Homeopathy, Blacklisting, and the Misuse of Choice

It seems that homeopathy might at last be facing some serious opposition from within the NHS, with the prospect of its being blacklisted being considered.

There’s any number of people who’ll be entirely on board with that. Homeopathy doesn’t work.  Of course, a lot of medicines turn out not to work, or not to work well.  But the difference between homeopathy and unsuccessful drugs is that the latter are at least more likely to have a plausible mechanism – roughly, one of throwing molecules at other molecules, or coaxing the body to throw molecules at molecules.  Homeopathy doesn’t even have that.  It relies on water having a memory.

At the very best, it contributes nothing. But it does cost money – not much, but more than none, and in the end, the taxpayer has to pony up for it.  Money is being wasted every time the NHS pays for homeopathic treatment, and that looks to be unjust.  (It’s not the most unjust thing in the world, but that’s neither here nor there.  Wrongs are wrongs, even if harms might vary.)

It might even get in the way of effective treatments, if patients use it rather than them.  That might mean that they’re worse off than they could otherwise be.  At the outside, it might mean that they’re a danger to others – they might be spreading illness by dint of not getting treated properly for it.

To that extent, Simon Singh strikes me as being bang on the money:

Simon Singh, the founder of the Good Thinking Society, said: “Given the finite resources of the NHS, any spending on homeopathy is utterly unjustifiable.

“The money spent on these disproven remedies can be far better spent on treatments that offer real benefits to patients.”

We don’t have to be able to make a positive claim that homeopathy doesn’t work; all we have to be able to show is that it is not, and is not likely to be, the best thing.

Nothing else.

Now look at the defence of the procedure mounted by Helen Beaumont in that same article.  She’s described as the president of the Faculty of Homeopathy… but is strangely reluctant to offer a positive defence of it, saying only that

other drugs such as SSRIs (selective serotonin reuptake inhibitors) for depression would be a better target for saving money, as homeopathic pills had a “profound effect” on patients.

She told the BBC News website: “Patient choice is important; homeopathy works, it’s widely used by doctors in Europe, and patients who are treated by homeopathy are really convinced of its benefits, as am I.”

But, notwithstanding this, the evidential base for homeopathy simply doesn’t exist; and even granted (for the sake of the argument) that there might be some evidence for its effectiveness, it’s vastly overwhelmed by the evidence that you can get better results doing other things.  (Show me someone who claims to have been cured of something when using homeopathy and nothing else, and I’ll show you the distinction between cause and correlation.  Show me a peer-reviewed RCT demonstrating effectiveness in the BMJ or NEJM, and I’ll listen.*)  And, of course, “profound effect” could mean anything.

That’s of epidemiological and medical interest.  But the other parts of her comment are at least as important from an ethicist’s perspective.

It’s not about choice.

I’ve said it before, but at risk of labouring the point: choice doesn’t generate entitlement.  The fact that someone would prefer a particular kind of treatment may mean that they should – all else being equal – be allowed to pursue it.  It does not follow that the NHS should be providing it, much less endorsing it.

To witter on about choice is, actually, to admit that the clinical evidence is threadbare.  For things that work, the primary reason to administer them is that they work; choice comes into it in the form of a veto.  To break it down to near-parodic levels, choice works like this:

“Doctor, my leg hurts.”

“I diagnose knee-measles.**  The evidence supports hacking off the limb with a tablespoon as treatment.”

“I’ll take my chances, ta.”

Choice generates for us reasons not to act; and the prevailing mood is that those reasons are likely to be overwhelming.  Indeed, it’s accepted in law that, all else being equal, a patient can reject treatment for any or no reason at all: the rejection itself is reason enough for it not to be given.

On the other hand, we should accept that choice does give us a reason to act – but only the kind of reason that is easily overwhelmed by other considerations.  Efficacy, or the lack thereof, is one of them.  Time, energy, resources are in short supply.  “I choose this” is a reason to provide it; but “It won’t do you any good” defeats it, especially when third parties are the ones paying for it.

In other words, even if the prevailing mood about choice does, sub specie aeternitatis, have right on its side, it still doesn’t do what Beaumont thinks it does.

And, as for homeopathy, so for other things.  Choice is important in medicine; but it should be kept in its place.

 

* Yes, this is setting the bar high.  I think that a homeopathic study should have to appear in a top-10 journal to have the same impact as a conventional study, even if the conventional study appears in a much less prestigious journal.  Why?  Simply because homeopathy’s claims are extraordinary.  Should homeopathy earn its spurs as a discipline, then that burden will be less onerous; it would tend towards being the same as that carried by studies in conventional medicine.  For the time being, though… nope.  It has to earn its place.

** Totally a thing.