The NHS is right to fund homoeopathy
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2642 (Published 04 May 2011) Cite this as: BMJ 2011;342:d2642
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Everything needing to be said about homeopathy was said by Oliver
Wendell Holmes in 1842 (1). Declining to discuss it further, he ends,
"...time is too precious, and the harvest of living extravagances nods too
heavily to my sickle, that I should blunt it upon straw and stubble." And
there's not much writing like that in the BMJ these days.
1 Holmes, OW. Homeopathy. In: Stalker D, Glymour C. Examining
holistic medicine. New York, Prometheus Books: 1989, p.221-243.
Competing interests: No competing interests
Clare, perhaps you were replying to others more than to me, but you
seem to have missed the point that I was trying to make.
I agree with you that placebo effects can be clinically useful in
some circumstances. My concern is about the ethics of placebo treatment.
What does a clinician prescribing a placebo say to the patient? Can a
patient ever give truly informed consent to placebo treatment? Could we
live with imperfectly informed consent if the patient has a good outcome?
These are difficult ethical questions, to which I don't claim to know
the answers. I'd be interested in your views.
Competing interests: As declared previously
I am relieved that such distinguished campaigners have taken the
trouble to respond to my article. As I anticipated, misrepresentation of
some of my points enables commentators to disagree with me. However, none
of the responses addresses my key point and I challenge Dr Fisken to
explain the clinical response to any medicine other than cytotoxic agents.
Let's start with something simple: aspirin.
All the critics of my article agree that a placebo response underlies
the perceived benefits of homeopathic treatments. It is the question of
whether or not that response has any merit that attracts such hostility.
Campaigners argue that the placebo response is useless. The placebo
response is a manifestation of a conditioned response. Conditioned
responses can dominate the mind and behaviour - ask any addict about
environmental cues that remind them of their habit. The White Coat
Syndrome is another example. If a placebo response doesn't count, why are
untreated controls regarded as inadequate and why are placebo controls
mandatory?
Unless the campaigners are dualists (and I don't know any scientist
who is), they must agree that real physiology underlies the placebo
response. Suppose, hypothetically, that a pill is developed, which
contains an active chemical designed to trigger physiological changes that
are the same as those recruited by the placebo response to homeopathy.
Would the campaigners object to the use of that pill too? If they would,
how do they justify their objection bearing in mind that potentially
harmful, conventional medicines would be used instead? If they would not
object, what factors distinguish the pill from homeopathy in ways that
compromise patient welfare?
There is a real risk that the campaign is doing more harm than good.
The banning of homeopathy from the NHS would be hard to unravel, even if
such a decision turned out to offer no benefit to the population, overall,
or resulted in some patients being harmed unnecessarily. As one GP has
commented to me: "... My elderly ladies loved it and it didn't make them
fall over. And at least half the time it worked". Patients who have
nothing wrong with them do not approach their GP for treatment. Sometimes,
the most appropriate treatment might be one that offers a change of
mindset. The backdrop of NHS care helps to distinguish such patients from
those with other serious conditions.
In my view, the Department of Health's position is spot-on. The use
of homeopathic treatments must be a matter of expert clinical judgement
and informed patient consent, as with any other form of cognitive or
chemical medication.
Competing interests: No competing interests
Thanks to Mark Struthers. I would mention additionally that US
vaccine compensation officials have told CBS reporter Sharyl Attkisson
before now [1]:
"The government has never compensated, nor has it ever been ordered
to compensate, any case based on a determination that autism was actually
caused by vaccines. We have compensated cases in which children exhibited
an encephalopathy, or general brain disease. Encephalopathy may be
accompanied by a medical progression of an array of symptoms including
autistic behavior, autism, or seizures."
Leading vaccine programme advocate, Paul Offit, was echoing this line only a few days ago[2]:
"Dr. Offit said the study authors reach erroneous conclusions due to
an erroneous definition of autism. A child with measles encephalopathy, he
said, may have severe cognitive deficits that fall into the autism
spectrum, but such symptoms themselves do not necessarily translate into a
diagnosis of autism."
So, what is the difference between an autistic spectrum disorder and
an autistic spectum disorder? I think we should be told.
[1] http://www.cbsnews.com/8301-31727_162-20016356-10391695.html
[2] Robert Lowes, 'Anti-vaccine Proponents Claim Court Paid for Autism Cases', Medscape News Today 10 May 2011, http://www.medscape.com/viewarticle/742471
Competing interests: Autistic son
The studies referenced in this article are massive whereas Wakefield falsified data on just 12 children. If there is a link, it is yet to be proven and the weight of evidence strongly suggests that there is no link. Dr. Struthers should also take note of the autism/vaccine compensation claims which have been rejected:-
http://articles.latimes.com/2010/mar/13/science/la-sci-autism13-2010mar13
The "vaccine court" in the US operates on a no-fault compensation basis:-
http://en.wikipedia.org/wiki/Vaccine_court
Others posting replies to this article seek to make a rather tenuous link between a belief in God and having a rational mind or not. This is a fallacious argument.
Religious freedom in modern civilised societies allows people to publicly declare their atheism in a way that in years gone by or in less enlighted regimes may have resulted in persecution or death. Therefore a historical belief in God has no bearing on the possession of a rational mind or not. To then appeal to writings in the bible as matters of historical fact is stretching credulity, given that are multiple versions with heavy editing through history.
If people wish to consult a homeopath privately and pay for consultations and remedies, that is up to them. I do ask, however, that any remedies prescribed are evidence-based and that the patients are made aware of the evidence (or, rather the lack of evidence). However, given the lack of evidence, the NHS should not fund what is a placebo.
Competing interests: No competing interests
Only fruitcakes believe in God? Correction of inverted inheritance of
solomonic genius.
In my rushed rapid response to Mark Struthers' remark (9 May) that
believers in God were/are fruticakes [1] I made King David of Jerusalem
the recipient of solomonic genius, when he was in fact the father of the
legendary King Solomon. Sorry about that. David's Psalms are still worth
reading as they are full of extraordinary wisdom, including his published
diagnostic observations in Psalm 14 verse 1, and Psalm 53 verse 1. Some
will say King Solomon inherited the brilliance of his father, but
Scripture implies something more profound, indeed something
suprascientific. [3]
F I D Konotey-Ahulu MD FRCP DTMH
Kwegyir Aggrey Distinguished
Professor of Human Genetics University of Cape Coast, Ghana
and Consultant
Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies,
10 Harley Street, London W1G 9PF
Conflict of interest: Nothing to declare
1. Struthers Mark. Re: Luc Montagnier ... and Andrew Wakefield:
living parallel lives BMJ Rapid Response 9 May 2011
http://www.bmj.com/content/342/bmj.d2642/reply#bmj_el_260294
2. Konotey-Ahulu FID. Only fruitcakes believe in GOD? BMJ Rapid
Response 11 May http://bmj.com/content/342/bmj.d2642/reply#bmj_el_260425
3. Second Book of Chronicles, Chapter 1 verses 7 to 12.
Competing interests: No competing interests
It is interesting that Anthony Hedley suggests to you , David, that a
less negative choice of words might enable a more constructive dialogue
between medical homeopaths and their critics.
You will remember we chatted about that, and other things, over a friendly
lunch in london, last year. I felt there was common ground.
Hedley's point is an important one.
Medical homeopaths, practising in the NHS, are well aware of the huge
advances in conventional medications and methods in recent decades. We,
and our patients, see the benefits every day in our practices. Those of us
fortunate to work abroad see many people plucked from the jaws of death
by ARVs and anti bacterial therapy.
Back home, we also see people with chronic problems which are sometimes
not successfully treated by conventional approaches. Some respond to
homeopathic treatment in a way that often leaves us amazed, though we may
be sceptics to the bone.
Even mediocre homeopaths, like me, can achieve some success, by following
well trodden paths.
Constructive dialogue might be improved if our critics had the opportunity
to meet with us and our patients, and discuss homeopathic methods and
results.
I often ask satisfied patients if they would be happy to discuss their
story with a third party. They always agree.
Then comes the problem.
In general, so dismissive and contemptuous are the tone and language of
critics, that it would surely be unethical to expose a person, trying to
be helpful, to critics who so readily resort to the use of intemperate
language about professional colleagues.
Unless critics of medical homeopaths can show themselves to be a little
more open minded, warm hearted and even tempered, their education in
homeopathic matters will unfortunately be delayed. For ethical reasons.
Competing interests: No financial gain from homeopathy, but many surprises and much satisfaction.
Clare Stanford's argument in support of homeopathy on the NHS is so
pervaded with logical flaws that one hardly knows where to start. She
opens with an appeal to the supposed authority of the Department of
Health. The reality is that whenever anyone questions a health minister on
this matter, they get a totally standardised answer, word for word
identical. Both of the present authors have these on file. One of them
arrived this very day, this time from a civil servant, to whom Earl Howe
(the minister responsible for quality) had delegated it. The standard
letter agrees that homeopathy does not work, and then states that this is
a clinical matter and if the patient and physician feel that it does work,
then the decision is theirs alone. In other words, the government has no
problem with physicians being deluded and patients being misled.
Whereas proof of efficacy is a different matter from mechanism of
action, a prerequisite for a clinical trial is that there is a rationale.
This might be in the form of scientific theory or in vitro or in vivo
evidence, but the problem with homeopathy is the lack of any such
rationale. There is renewed interest at present in the Bayesian approach
to clinical research. This starts with an assessment of prior probability,
on which the study design is built. If this were to be applied to
homeopathy, no trials could be carried out, because the prior probability,
assembled from previous research and scientific plausibility, would be so
low that the sample size would be virtually infinite. This is an important
lesson to learn about scientific plausibility.
The matter of the total NHS spend on homeopathy is only marginally
relevant. Evidence based medicine (EBM) is arguably the greatest
achievement of science, certainly in terms of impact on the maximum number
of people, and a `laissez faire' attitude seriously undermines that. The
NHS is moving steadily in the right direction, but there remain many areas
of practice that lack good evidence. We should emphasise that we take an
inclusive view of evidence, with the randomised controlled trial (RCT)
necessarily leading on to further types of research which can test
generalisability to clinical practice. Homeopathy of course falls at the
first fence, and no number of poor quality clinical trials and user
satisfaction surveys can remedy that.
We are at a loss to see how Stanford concludes that "To infer that
these treatments lack efficacy, they would have to offer less
"satisfaction" than placebo". Good quality RCTs consistently show that
homeopathy is the same as placebo. Even its most militant critics do not
claim it is worse than placebo.
Stanford considers that it is ethically acceptable for both physician
and patient to be deluded, and then says this is "precisely why we need
double blind clinical trials". But surely we need double blind clinical
trials in order to minimise the bias of such delusions? The logic here
seems impenetrable.
Stanford misunderstands the role of NICE. To appraise cost-
effectiveness, which is what NICE does, there has to be evidence of
effectiveness. Our own dialogues with ministers and civil servants, over
successive governments, show that there is no political will to refer any
`alternative' treatment to NICE for appraisal. This despite a government
commitment to do so in response to the House of Lords report on
Complementary and Alternative Medicine in 2000.
Let us end near the beginning. Stanford uses the entirely spurious
analogy of alcohol and tobacco, which are clearly harmful but not covered
by the Misuse of Drugs Act. The point is that the state is not buying
alcohol and tobacco and prescribing them to patients.
Competing interests: LR is an independent consultant in clinical science, with pharmaceutical companies among his clients. He receives no material benefits of any kind for his charitable work in support of EBM.MB has no competing interests.
I keep reading here that the placebo effect is large and beneficial.
This is actually quite dubious. There is some reason to think that the
placebo effect is actually quite small and transient. The reason that so
many people think that ineffective treatments work is probably regression
to the mean. Echinacea cures your cold in only seven days when otherwise
it would have taken a week. Most people (if they have any sense at all)
would take homeopathic pills only for minor, self-limiting conditions.
The condition goes away and the pill gets the credit. That doesn't need
any placebo effect whatsoever.
If this interpretation is roughly right, it removes the last plank
from Stanford's argument.
Competing interests: No competing interests
Re: The NHS is right to fund homoeopathy
I completely agree with Dr. Stanford in as much as the psychological benefits of homeopathy seem to currently outweigh the cost to the NHS. I am aware there is limited to no scientific data to back the claim that patients are benefiting from the treatment but, at least personally I do hear of instances where GPs have found that there is improvement in some patient's well being. Albeit the very small sample size I am taking my data from.
My only reservation with offering homeopathy on the NHS is that if/when the popularity of this alternative treatment increases then it gives other alternative therapies a case to also be funded in the NHS. This may result in a higher proportion of the NHS budget being diverted away from scientifically backed treatments in favour of these new alternative therapies.
Competing interests: No competing interests