate to close down are all staffed by medically
qualified personnel. Furthermore, no patient attends those hospitals
without referral from an NHS GP who has considered all the diagnostic and
treatment options in front of him before doing so. Both categories of
conventionally trained and qualified health practitioner
together with their patients daily make the kind of clinical decisions
that Prof. Sir Micheal Rawlins is calling for based on a range of
unhierarchised evidence.
There is a range of observational and experimental evidence for
homeopathy which is very positive, admittedly RCT evidence is more
difficult to establish. This is because RCT's are highly appropriate for
the one drug-one disease/symptom approach of pharmaceutical medicine, the
whole-patient individualised medicinal treatment approach of homeopathy is
more difficult to research in the same manner though some good trials
exist.
I am sure that not for one moment did Sir Michael think he was
defending homeopathy when he wrote and gave his speech but either the
fundamental message he gave is appropriate for assessing all forms of
treatment or it is not, I believe it is .
Competing interests:
I am a practising homeopath
Competing interests: No competing interests
I applaud Professor Ernst for his courage and his outspoken
denunciation of treatments that are not supported by proper scientific
evidence. Indeed, when subjected to proper evaluation, such treatments are
usually laughed out of court.
Medical practice, and thus people's health, are under constant attack
by unorthodox practices, treatments, and medications. A few of the many
examples are as follows.
ALTERNATIVE MEDICINE is particularly dangerous. Unproven therapy is
recommended and orthodox therapies (e.g. for cancer or AIDS) are described
as dangerous or inferior. The patient may decline orthodox treatment and
may remain ill or even die. COMPLEMENTARY MEDICINE is less dangerous but
is cynically dishonest. A variety of substances and treatments - usually
expensive - are recommended to be used in addition to conventional
treatment. This approach does not dissuade patients from receiving proper
treatment, but defrauds them of significant amounts of money. IMPROPER USE
OF THE TITLE "DOCTOR" is illegal in some jurisdictions and should be
illegal everywhere. A "DOCTOR" should have a university degree at doctoral
level, or in the case of holders of the MB;BS the title is a civil one
conferred by law. Improper use of the title is outright fraud and can
delude many innocent people. UNPROVEN PHARMACY is rife everywhere. Shelves
full of "remedies" with dubious or no credentials can be found in a great
many pharmacies. Magazines and the Internet are full of advertisements for
such nostrums.
Unfortunately, when medical professionals speak out against cancer
quackery, acupuncture, reflexology, iridology, chiropractic, homeopathy,
naturopathy or extraordinary dietetic measures they are apt to be accused
of arrogance, cant, bias, blindness, or sheer financial self interest. In
fact, individuals like Professor Ernst are stoutly defending the public
interest.
Competing interests:
None declared
Competing interests: No competing interests
I find quite astonishing the vituperation that is poured on Professor Ernst, simply because he assesses evidence with scrupulous fairness. The only people who would want to do that are those who don't like scrupulous fairness when it threatens to harm their income.
Perhaps the homeopath, Stephen Gordon, should listen to what Michael Rawlins actually says, rather than the parody of it that has appeared in the media. He was referring to treatments that had already passed RCTs and saying that they should be followed up in the wider population of patients to see if they lived up to their initial promise.
Homeopathic treatments have failed to show any initial promise when they have been tested properly. They can fairly be called the most discredited of all the widespread branches of CAM (I exclude crystal therapy and dowsing).
For homeopaths, the game is up. That being the case it is not surprising that those who make a living from it have to resort to grasping at straws.
I don't want to ban homeopaths, crystal therapists or any other sort of delusion, as long as they do no harm by pretending they can cure malaria or AIDS. I'm with Goldacre on this: these sorts of witchcraft can be thought of as a voluntary tax on the scientifically-illiterate
Competing interests:
None declared
Competing interests: No competing interests
While I might take issue with Sir Michael Rawlins' use of language,
what he actually said bears some examination. He did not recommend
ditching RCTs. He did question their generalisability, and on that I agree
with him. Now what happens with orthodox medicines is that they are
registered on the basis of RCT data, which have to show efficacy or no
such registration is granted. After that, questions might be raised as
experience is gained in the general population. What happens with CAM for
the most part is that we don't see any good quality RCT data to support
its claims. What we do see are claims based on uncontrolled observational
data, and poor quality RCTs. This is a fundamental difference - RCTs are
the bedrock, on which we build an edifice of evidence from other sources.
The problem with most CAM is that it lacks foundations - one puff and it
falls over.
I am sure that Rawlins will agree that the controlled experiment is
one of the key tools on which all of science is based. It is how we have
learned what we know about the universe. The RCT is just one type of
controlled experiment. If we say it isn't appropriate for whatever we are
claiming, what does that say about our claim?
Homeopaths presumably claim that an ultra-dilute (ie beyond
Avogadro's number) solution has measurable therapeutic effects. Hardly
anything could be easier to test, and has been so tested, with generally
negative or inconclusive results. This is science.
Competing interests:
None declared
Competing interests: No competing interests
People who feel that their integrity or livelihood is threatened will
always react,
and sometimes unpleasantly. We can never stop such people writing letters,
or
conducting media campaigns, but reform of this country's libel laws would
go a
long way to taking much of the sting out of their efforts.
Competing interests:
None declared
Competing interests: No competing interests
Removing the cancer
The cavalier attitude towards evidence adopted by so many of the
proponents of Complementary and Alternative Medicine (CAM), and which
Professor Ernst has documented, is a cancer that must be removed from the
body physic.
The attitude of some proponents of CAM seems to be that, if certain
forms of alternative therapy are not proven to be effective, the problem
must lie, not in the therapies themselves, but in the standard methods of
scientific research. If clinical trials cannot prove that acupuncture is
no better than a placebo, then there must be a problem with the
methodology of clinical trials. Perhaps the effects of acupuncture and
other alternative methods are too ‘subtle’ for the ‘reductionist approach’
of orthodox medical research. Sometimes, this argument takes on almost
mystical overtones, in which the materialist approach of Western medicine
is contrasted unfavourably with the spiritual sensitivity of the various
alternatives.
The implication is that people holding different different views
cannot engage in rational debate. Doctors and alternative therapists must
simply agree to differ, because they work in different paradigms.
Evidence and argument are completely abandoned.
Clearly, this is not a recipe for progress. If we wish to heal the
rift between orthodox and complementary medicine, we must begin by finding
some common ground, and the methodology of the clinical trial is the
perfect candidate. Contrary to what some have claimed, the clinical trial
is not ‘biased’ towards any particular school of thinking in medicine. It
is grounded in very basic ideas about evidence that would, in any other
context, hardly be in dispute. The principles of the clinical trial are
really just common sense writ large. Whether applied to tasting tea or
testing medicine, they involve no special commitment to any particular
‘paradigm’.
I was greatly heartened by Professor Ernst's letter to the BMJ. I
hope he keeps up the good work, and doesn't let the harassment get him
down.
Competing interests:
None declared
Competing interests: No competing interests