Monty Pythons’ Life of O’Brien

Much has already been written on the subject of the first two oral evidence sessions in Science and Technology Committee’s investigation of  homeopathy, more than enough, in fact, to allow me to point you in the direction of a couple of articles by Ben Goldacre and Skepticat’s excellent commentary and let you take it from there.

What’s just as interesting, and in parts rather worrying, in the transcript of the final oral session in which Mike O’Brien, the Minister for Health Services, Professor Kent Woods, of the MHRA, and David Harper, the Chief Scientist at the Department of Health, found themselves under the spotlight and, in O’Brien’s case, responding to the committee’s delightfully probing questions with complete and utter gibber.

Looking, first, at the evidence given by both Woods and Harper, the impression that I certainly get is one which stands as a sad and desperate indictment of the corrupting influence of politics on science and scientific inquiry. It’s perfectly obvious that both are fully aware of the fact that there is absolutely no credible scientific evidence for the efficacy of homeopathy beyond the placebo effect and no scientific basis for any of the theoretical claims made for how homeopathy allegedly ‘works’.

Homeopathy amounts to nothing more or less than giving people water and/or sugar pills in the utterly misconceived and superstitious belief that symptoms can be relieved and illnesses cured using sympathetic magic. The ‘principles’ on which homeopathy is ‘based’ are derived directly from medieval alchemy, and particular from the doctrine of signatures.

Despite this, both Woods and Harper were forced to dissemble in order to defend the current public public policy, under which sizeable sums of taxpayers’ money are being frittered away on providing ineffectual palliatives to people with utterly idiotic beliefs.

This is Woods’ response to a direct question about whether there is any evidence to show that homeopathy works beyond the placebo effect:

One has to look at the totality of the evidence and in my view there is no single piece of evidence that gives that reassurance. It is difficult from the point of view of research in that the underlying theory does not really give rise to many testable hypotheses and therefore I think the research effort has been bedevilled by that. One could then ask what about the empirical evidence that homeopathy has a beneficial effect and, as you have heard, the studies are ambiguous; they present a variety of results.

So, the short answer is ‘no’, but Woods then goes on to add:

From the point of view of evidence, certainly from a regulatory perspective, it is very important evidence that something like ten per cent of the population have used a homeopathic remedy or have gone to a homeopath in the previous 12 months, and that I think is a starting point for deciding what is the public health significance of this phenomenon.

Well it does take us some way toward a usable measure of the prevalence of gullibility in the general population, so I suppose there may be some public health significance in that, but don’t think for a minute that Woods is either finished or that that’s the conclusion he’s building up to:

It is the way in which they are used rather than, as you said in your very first words, the argument about whether homeopathy works or not. I think in terms of developing evidence we have to acknowledge that there are some people who firmly believe that homeopathy works. There is a degree of use which suggests we might have to consider the public health implications of a significant group of people using homeopathic remedies and if there are potential public health implications, how should we regulate it,

Or we could invest in a public health campaign which tells people the truth about homeopathy; that it has absolutely no medicinal value beyond the placebo effect and that they, and the NHS, are pissing money down the drain on cake decorations coated with distilled water. Much of the work that public health departments carry out under the broad heading of ‘preventative medicine’ consists of providing the public with accurate information in the interests of trying to help them protect themselves from their own stupidity and there’s absolutely no valid reason why that tried and tested approach cannot be used with homeopathy. Yes, homeopathy is a £1.5 billion a year industry across Europe but that’s still peanuts compared to size of the global tobacco industry and that didn’t prevent public health professionals from publicising the link between smoking and cancer.

The only significant regulatory issue we need to be concerned with here is that of just how big the words ‘WARNING: There is absolutely no credible scientific evidence that homeopathy works’ needs to be on the packaging and any accompanying leaflets or other literature and that’s one that I can happily sort out – just make it double the point size of the title font, bold, bright red and put it right at the front/top where it can’t be missed. Sadly, that response seems to firmly off the agenda:

Q235 Dr Harris: But for them to be protected from being led to believe that it works when there is no evidence that it works is a valuable public health message to get across, all other things being equal. Would that be good?

Professor Woods: It is certainly not our intention to do that.

Remember, Woods knows perfectly well that homeopathic ‘remedies’ are a crock of shit but he, and the MHRA, has absolutely no intention of informing the general public of that fact. At best that seems entirely unethical. At worst its the active facilitation of the sale, for profit, of worthless ‘remedies’ in the full knowledge that these preparations have no medicinal value beyond placebo and that would seem to be open collusion in a public fraud.

As regards Professor Harper’s contribution, I actually feel rather sorry for him as he was clearly put in the desperately unfortunate position of trying to defend a Minister, O’Brien, who was simply gibbering away nonsensically for almost the entire session.

As a result, Harper got drawn into playing the old ‘mixed opinions’ canard:

Professor Harper: This is clearly a very challenging area. There are mixed views from the scientific community, as you are well aware from the evidence that already has been given, but I think it is undoubtedly the case that the majority of independent scientists feel that the evidence is weak or absent.

Q177 Chairman: Can you point us to any specific piece of scientific evidence which would stand up to normal scientific scrutiny that the Department has used to support the Government’s policy on homeopathy?

Professor Harper: There are a number of meta-analyses and randomised clinical trials and I think you have heard and seen from previous evidence that it is possible to be quite selective about how that information is used. One of the real difficulties that we face is that it is not so much a lack of research or a lack of randomised clinical trials; it is a lack of agreement between experts working in this field.

If you’ve ever taken the time to look at the quality and construction of the kind of homeopathic trials that do appear to produce positive (i.e. better than placebo) results or read of the systematic reviews of the evidence you’ll quickly come to the conclusion that the word ‘expert’ is all-too often (and inappropriately) over-used, often in circumstance in which ‘quack’ would be by far the more accurate term, a point to which Harper finally alludes right at the end of the session:

Q255 Dr Harris: Professor Harper, you said earlier that you thought there was an evidence base on RCTs, meta-analyses and systematic reviews to underpin a decision about whether NICE is efficacious, therefore effective beyond placebo, and therefore cost effective because you can cost it. How, therefore, do you respond to the assertion that there is not a testable evidence base, which is what the Minister said just now or before, to judge whether the spending of this money, in itself, on the basis of effectiveness and cost effectiveness, is a valid question to test, because that would suggest we need more research of the RCT type, which you thought we did not earlier?

Professor Harper: What I tried to flag up earlier is that there is an evidence base but it is subject to different interpretation, and that is at the crux of the challenge we face on this. It is a very difficult evidence base to test, so there have been quite a number of randomised clinical trials. Whilst I am not a homeopathic practitioner, homeopathic practitioners would argue that the way randomised clinical trials are set up they do not lend themselves necessarily to the evaluation and demonstration of efficacy of homeopathic remedies, so to go down the track of having more randomised clinical trials, for the time being at least, does not seem to be a sensible way forward.

In reality, RCTs are ideally suited to assessing the efficacy of homeopathic ‘remedies’. The delivery mechanism used in homeopathy, ingestion of a pill or liquid, is identical to that used in trials of the vast majority of pharmaceutical drugs, all of which are readily controlled by either placebo or by reference to an existing treatment, one that is typically the best that’s currently available.

I’ve left O’Brien to last because he genuinely did spend the entire session talking complete bollocks. so much so that its actually difficult to pick out the lowlights of his performance without fisking the entire transcript.

Nevertheless, he did manage to throw in this staggering response to a line of questioning that about the funding of homeopathic  research and, tangentially at least, about the £910,000 that the NHS has given to OfQuack:

Mr O’Brien: Of course, we have spent some money, in fact £910,000 over three years, in trying to get some regulation set up in this area. We also took the view at the start of this year that it would be useful to undertake some testing of some of the homeopathic “medicines”. At this point we have not started such a study. We were looking to see the outcome of the Northern Ireland study which did not deal with homeopathic medicine but did deal with complementary and alternative medicines of different kinds. We took the view that we would wait a while to look at the overall budgetary situation before deciding whether to proceed with this.

Q186 Chairman: In terms of Government policy in terms of homeopathy you are not really saying that it is evidence-based other than that there is a community who believe that they work?

Mr O’Brien: Yes.

Q187 Chairman: And you feel that that is acceptable?

Mr O’Brien: And also that there is a placebo effect, so there are the two arguments there. Certainly in terms of the placebo effect there is a view that that makes a significant number of people better, if indeed it be a placebo, and there is also a community of GPs and others who take the view that this is an area which does work, and therefore we take the view as ministers that it is not our job in relation to this, which is a somewhat controversial area – again I say in inverted commas – of “medicine”, to stop clinicians who take the view they want to prescribe it from doing so.

Q188 Dr Harris: Could I just pursue that because I understand where you are coming from and I empathise with your position. I do not think it is controversial in any of the evidence we have had that there is a placebo effect and that might well be powerful enough to justify a number of policies based on it, as Professor Woods said.

Mr O’Brien: Can I just pause you there. We do not need to justify it. What we need to do is the opposite. We would need to justify stopping the funding now. It is a subtle but possibly important difference.

From experience, I suspect that the Public Accounts Committee might well take a different view on the question of exactly what O’Brien does and doesn’t need to justify when it comes to spending taxpayers’ money on homeopathic research, particularly in view of Professor Harper’s evidence which indicates that there is no real shortage of research, itself, just a very marked and glaringly obvious shortage of research that provides homeopaths with the evidence they wish existed.

As such, the correct response here is not throw even more good money after bad but to ask homeopaths “which part of ‘it’s fucking water’ do you not understand?”.

This is after O’Brien has admitted, on the record, that there is no credible scientific evidence for the efficacy of homeopathy, BTW:

Q174. …Does the Government have any credible evidence that homeopathy works beyond the placebo effect?

Mr O’Brien: Certainly there is the placebo effect. There was also some research done in Northern Ireland in an examination of the effect of a number of complementary and alternative medicines not including homeopathy.

Q175 Chairman: Keep with homeopathy.

Mr O’Brien: In that case the straight answer is no.

Still, if you think that O’Brien was plumbing the depths of absurdity with his response to the questions about funding homeopathic research, wait until to see what he had to say when pressed on the question of the NHS providing homeopathic ‘treatments’ at the taxpayers’ expense:

Q245 Graham Stringer: Should NHS spending not be dependent on proved effectiveness or efficacy, whether it is £10,000 or £12 million?

Mr O’Brien: You are asking two slightly different questions: one concerns effectiveness and the other efficacy. It is arguable that if two people, ie the clinician and the patient, genuinely believe that homeopathy works, and it happens to but maybe not in the efficacious way they believe, then is that something that the NHS should stop spending money on? That is essentially your question. My answer is that at this point I have not got the evidence to do that, and I would not seek to do that.

So, what he’s saying is that doctors are entitled to prescribe anything they like, even a course of Ju-Ju, as long as they and the patient are gullible enough to believe that it works unless there is absolute proof that it doesn’t work.

If doctor and patient are both idiots then you have to try and prove a negative before O’Brien will step in to point out that sacrificing a goat and consulting an astrological chart drawn up its congealing blood is not a valid diagnostic practice within the NHS.

You can just tell, even without looking it up, that O’Brien is a fucking lawyer, can’t you!

That said, perhaps the single most staggering exchange in the whole session occurred when O’Brien was pressed on the decision taken by West Kent PCT to discontinue funding for homeopathy after its own study of the effectiveness and efficacy of a homeopathic hospital led them to conclude that it was ‘a waste of public money’. I have edited the transcript for brevity, but you can read it in full by following the link I posted earlier:

Q249 Graham Stringer: …The real point is that you do have more evidence than you are owning up to at the moment, because West Kent PCT looked thoroughly at the effectiveness and efficacy of the homeopathic hospital in West Kent and we had the person here who carried out that survey who said, in words of one syllable: “This is a waste of public money”. So if West Kent believes that spending that money is a waste of public money, why is it different in Liverpool or Gloucester or wherever else these hospitals are?

Mr O’Brien: As far as that study is concerned that was an examination of a particular clinical experience and the person who did it was entitled to reach the conclusion they did. There are others who take a different view. They may not have done any substantial empirical peer reference study that will enable us to say: “This works”, but the question for me as a Minister is not so much the one you are putting to me, in a sense, which is fairly reasonable, but is there a justification for stopping spending in relation to homeopathy now, and my judgment is there is not that amount of evidence to justify me stopping spending on homeopathy.

As you can see, O’Brien is still demanding proof of a negative, even in the face of an empirical study which demonstrated that the NHS in West Kent was pissing money down the drain by funding a homeopathic hospital.

Believe it or not, we’re actually beyond the usual realms of policy-based evidence-making here as what O’Brien is advocating is actually policy-based evidence-avoidance. If the government plan to continue to fund homeopathy because of a lack of case-by-case empirical evidence to show that its a waste of time and money then its creates a clear incentive for homeopaths to avoid doing any actual research, like the plague, on the basis that uncertainty is their best and only guarantee of staying on the gravy train.

To be honest, If I was a shareholder in a pharmaceutical company I’d be getting seriously pissed off by now, because any return on my investment comes only after the company has spent several years and millions of pounds on tests to prove the effectiveness and efficacy of its products just to get them onto the market and, particular, onto NICE’s list of approved and recommended treatment and yet these bastards are able say ‘but we believe it works’ and get their noses straight into the fucking trough.

And Mike isn’t finished yet…

If you are asking me a different question which is whether I can justify all the spending on homeopathy today the answer would probably be “No” too, but that spending is there and a significant group of people believe it works, and therefore my view is that it would be illiberal and a denial of personal choice, because there is a significant “scientific” community behind it who take a view that it should be allowed to continue.

‘Personal choice’ is an argument for not banning homeopathy outright, and no one, even its more ardent opponents is advocating that other than in regards to some of its most irresponsible and dangerous claims, i.e. homeopathic ‘treatments’ for HIV/AIDS, malaria, tuberculosis, etc. these being instances in which Mill’s harm principle is clearly applicable.

It is not, however, an argument for spending taxpayers’ money on woo.

If people want to piss their money away on an idiotic belief in sympathetic magic then by all means let them do so – its the whole business of pissing taxpayers’ money down the drain that sceptics, like myself, find utterly objectionable and indefensible.

Q250 Graham Stringer: I will move on but I do find it an extraordinary liberal view that we have a study within the NHS which shows it is not effective —

Mr O’Brien: I think, with the greatest respect, Graham, that it is extraordinary indeed. I am expressing the liberal view and Evan Harris is expressing the illiberal view.

Dr Harris: Evan Harris is not expressing anything!

If Evan was expressing any view at all, its the rational view. O’Brien’s view is just gibber.

Q251 Graham Stringer: Do you think we could get out of this difficulty with different parts of the NHS spending public money on quite different criteria by getting homeopathic treatments evaluated by NICE?

Mr O’Brien: I have no objection to NICE evaluating this but they do have a couple of problems with it. Firstly, they have a large queue of drugs that they need to evaluate and there are greater priorities. Secondly, there is a somewhat limited evidential base and before evaluating things NICE want to see an evidential base, and for the reasons we have already discussed it simply is not there at the moment. They could decide to spend a lot of public money – probably with great objection from some people on this Committee – establishing that evidential base, but that is not a priority for them or us at the moment.

Hang on a second, Mike…

Professor Harper: There are a number of meta-analyses and randomised clinical trials and I think you have heard and seen from previous evidence that it is possible to be quite selective about how that information is used. One of the real difficulties that we face is that it is not so much a lack of research or a lack of randomised clinical trials; it is a lack of agreement between experts working in this field.

So your scientific advisor is actually saying that there is an evidence base that NICE could review, if only you had the balls to look past the fog of homeopathic bullshit that being put up around it by people with a clear vested interest in keeping their seats on the NHS gravy train.

As a final thought, I want to quickly go back to what quickly became the signature admission of this entire inquiry, that of Paul Bennett, the professional standards director and superintendent pharmacist of Boots:

Q3 Chairman: So you sell them? [homeopathic remedies]

Mr Bennett: We do indeed sell them and there is certainly a consumer demand for those products.

Q4 Chairman: I did not ask you that question. I said do they work beyond the placebo effect?

Mr Bennett: I have no evidence before me to suggest that they are efficacious, and we look very much for the evidence to support that, and so I am unable to give you a yes or no answer to that question.

As it happens, I found myself in a branch of Boots over the weekend, doing what most men do in their when dragged along into the shop by their partner, i.e. standing around and feigning interest in the contents of one of the shelves while waiting for teir better half to be served.

One of the more important parts of this particular ‘game’ is that of finding a bit of neutral ground to stand in, somewhere where you won’t look either noticeably out of place (e.g. the feminine hygiene products aisle) or as if you’re shopping for treatments for an embarrassing condition (the Anusol aisle is major no-no). On this particular occasion the nearest safe haven turned out to be an aisle which contained a rack of aromatherapy oils and an assortment of other woo and so, in order to maintain the necessary low profile, I picked up an item of the essential oils rack and started scanning the small print.

It turned out that what I’d picked up was a small bottle of tea tree oil, one that was being marketed as Boots own-brand ‘anti-septic oil‘.

Now there’s nothing wrong with that, per se, as tea tree oil does have measurable anti-septic, anti-fungal and anti-bacterial properties when used in a high enough concentration (above 4%). What did catch my attention, however, was a warning in the small print on the packing, just under the bit about recommended uses:

Do not use if:

  • You suffer from epilepsy
  • You suffer from skin allergies
  • You are pregnant or breastfeeding
  • You are using homeopathic remedies.

Seek professional advice before using pure essential oils under these circumstances.

As far as I can tell, the warnings about using tea tree oil when pregnant, breastfeeding of if you have epilepsy look to be standard disclaimer warnings of the ‘we don’t know if it’ll cause a problem but would prefer not to blamed if shit happens’ variety. One thing all producers of medicinal products, even the ones based on woo, are cautious of is the always dangerous combination of the availability heuristic and the post hoc fallacy.

People have a known tendency to assume a causative link between unrelated events which occur in close proximity, even if those events are unrelated and their proximity no more than a coincidence. If someone is unfortunate enough to have an epileptic fit (especially if they’ve not had one for a while) or if they have a miscarriage or their baby falls ill then they have an innate tendency to look for the cause of the problem in events that may have taken place just prior to the incident in question, and particular in anything that stands out as being unusual, different or that amounts to a change in their normal routine. So, if someone uses tea tree oil for the first time and, a few hours later, they have a fit then there’s a very good chance that they’ll automatically assume that the two events are connected and that, therefore, using the oil is what caused them to have the fit.

So, even if there’s no evidence to show that a particular product causes an adverse reaction during pregnancy/breastfeading or serves as trigger for epilepsy, the manufacturers will still put a warning on the packaging as an arse-covering measure.

As far as I can see, there is no particular evidence that tea tree oil does cause problems for people with epilepsy, in fact I’ve run across forums and message boards where its being recommended by members for use to counter the side-effects of certain epilepsy drugs which are known to cause outbreaks of acne in some patients. As for pregnancy and breastfeeding, I could not evidence of adverse effects either, but that’s hardly surprising given the obvious problem of trying to carry out safety-trials on pregnant women.

But homeopathy?

As warnings go that one amounts to ‘not to be taken with water’, which is absurd, of course and having taken a quick look around I can find nothing whatsoever to suggest that homeopaths take the view that tea tree oil should not be used externally when using homeopathic remedies, which makes this a redundant warning, yes?

No, not really.

The warning does serve a purpose, not because it has value in itself but because it creates/reinforces the false impression that homeopathy does have an effect other than as a placebo. It exists solely to place homeopathy on the same footing as other genuine medicinal products which do, for genuine reasons, carry warnings about known, and problematic, interactions with other drugs and medicines.

The warning not to use tea tree oil if taking homeopathic remedies is just another facet of an elaborate fiction created by a £1.5 billion industry to suggest to consumers that homeopathy actually works, even though there is no credible supporting evidence for that or anything of the other claims made for homeopathy beyond the fact that makes a perfectly viable placebo…

…and its a fiction that Boots seem to content to participate in, given that the warning appears on one of their own, Boots-branded products.