Homeopathy in the BMJ: A response to Clare Stanford

My attention has been drawn, this morning, to a thoroughly absurd attempt to defend the provision of homeopathy on the NHS by a Dr Clare Stanford, a reader in experimental psychopharmacology at the Department of Neuroscience, Physiology, and Pharmacology, University College London.

The text that follows comes from a letter published in the British Medical Journal, where the full text reside behind a paywall and its therefore necessary to state for the record that it is reproduced here for non-commercial purposes and for the purpose of commentary and criticism in line with the principles of fair use/fair dealing.

So, preamble over, lets’ get fisking…

The campaign to expel homoeopathy from the NHS continues unabated despite a position statement from the Department of Health: “We believe in patients being able to make informed choices about their treatment, and in a clinician being able to prescribe the treatment they feel most appropriate … which includes … homeopathy.” To put this skirmish into perspective, the NHS spends about £4m (€4.5m; $6.6m) a year on homoeopathic prescriptions, which is peanuts. Even if subsidiary costs are rolled in, this battle is clearly more about winning a scientific argument, and protecting patients from themselves, than preserving NHS coffers.

In the current economic climate, a cost saving of £4 million+ is not to be sneexed at but, yes, this is primarily about science and evidence based medicine. Where I would disagree strongly here is in describing this is issue a ‘scientific argument’. It isn’t, its an argument between science and an irrational and unscientific belief system (homeopathy) which is based on pre-scientific notions derived from archaic beliefs in sympathetic magic. Homeopathy may pretend to be scientific but is founding principle are to be found in Frazier’s ‘Golden Bough’ not in Newton’s ‘Principia Mathematica’ or Darwin’s ‘On the Origin of the Species’.

To avoid being misrepresented, let me be clear that I am not pro-homoeopathy. I would not use homoeopathic preparations myself, and I do not believe that they have actions that can be measured in vitro. So should homoeopathy be available on the NHS? Absolutely. That is not to say that all alternative treatments should be funded by the state. Homoeopathy within the NHS is an historical accident. By analogy, most people can live with the fact that nicotine and alcohol are exempt from the Misuse of Drugs Act.

If homeopathy is permissible then I’d be interested to know quite which alternative treatment aren’t, given that the overwhelming majority of alt-med ‘treatments’ are equally implausible in scientific terms. By analogy, most people don’t expect that drinking Volvic and swallowing Tic-Tacs will cure their health problems and, in any case, historical treatments are regularly discarded by the NHS, and the medical profession generally, where they have been either superseded by more effective treatments or where evidence shows them to be ineffective. Why should this not apply to homeopathy?

I agree that the scientific explanation for homoeopathy is implausible. However, I note that the Nobel laureate, Luc Montagnier, is open minded on the issue and is being pilloried as a consequence. He must feel like Galileo. To condemn a treatment because the proposed mechanism of action does not fit scientific dogma has a rather Soviet feel to it. In any case, the mechanism is a red herring: we do not need to understand how drugs work before prescribing them, which is just as well.

Ah yes, a blatant example of special pleading – the old ‘they laughed at Gallileo’ gambit.

History is littered with self-styled maverick scientists and their discoveries and theories that ran entirely against the grain of accepted scientific theory at the time they published their work, the overwhelming majority of whom are long forgotten for one very simple reasons – they were completely wrong. The evidence just did not stack up and support their ideas.

Luc Montagnier may well feel like Galilleo but there the comparison ends, Gallileo was right, the empirical and observational evidence supported his theory that the solar system is heliocentric and not geocentric. The evidence simply does not support Montagnier’s views on homeopathy, no matter that he is a Nobel Laureate allbeit one operating far outside his field of expertise in his efforts to shore up support for homeopathy. In Montagnier’s case, a more accurate comparator is to be found amongst the legions of quacks and snake oil peddlars who promoted first electricity and then radioactivity as a university panacea not amongst those few great scientists whose discoveries genuinly changed our fundamental view of workings of the natural world.

By the same token, the veiled reference to Lysenko is similarly inaccurate and inappropriate for the simple reason that Lysenko, like Montagnier, was just plain wrong.

Finally, while we do not necessarily need to understand how drugs work before prescribing them, we do need to be satisfied that they do work and that the available evidence supports any claims of efficacy made in respect of a particular drug and they their effects could, with further research, be satisfactorily explained in terms of a plausible scientific modality. Homeopathy satisfies neither of these conditions, despite having had 200 years in which to produce satisfactory evidence of efficacy and/or a scientifically plausible account of its mode of operation and, hence, cannot legitimately be defended on the basis that ignorance is bliss.

The main argument against the NHS funding homoeopathy is that “patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions,” according to the fourth report of the House of Commons Science and Technology Committee (www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/45.pdf). In short, the NHS should not pander to patients’ irrational beliefs, with an acknowledgment that homoeopathy triggers a placebo response that can be beneficial. To infer that these treatments lack efficacy, they would have to offer less “satisfaction” than placebo. I am not aware of any evidence to support that claim, with the possible exception of a dubious study carried out on wounded soldiers in St Petersburg in 1829.

For any other drug treatment entering the market the universally accepted and absolute minimum standard for proof of efficacy is that of evidence demonstrating an effect beyond placebo. For most drugs, standards of evidence required before prescribing are even more exacting, with doctors requiring evidence not just of an effect beyond placebo but a clinically significant effect as well. Ideally, one would also look for evidence of efficacy beyond that of the current best available treatment, although is not an absolute requirement given that issues such as patient tolerance, risk of side effects a cost relevant to benefits are also relevant factors in prescribing decisions.

Why should homeopathy be treated any differently or handed an exemption to these exacting standards?

It shouldn’t and nor should any other drug treatment.

Given that patients’ treatment response is influenced by their expectations, homoeopathy can be regarded as a so called thinking therapy at the least. In other contexts, cognitive therapies are championed for their apparent efficacy without any drugs at all. In fact, some of the same campaigners who deride homoeopathy as a placebo response also assert that a placebo response accounts for the therapeutic effects of antidepressant drugs. This contradiction exposes a double standard in the interpretation of evidence, propped up by prejudice. Clearly, there is a need for more stringent criteria for comparisons of efficacy.

Oh no. Not having this at all.

If redefining the meaning of efficacy is shifting the goalposts, recategorising homeopathy as a psychological therapy is throwing away the goalposts and installing a basketball hoop instead.

What Stanfield is inching towards here is the old canard that homeopathy is an acceptable method of administering a placebo. It isn’t. Even if one accepts that there may be legitimate and even ethical uses for placebos in general medicine, i.e. outside of clinical trials, the use of homeopathy is still unethical.

Let’s try and take this from first principles, which means that we start by acknowledging that the use of placebos in any circumstances entails a deception on the part of the doctor and, therefore, a breach of trust in the doctor-patient relationship. What the patient expects from the doctor is a treatment or therapy that will bring about a direct and active improvement in their condition and, preferably, one that seeks to treat the underlying cause of the problem. What the patient is given, if administered a placebo, is a treatment that only has, at best, an indirect, psychosomatic, effect on their condition and one that, in addition, has no effect whatsoever on the underlying cause of the problem – placebos are, of course, inert and carry no active ingredients.

So the question becomes one of whether there are circumstances in which the use of placebos can be ethically justified on the grounds their positive effect on the patient outweighs the negative effect of having doctors engaging in deception and breaching the trust of their patients, regardless of whether the patient is aware that a breach of trust has occurred?

In certain context, I suspect that it can. I’m not averse to the use of placebos in, for example, psychiatric medicine as a short-term and largely palliative measure. Many common psychiatric problems are, in their milder forms, both intermittent in effect and transient. Panic and anxiety attacks can last a matter of a few minutes or hours. Bouts of mild depression can be over and done with a matter of days. And if the use of a placebo can reliably help certain patients to ‘get over the hump’ of their transient symptoms without the risk of significant side effects then why not consider their use; subject, of course, to evidence of efficacy and to clear ethical guidelines covering their use.

The latter is, perhaps, the major issue that needs to be addressed in regards to the use of placebos in general medicine. There is a major ethical debate to be had which simply hasn’t taken place, as yet, within the context of changes in medical practice and ethical standards over the last 30-40 years. The limited use of placebos can, I think, be justified in some contexts as a means to an end where it serves to promote the patient’s best interests or even, perhaps, to buy doctors a little more time to investigate the underlying cause of patient’s condition if this is not readily apparent and can be undertaken safely.

What is ethically impermissible, in my view, is the use of placebos as an end in themselves, i.e. as a means of managing the patient. This may once of have been relatively common practice; common enough for it to have been referenced in the second of the Dirk Bogarde ‘Doctor’ films in a scene which Bogarde, as a newly qualified doctor working in grubby NHS clinic in, I think, East London, refuses to give a patient their usual medicine, on the ground that they don’t need it, only to be overruled by the practice’s senior GP who clearly dispenses this medicine to the patient simply to keep them off his back. It is not, however, an acceptable practice today for that it may continue unnoticed in some GP practices, and particularly (perhaps) in relation to the use of antidepressants for the treatment of mild cases of depression where, arguably, patients would benefit far more by being given much greater access to talking therapies.

Given that an argument can be made for the limited use of placebos in general medicine, why should this same argument not apply to the use of homeopathy and/or other so-called alternative treatments and therapies. Is this not, as Stanford suggests, evidence that a double standard is being applied to CAM?

No.

The difference between antidepressants, which may be no more effective than a placebo in many patients, and homeopathy, which definitely is a placebo, is that the former’s mode of action is based on clear scientific principles even if the drug as not as effective as was initially thought to be the case, while the latter has no basis in science whatsoever. An inert placebo used in place of an antidepressant drug would still, in one sense, be scientific insofar as the patient is given a pill which the are led to believe contains an active chemical ingredient. A patient given a homeopathic product is being given nothing more than a sugar pill and a bunch of unscientific bullshit and this continues to be bullshit even if you accept that homeopathic products are nothing more than placebos.

One promotes scientific values, even if the remedy itself is a deception, the other is just a deception all the way and that makes it wholly unethical and unacceptable.

If homoeopathy is a hoax then patients who believe it is beneficial must be deluded. It follows that their medical complaints are also an illusion or resolve spontaneously. These patients will not take kindly to being told that there is nothing wrong with them. Prescribing homoeopathic treatments in such cases would be a problem if they were potentially toxic. Thanks to a recent experiment, in which campaigners consumed industrial quantities of homoeopathic preparations, we can be confident that these treatments are harmless—at least in the short term. If they were banned from the NHS, an obvious alternative would be to prescribe conventional drugs. These will be more expensive and have real side effects, some of them potentially harmful. This is not desirable when clinicians are already accused of playing fast and loose with prescription drugs and of medicalising problems that do not need treating.

I sense a bit of an attempted bear trap here. Some patients who believe in homeopathy may genuinely be deluded, most, I suspect, are simply mistaken in their beliefs for what are otherwise honest and genuine reasons. Frankly, one would expect an academic psychopharmacologist to avoid resorting to the use of clinical terminology in such a loose manner, even if only for rhetorical effect. That said, if a doctor does encounter a patient who is genuinely deluded and presenting with a purely illusory condition then the correct, and ethical, response to that situation would be to refer the patient for psychiatric evaluation not pander to their delusions by giving them a sugar pill. Patients are there to be treated and not simply managed so as to minimise their nuisance value, at least until the point at which it become clear that the patient has an active personality disorder for which management is the only viable option – and even then, they should be managed by means of a ‘treatment’ based on a scientific, and not a pseudoscientific, modality.

Conventional drugs may be an ‘obvious alternative’ to homeopathy but they are not the only alternative and, in many cases, they’re not even an appropriate alternative. The cheapest alternative is, of course, that of simply telling the patient the truth – they may not like it but that nevertheless does not mean that this should be ruled out as option. Other patients might benefit far more from a referral to counselling, particular if they underlying cause of their problems seems to be more social than medical. In many cases the only real therapeutic value offered by homeopathy is the time spent in consultation with the doctor; the benefits of therapeutic contact are not to be dismissed lightly but these can, nevertheless, be delivered by other means, ones which do not also promote superstition, magical thinking and other irrational beliefs.

As for the charge that doctors are too readily medicalising problems that do not need treating, what are homeopaths and other CAM practitioner doing if not exactly the same thing. One of the more recent hot topic on the medicalising normal behaviour front was, of course, Female Sexual Dysfunction, the public profile of which was raised by efforts to promote flibanserin as a so-called ‘female viagra’.

So how did homeopaths respond to the publicity surrounding FSD? Did they complain, as many did, that this looked like a clear example of disease mongering by a drug company, the view taken by many advocates of conventional, evidence-based medicine?

Or did they rush to put their own homopathic ‘remedy’ for FSD out into the market place?

And what of  so-called ‘Morgellon’s Fibre Disease’, which mainstream medicine correctly, in my estimation, regards as a manifestation of delusional parasitosis, a purely psychiatric condition, but which has rapidly become a veritable magnet for homeopaths and assorted other quacks? Let’s not pretend here that drug companies are solely responsible for inventing spurious medical conditions for the sake of peddling their wares to the masses.

Doctors can, at least, offer some protection against such shoddy practices by approaching these new conditions sceptically and examining the evidence before adding it to their diagnostic repertory, which cannot be said for many CAM practitioners.

Another complaint is that homoeopathy is used when patients need conventional drugs. Such medical neglect will not be resolved by homoeopathy’s expulsion from the NHS. The current position optimises opportunities for responsible practitioners to refer patients for more appropriate treatment, if necessary. A good example of that practice is the (former) Royal London Homeopathic Hospital, which was cowed into changing its name after relentless battering from campaigners. A seamless switch to conventional medicine will be impossible if homoeopathic treatments are available only on the high street. All this will enrage homoeopaths, who assure us that they do not deceive their patients and agree that prescription of any old thing is unethical. Both they and their critics are ignoring the difference between homoeopathy and the intentional administration of an inert pill. Only in the former case do patients and practitioners believe that the treatment works. This paired belief will influence clinical outcome, which is precisely why we need double blind clinical trials. Even if homoeopathy does trigger merely a placebo response, its provision by the NHS still makes sense on grounds of safety, tolerability, efficacy, and cost. I am convinced that the National Institute for Health and Clinical Excellence would have concluded that it is thoroughly good value for money.

No. expelling homeopathy from the NHS will not directly address the unethical and unscientific practices of lay homeopaths and other CAM practitioners, but it will send a clear signal to the public that homeopathy has no scientifical basis or credibility whatsoever and that the claims made by homeopaths for the supposed efficacy of their products cannot be trusted.

What homeopaths believe and the sincerity with which they hold those beliefs is of no relevance whatsoever.

What matters is whether those beliefs can reasonably be held given the scientific evidence for homeopathy, which clearly indicates that it is nothing more than a placebo; and this doubly true for doctors that are also members of the Faculty of Homeopathy and who use homeopathy in general practice, where the bar for what constitutes a reasonable belief can legitimately be held to be much higher than than which applied to lay homeopaths. A doctor who prescribed an inappropriate conventional treatment to a patient out of a mistaken belief in its efficacy, when published evidenced says otherwise, would rightly have their competence and fitness to practice called into question and might even face charges of negligence. Doctors have a positive duty to keep abreast of the evidence and update their knowledge accordingly an this is true not only of conventional drug treatments and surgical practice but of the evidence as its relates to homeopathy and other so-called alternative remedies. One cannot simply license and prescribe medical treatments on the basis that practitioners have successfully deluded themselves before going on  to delude their patients for reasons not only of patient and public safety, ethics and public health but because patients are ultimately being given entirely worthless treatments with no medicinal value beyond placebo.

Expelling homeopathy from the NHS is only the beginning, Having tackled that issue, it then becomes necessary to address the issue of the unethical and sometime dangerous practices adopted by lay homeopaths, a process that has already begun following the extension of the ASA’s remit to cover online advertising and claim made on CAM websites. From there, we need to look closely at the egregiously flawed regulatory system foisted on the UK by the European Union and worked towards, as a minimum, removing the licensing exemptions given to producers of homeopathic products, particular where those products are used, by homeopaths, to treat serious diseases. Although not naturally a fan of prohibitionist measures, I could happily countenance the extension of prohibitions enacted in relation to the treatment of cancer by the Cancer Act 1939 to cover other serious diseases and conditions, not least those which remain on the current list of notifiable diseases.

What homeopathy’s supporters within the medical profession need to wake up to is the fact that it is just a quaint, quasi-mystical palliative for minor self-limiting conditions, and it certainly isn’t an ethical or acceptable method of administering a placebo, it’s a genuine threat to public health, not least in terms of the active role its proponents are playing in the anti-vaccine movement, and thoroughly undeserving of public support.

  •  I agree that homeopathic treatments cannot be likened to prescribing placebos (whether that is considered ethical or not) as it is not just the prescription that is being given to the patient but also a potentially dangerous belief in an ineffective method of treating illnesses.

    It is the statement of the efficacy of homeopathy from a position of authority that is unethical and dangerous.