Edzard Ernst: I don’t care how treatment works, as long as it helps my patients.

During the last two decades, many doctor’s attitudes towards alternative medicine have become more liberal. The general attitude seems to be: “I don’t care how it works, as long as it helps my patients.” At first glance, this argument seems correct—after all, clinicians have a duty to do all they can to alleviate the suffering of their patients. Once we dissect the argument carefully, it turns out to be ill conceived when debating the value of ineffective interventions.

Essentially, the argument links two fundamentally different issues: the mechanism of action, and the clinical effectiveness of a treatment. To make things clearer, it might be best to discuss them not in the abstract, but in the context of a concrete form of alternative medicine: homeopathy. About 200 clinical trials of homeopathy have so far been published. Their results are, of course, not entirely uniform but the totality of this evidence fails to show that the effects of homeopathy differ from those of placebo.

The principles of homeopathy are scientifically implausible, and even most homeopaths admit they have no clear explanation as to “how this treatment works.” In fact, scientists are keen to point out that a mechanism of action of highly dilute homeopathic remedies is not just unknown but unknowable, there is no way to explain how they work without re-writing several laws of nature.

At the same time, nobody can deny that many patients feel better after having consulted a homeopath. Therefore the argument applies in an almost classic way: “I don’t care how homeopathy works, as long as it helps my patients.” In a way, it sanctions the use of a disproven treatment for the sake of pleasing the patient.

Proponents of homeopathy disagree and argue that, as patients benefit from it, the use of homeopathy is adequate. Vis a vis thousands of patients who are convinced that homeopathy has helped them, the case against homeopathy is often not easy to make but it is nevertheless supported by several logical arguments.

Patients can improve for a range of reasons which are related to any specific therapeutic effect: the natural history of the condition, regression towards the mean, placebo-effects etc. Thus even if thousands of patients of swear by homeopathy, this does not constitute proof for its efficacy. The most logical explanation of the apparently different results from experience and clinical trials is that the empathetic encounter with a homeopath is therapeutic, while the homeopathic medicine is not.

This should encourage clinicians to build good therapeutic relationships with their patients rather than to dish out placebos. Good medicine constitutes maximising the context effects and applying the optimal therapy. Encouraging an attitude whereby the latter element is neglected is not good medicine and arguably unethical. I fear that the argument “I don’t care how this treatments works, as long as it helps my patient,” might do just that.

Edzard Ernst is a professor of complementary medicine at the Peninsula Medical School, Exeter.

  • How are clinicians supposed to build good therapeutic relationships with us in the ten-minute appointments we get in the NHS? My GP appointments are even sometimes shared with other patients, whom she speaks to on the phone while I’m with her.

    Looking at the websites of various homeopaths, I see that between 60 and 90 minutes is typically allowed for a first consultation. No wonder people feel better after such a nice long chat.

  • Juan_Der_Meant

    The paradox is that if you tell a patient s/he’s receiving a placebo, the “medication” will have no therapeutic effect. The real ethical conundrum is whether it’s ever ok to deceive a patient for “her own good.”

    But the best placebo effect is to be expected in the case where the practitioner also believes in the effect, eg. homeopathy.

    Science has more to learn about the limits of placebo treatments. Obviously, a placebo won’t dissolve a brain tumor, but can it “cure” mild to moderate depression? In homeopathy, you sure don’t have to worry about side effects; that’s one advantage.

  • Andrew_Sikorski

    Ernst argues illogically from his perspective which is far removed from clinical practice. Studying Homeopathy results in more and more questions to pursue with vigorous inquisitiveness rather than trying to pretend it has no basis in fact through spurious and vacuous declamations. His title could have read: ‘Clinicians care’ and work to the Hippocratic Oath.

    For example, the results of an analysis of Homeopathic trials closely mirror the results of conventional medicine trials.

    By the
    end of 2010, 156
    RCTs of homeopathy (on 75
    different medical conditions) had been published in peer-reviewed
    journals of which :

    had a balance of positive evidence:

    had a balance of negative evidence:

    were not conclusively positive or negative.
    cursory glance at these statistics might cause one to think the ratio
    of positive to negative trials was clearly in homeopathy’s favour….
    except when one takes into account the number of trials for which no
    conclusions either way can be drawn, i.e., >50%. When one then
    looks at similar stats for RCTs of conventional medicine, something
    odd appears.

    data obtained
    from an analysis of 1016
    systematic reviews of RCTs of conventional medicine indicate that:

    of the reviews concluded that the interventions studied were likely
    to be beneficial (positive),

    concluded that the interventions were likely to be harmful
    (negative), and

    reported that the evidence did not support either benefit or harm (non-conclusive). That
    a similar spread of statistics was obtained regardless of the
    therapeutic modality would suggest:-Either: Homeopathy
    fairs no better or worse in RCTs than conventional medicine:
    therefore rejecting homeopathy on the basis of RCT data is false and
    biased as many conventional drugs/procedures should similarly be
    rejected but aren’t;

    Or: There
    is something fundamentally wrong with the RCT (and those who claim
    it to be a ‘gold standard’), when around 50% of RCTs fail to
    deliver a clear result.

    has been highlighted by Dr Amy Abernathy from the Duke
    Centre for Evidence-based Practice in the US, who reviewed thousands
    of RCTs and concluded, “Because
    of the paucity of high quality evidence, the data available –
    though voluminous– may have little meaning or value for informing
    clinical practice.”

    Applying ineffective medical interventions is both more costly and more dangerous than applying Homeopathy, yet Ernst is silent on this paradox, often relying for his defence on the fact he is a professor of Complementary Medicine and by his own hand showing he is particularly exercised by the time tested Homeopathic method. Homeopathy is applied alongside conventional medicine in the NHS by regulated, qualified and insured clinicians who gain no additional remuneration and use usual methods of investigation and treatment to ensure diagnoses with appropriate conventional treatments are not missed.

    Once we dissect Ernst’s arguments carefully,they turn out to be naive, ill conceived and biased when debating the value of ineffective interventions.

    Here is an alternative view from Scientific American:

    Additionally Switzerland has included Homeopathy on their National compulsory health insurance system after reviewing the evidence:

    The English translation of the Swiss Health Technology Assessment
    (HTA) report on homeopathy was published in December 2011. This
    extensive and authoritative report offers an unambiguus endorsement of
    the evidence base for homeopathy. HRI Executive Director, Dr Alexander
    Tournier, provides an overview of the report and its impact in
    Switzerland. The report also provides strong evidence for the
    effectiveness of homeopathy in upper respiratory tract infections and
    allergic reactions (URTI/A). Full text http://www.homeoinst.org/newsletter

    It is obvious clinicians care, moreover patients care deeply how their clinicians care, and both embark on a voyage to return to as near health
    as possible.

  • How easy it is to construct a comparison by ignoring the matter of RCT quality. What about Cochrane reviews, or Bandolier?