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Keep libel laws out of science

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2783 (Published 09 July 2009) Cite this as: BMJ 2009;339:b2783

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Re: Re: Re: Re: CAM, free speech, and the law

I am no lawyer and presumably neither is Mr Rawlins, but conflating
law and metaphysics in order to suggest negative trials published in the
peer reviewed literature could be considered defamatory is just a little
extreme, and no-one is suggesting it. Mr Rawlins then issues an
interesting challenge. I preface my response with the following:-

a. Total NHS spending on ALL homeopathic prescriptions in 2007 =
£321,000.
b. Total drug spend by ONE NHS hospital in NW London in 2007 =
£86,000,000.
Combine this with the previously-mentioned emerging evidence of
homeopathy’s therapeutic and cost effectiveness in the treatment of
chronic long-term chronic conditions (e.g., fibromyalgia [1]), and it
would be nice were NICE to conclude that NHS funding of homeopathic
remedies is excellent value for money and should continue.

As with acupuncture for lower back-pain, it is not inconceivable that
NICE could recommend this to the NHS but as Mr Rawlins well knows, it is
PCTs which determine how money is spent, and this feeds into the more
general problem of patchy local provision of therapies/procedures (Mr Rose
and his colleagues might wish to take credit for PCT decline homeopathy
provision, but it had started well before their letter to the Times [2]).
So I wish Mr Rawlins good luck in repeating his South Devon BMA chapter’s
call to NICE, but I will not be joining him.

I also thank Mr Rose for his encouraging comments about the
shortcomings of RCTs, and can assure him that not only have I have read
Sir Michael Rawlins’ Harveian Oration, but that my use of the word ‘other’
in the context of forms of evidence means complementary, not alternative.

In many respects, Sir Michael was echoing the original definition of
Evidence-Based Medicine as ‘….an approach to health care that promotes the
collection, interpretation, and integration of…. patient-reported,
clinician-observed, and research-derived evidence. The best available
evidence, moderated by patient circumstances and preferences, is applied
to improve the quality of clinical judgments.’ [3], a view suggesting that
within EBM, the RCT was originally envisaged as part of an evidence
‘package’ derived from multiple sources.

Indeed, David Sackett (one of EBM’s founders) later went further,
‘Evidence-based medicine is not restricted to randomised trials and meta-
analyses. It involves tracking down the best external evidence with which
to answer our clinical questions.....if no randomised trial has been
carried out for our patient’s predicament, we follow the trail to the next
best external evidence and work from there’ [4].

This suggests that as far back as 1996, Sackett was concerned EBM
might be in danger of turning into an evidence ‘mono-culture’, where the
primacy of an ‘ideal’ scientifically-determined efficacy would subsume
other no less important forms of evidence, to the possible detriment of
patient and clinician concerns. Mr Rose’s use of the terms ‘bedrock’ and
‘lower grade’ to describe respectively RCT and ‘other’ forms of evidence,
it could be argued is the extent to which Sackett’s concerns have been
realised. Indeed, ten years later, voices were raised within the nursing
profession concerning EBM’s intolerance of therapeutic pluralism in
healthcare systems [5]. As with everything, ‘It begins with a blessing,
and ends with a curse….’ [6].

References
1. Relton C, Smith C, Raw J, et al. Healthcare provided by a homeopath as
an adjunct to usual care for Fibromyalgia (FMS): results of a pilot
randomised controlled trial. Homeopathy. 2009, 98(2):77-82.
2. Baum M, Ashcroft F, Berry C, et al. Use of “Alternative Medicine” in
the NHS. The Times, May 19, 2006.
3. McKibbon, KA, Wilczynski N, Hayward RS, et al. The medical literature
as a resource for evidence based care. Working paper from the Health
Information Research Unit, McMaster University, Ontario, Canada, 1995.
http://hiru.mcmaster.ca/hiru/medline/asis-pap.htm.
4. Sackett, DL., Rosenberg WMC, Muir Gray JA, et al. (1996) Evidence based
medicine: what it is and what it isn't. BMJ 1996; 312 (7023): 71-2.
5. Holmes D, Murray SJ, Perron A, Rail G. Deconstructing the evidence-
based discourse in health sciences: Truth, power, and fascism.
International Journal of Evidence Based Healthcare 2006;4:180.
6. ‘Why are we sleeping?’, Lyrics by Kevin Ayres, The Soft Machine ca
1968.

Competing interests:
None declared

Competing interests: No competing interests

18 July 2009
Lionel R Milgrom
scientist, writer, homeopath
NW2 3ES