A dose of humility
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3857 (Published 16 July 2015) Cite this as: BMJ 2015;351:h3857
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It is curious that in This England of ours, homoeopathy gets a good deal of kicking - witness the rapid responses. One gentleman even denounces the BMJ for the Head to Head debate (Fisher and Ezard), claiming that the very publication of the debate is bad.
Yet, although there is universal agreement in the debate on paracetamol that it has the potential to cause harm, no one has suggested that this drug should be a prescription only medicine.
I do not suggest that paracetamol should be banned completely. But, can anyone, medically qualified, who has practised in this country, give reasons for restricting its prescription by registered medical practitioners only?
Competing interests: I have been prescribed paracetamol in the past and doubtless, I will in future too.
If paracetamol is "no better than placebo for back pain", why not put it this way: "Placebo is as good as ..." and make every effort to improving physician-patient-relationships (Benedetti 2013).
The term placebo („Placebo Domino in regione vivorum“, Vulgata 114:9) is misleading. E.g. a placebo-control might contain the same adjuvant as the verum-group (Villa 2005/2006).
Our current knowledge of placebo-effects should have scientific implications (Bendetti 2014). We should refrain from shame-surgery or pseudo-placebo-treatments, which are still ethically accepted in Germany under certain conditions (BÄK 2010).
Treatments come with different effects:
Specific (receptor oriented)
Weakly specific (off target: side effect)
Systemic: (e.g. mother-newborn-relationship, health-communication, the art of touching a patient, ...)
RCTs are perfectly designed to measure specific effects. The observation of system-effects might need longer time-periods, different designs (cmRCT? Relton 2010), and other indicators: "quality through the patient’s eyes", less costs for further medications, behavior change, qualitative observations etc.
Systemic effects might also be induced by highly specific devices or chemical products (e.g. adjuvants targeting specific receptors, 3D-“baby-television”-ultrasound, vagus-nerve-stimulation, ...). These products (designed for systemic outcomes) are less controlled than specific interventions.
Homeopathy is a good example to reflect on specific and systemic effects:
The mortality of cholera in the 19th century was ~40%.
Specific standard treatment (blood-letting and fluid restriction) raised the mortality rate to ~60%.
Hahnemann reported far better results, because he diluted the specific effect to absolute zero, eliminated all side effects, let his patients drink, as much as they wanted, talked to them and refrained from bloodletting (Hahnemann 1831). Florence Nightingale went even further and concentrated herself completely on the systemic cure-effect (care without a believe-system).
The problem with homeopathy is that the physician who uses it has to be absolutely convinced that the effect is indeed "specific". His strong belief is than mirrored by the patient, who therefore is convinced that the future will be positive. Therefore homeopathy is a belief-system which might induce systemic effects (and very weak or non-specific effects). It has no “specific” side effects, but surely can cause harm, if a specific standard treatment would work better.
I argue that we should study systemic effects more seriously. There might be even an evolutionary reason why a far too optimistic homo sapiens (Sharot 2011) feels pessimistic when ill, and why he needs someone to care for him, in order to let his nature do the cure (Placebo-Paradox: Humphrey 2012).
If we understand systemic effects better, we might improve health outcomes and use less specific treatments, thereby reducing costs - and the need for overdiagnosis, overtreatment and medicalization.
References
• BÄK 2010: Placebo in der Medizin: www.bundesaerztekammer.de/aerzte/medizin-ethik/projektbezogene-themen/pl...
• Benedetti F: Placebo and the New Physiology of the Doctor-Patient Relationship. Phys Rev 2013, 93(3):1207-46
• Benedetti F: Placebo effects: From the Neurobiological Paradigm to Translational Implications, Neuron 2014, 84: 623-637
• Hahnemann, Heilung von der asiatischen Cholera und Schützung vor derselben, 1831
• Humphrey N et al.: The evolutionary psychologiy of healing: a human success story. Curr Biol. 2012 Sep 11;22(17):R695-8
• Relton C (2010): Rethinking pragmatic randomised controlled trials: introducing the “cohort multiple randomised controlled trial” design, BMJ 2010; 340:c1066340
• Sharot T.: The optimism bias. Curr Biol 2011, 21, R941-945
• Villa LL et al. (2005): Lancet Oncol 2005 6(5):271-8 : „The study had two placebo groups with adjuvant doses of 225 μg or 450 μg for appropriate safety comparisons.“ . Br J Cancer. Dec 4, 2006; 95(11): 1459–66: „The placebo contained the same adjuvant and was visually indistinguishable from vaccine …“
Helmut Jäger
Competing interests: No competing interests
From Hubris to Humility
Dear Fiona,
"Vidya Dadhaathi Vinayaha" is an old saying in the ancient Sankya School of Indian philosophy. True education bestows humility on the educated, says the slogan. How true? I must congratulate Fiona Godlee for this editorial. Modern medicine, so called, had been so arrogant that it alone is scientific and the rest of the healing systems in the world are all unscientific. The American Homeopathy Association was started in the early part of the nineteenth century by disgruntled MDs there who were shocked by the cruel methods of treatment in their own system. When homeopaths started making money some other elements in the older system started the American Medical Association nearly half a century later. When asked why they started AMA the answer was:"they came to our area and made money so we want to get back our turf to make money." Science was not in the picture.
Advances in quantum physics have shown how fallacious our modern medical reductionist oscience is. One of them called it a statistical non-science. One example will suffice. Consciousness is fundamental in physics now. All matter is derived from consciousness. So the human mind is what looks like the human body and more beyond. Human mind therefore is not a product of the human brain. Psychiatric drugs therefore end up damaging the human brain but do very little to the human mind. (Dementia-a drug induced crime on mankind by Professor Grace Elizabeth Jackson and The Theory of Reality by Emeritus Professor David Wiebers of Mayo Clinic) .
While we condemn homeopathy as a placebo we should also look at our own reductionist chemical drugs. All of them also work like placebo because they are rejected by the human system as foreign poison (Mitochondria as Chi by DC Wallace in Genetics 2008; 179: 727 read along with Bingel et. al study of the Placebo Effect in Science Translational Medicine March 2011). Cancer research is another area which a double Nobel Laureate, Linus Pauling, called the biggest fraud. Their animal studies which gave lots of hope did not translate into patient benefit as now quantum physics shows that animal consciousness interacts with the researchers' consciousness in any experiment and cannot be extrapolated to human patients!
If our patients survive in spite of us we take credit. When they die we blame their delay in seeking help from us. We still fool ourselves about our omnipotence. If one is healthy at a given time it is just chance; if one is unwell it is also chance.
Man has two attractors in space-health attractor and death attractor. The usual possibility of one falling back into the health attractor when thrown out is quite high but occasionally if one is thrown too close to the death attractor the patient dies, modern medicine notwithstanding. We claim success and take credit when our patient on his own falls back into the health attractor and gets cured. When one knows more science one gets to know the enormity of our ignorance-then humility pours out! It is only a fool who thinks he is wise but a wise one knows that he is a fool.
Yes, even a placebo can have side effects when the placebo, as in many of our placebo trials, contains a drug. If the placebo is innocuous then it cannot have side effects. Another imaginary claim against homeopathy is that one cannot detect any chemical molecule in their drugs. Naturally, because all homeopathic drugs are in nano and piko forms and cannot be detected by our conventional science. In addition we now know that many drugs in very, very small doses are bio-positive while they could become bio-negative in larger doses, the process called Hormesis. Hormesis works with homeopathic drugs. Pride kills and pride damages the owner. Shakespeare was right when said something like this: man, proud man! Dress'd with a brief sense of authority, his glassy essence, like an angry ape, performs such tricks against high heaves that even makes the angels weep." Angels have been weeping for us if you read David Wootten's book-Bad Medicine-doctors harming society since Hippocrates. Let us not forget that homeopathy gave us one of our great drugs-sorbidle di-nitrate-which we have been using for more than 350 years in modern medicine. It is still useful as a simple EDRF keeping the small coronary vessels open.
Let us not forget that a patient can survive without doctors but a doctor cannot survive without patients. Before all patients leave us to go elsewhere let us set our house in order and not throw stones at others sitting in a glass house! Medical establishment has become the leading cause of patient death and disability (JAMA 2000; 284: 483-485) Fiona's humility suggestion is an excellent one. In fact, future sickness care has to depend on modern medical quick-fixes for all times to come but a judicious mix of other scientifically authenticated complementary systems would be nice. Homeopathy bashing, a fashion these days in the UK, should stop for the good of mankind's future. There is so much bad in modern medicine and so much good in homeopathy that neither of us has any right to criticise any of us. Positive criticism is good. He has a right to criticise who has a heart to help wrote Winston Churchill.
Yours ever,
Bmhegde
Competing interests: No competing interests
Bedlam is more than a medieval psychiatric hospital. It's a metaphor for chaos, confusion, and insanity. Today, when we think of Bedlam, we shake our heads and cluck our tongues at the mayhem of a medieval hospital. But someday, doctors of the future will shake their heads and cluck their tongues at the mayhem of today's hospitals. So let's temper our modern, medical hubris with humility, objectivity, and historicity. Today's modern medical center is tomorrow's Bedlam.
Competing interests: No competing interests
Re: A dose of humility
I am a pharmacist, counsellor and carer for my severely disabled son, which means that empathy is something dear to my heart. I wanted to thank Fiona for this insightful and humble editorial.
We have been trying to promote an 'empathic consultation' agenda within the pharmacy profession, with just a little resistance, for example, difficulty in getting an article published. We have managed to blog on our concerns:
http://www.pharmaceutical-journal.com/opinion/blogs/making-our-patients-... and we hope that the sentiments expressed will resonate with your readers.
The Royal Pharmaceutical Society's Four principles of Medicines Optimisation (https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-th...) include the imperative to 'understand the patient's experience.' Through experience as a clinician, counsellor and carer, I contend that this principle can only truly be achieved empathically. When we take our son to the GP, empathy is every bit as important to us as the technical standard of care. Food for thought?
Competing interests: No competing interests