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The Lancet - “Benefits and risks of homoeopathy”
November 16th, 2007 by Ben Goldacre in homeopathy, bad science |
This is a piece I wrote in today’s edition of The Lancet. You can also see this article there in a nice Lancet PDF, along with a “world report” on homeopathy, and the references in pleasantly accessible Crossref format. To be honest, it almost feels silly writing about homeopathy in the Lancet.
“Benefits and risks of homoeopathy”
http://www.thelancet.com/journals/lancet/article/PIIS0140673607617061/fulltextFive large meta-analyses of homoeopathy trials have
been done. All have had the same result: after excluding
methodologically inadequate trials and accounting for
publication bias, homoeopathy produced no statistically
significant benefit over placebo.[1–5] And yet homoeopathy
can still be clinically useful.
During the cholera epidemic in the 19th century,
death rates at the London Homoeopathic Hospital
were three times lower than those at the Middlesex
Hospital.[6] The reason for homoeopathy’s success in this
epidemic is even more interesting than the placebo
effect. At the time, nobody could treat cholera, and
while medical treatments such as blood-letting were
actively harmful, the homoeopaths’ treatments were at
least inert.
Similarly, modern medicine can offer little for conditions
such as many types of back pain, stress at work, medically
unexplained fatigue, and most common colds. Going
through a theatre of medical treatment, and trying every
drug in the book, will only elicit side-effects. An inert pill
in these circumstances seems a sensible option.
However, just as homoeopathy has unexpected
benefits, so it can have unexpected side-effects. The very
act of prescribing a pill carries its own risks: medicalisation,
reinforcement of counterproductive illness behaviours,
and promotion of the idea that a pill is an appropriate
response to a social problem, or a modest viral illness.
Similarly, when a health-care practitioner of any
description prescribes a pill which they know is no more
effective than placebo—without disclosing that fact to
their patient—then they disregard both informed consent
and their patient’s autonomy. Some could argue that this
cost is acceptable, but such old-fashioned paternalism can
ultimately undermine the doctor–patient relationship.
There are also more concrete harms. A routine feature
of homoeopaths’ marketing practices is to denigrate
mainstream medicine. One study found that half of all
homoeopaths who were approached advised patients
against the measles, mumps, and rubella vaccine for
their children.[7] A television news investigation found
that almost all homoeopaths who were approached
recommended ineffective homoeopathic prophylaxis for
malaria, undermined medical prophylaxis, and did not
even give simple advice on bite prevention.[8] Undermining
medicine is a wise commercial decision for homoeopaths,
because survey data show that a disappointing experience
with mainstream medicine is one of the few features
to regularly correlate with a decision to use alternative
therapies. But it might not be a responsible choice.
Homoeopaths can undermine public-health campaigns;
leave their patients exposed to fatal diseases; and, in the
extreme, miss or disregard fatal diagnoses. There have
also been cases of patients who died after medically
trained homoeopaths advised them to stop medical
treatments for serious medical conditions.[9,10]
All these problems have been exacerbated by
society’s eagerness to endorse the healing claims of
homoeopaths, and by the lack of a culture of critical
self-appraisal in alternative medicine. Publication bias
in alternative therapy journals is high: in 2000, only 5%
of studies published in complementary or alternative
health journals were negative.[11] To my knowledge, the
ethical issues of autonomy and placebo have never been
discussed. Homoeopaths routinely respond to negative
meta-analyses by cherry-picking positive studies. An
observational study,[12] which amounts to little more than a
customer-satisfaction survey, has been promoted[13] as if it
trumps a string of randomised trials.
Homoeopaths can misrepresent scientific evidence
freely to an unsuspecting and scientifically illiterate public,
but in doing so they undermine the public understanding
of what it means to have an evidence base for a treatment.
This approach seems particularly egregious when
academics are working harder than ever to engage the
wider public in a genuine understanding of research,14 and
when most good doctors try to educate and involve their
patients in the selection of treatment options.
Every criticism I have made could be managed
with clear and open discussion of the problems.
But homoeopaths have walled themselves off from
academic medicine, and critique has been all too often
met with avoidance rather than argument. The Society
of Homeopaths (in Europe) has even threatened to sue
bloggers,[15] and the university courses on alternative
medicine which I and others have approached have flatly
refused to provide basic information, such as what they
teach and how.[16] It is hard to think of anything more
unhealthy.
To ban homoeopathy would be an over-reaction, as
placebos could have a clinical role. However, whether the
placebo effect is best harnessed by homoeopaths will
remain questionable until these ethical issues and sideeffects
have been addressed.
Ben Goldacre
The Guardian, London EC1R 3ER, UK
ben@badscience.net
I am a medical doctor who is also employed by the media as a commentator on pseudoscience and the sociology of medicine.
1 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991;
302: 316–23.
2 Boissel JP, Cucherat M, Haugh M, Gauthier E. Critical literature review on the
effectiveness of homoeopathy: overview of data from homoeopathic
medicine trials. Brussels, Belgium: Homoeopathic Medicine Research Group.
Report to the European Commission. 1996: 195–210.
3 Linde K, Melchart D. Randomized controlled trials of individualized
homeopathy: a state-of-the-art review. J Alter Complement Med 1998;
4: 371–88.
4 Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efficacy of
homeopathy: a meta-analysis of clinical trials. Eur J Clin Pharmacol 2000;
56: 27–33.
5 Shang A, Huwiler-Müntener K, Nartey L, et al. Are the clinical effects of
homoeopathy placebo effects? Comparative study of placebo-controlled
trials of homoeopathy and allopathy. Lancet 2005; 366: 726–32.
6 Hempel S. The medical detective. London, UK: Granta Books, 2006.
7 Schmidt K, Ernst E. Aspects of MMR. BMJ 2002; 325: 597.
8 Jones M. Malaria advice ‘risks lives’. Newsnight, BBC2 July 13, 2006.
http://news.
bbc.co.uk/1/hi/programmes/newsnight/5178122.stm (accessed Nov 8, 2007).
9 General Medical Council Fitness To Practise Panel. Dr Marisa Viegas. 2007.
www.gmc-uk.org/concerns/hearings_and_decisions/ftp/20070628_ftp_panel_viegas.asp (accessed Nov 8, 2007).
10 Sheldon T. Dutch doctor struck off for alternative care of actor dying of cancer.
BMJ 2007; 335: 13.
11 Schmidt K, Pittler M, Ernst E. Bias in alternative medicine is still rife but is
diminishing. BMJ 2001; 323: 1071.
12 Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for
chronic disease: a 6-year, university-hospital outpatient observational
study. J Altern Complement Med 2005; 11: 793–98.
13 Grice E. Keep taking the arsenic. Daily Telegraph Nov 25, 2005.
www.telegraph.co.uk/health/main.jhtml?view=DETAILS&grid=P8&xml=/health/2005/11/25/hhomeo25.xml (accessed Nov 8, 2007).
14 Evans I, Thornton H, Chalmers I. Testing treatments: better research for better
healthcare. London, UK: British Library, 2006.
15 Goldacre B. Threats, the homeopathic panacea. Guardian Oct 20, 2007.
www.guardian.co.uk/science/2007/oct/20/homeopathy (accessed
Nov 6, 2007).
16 Giles J. Degrees in homeopathy slated as unscientific. Nature 2007;
446: 352–53.
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