On the other hand…

… the phenomenon of apologising for the wrong thing comes alongside people taking umbrage at the wrong thing.  Last week, the BMJ ran a head-to-head feature on the “question” of whether doctors should recommend homeopathy.  This was the latest in a series of articles in which a question is posed, apparently strictly on the understanding that it’ll accommodate a polarised debate, and one person is invited to give a “yea” response, and another to give “nay”.  I won’t bother here with a screed about homeopathy: Edzard Ernst does a good job in the BMJ piece, as have many others across the blogosphere.  (You could do worse, for example, than to have a wander through the Anomalous Distraction blog, which is written by an ex-schoolmate of mine, and which also has lots of pretty pictures of proteins and things.)  Since it’s a nice day, and I’m in a reasonably good mood, I’ll even admit that when Hahnemann was working, something like homeopathy was probably as good a punt as anything else that medicine had to offer.  But… y’know.

Aaaaaanyway…  A rather angry letter appeared.  I think it’s worth examining, because it makes a number of normative and value claims; and if norms and values aren’t the meat and veg of an ethicist’s life, then we might as well go home.

This article omits a third representation from the most important people in the discussion – the patients – of whom I one. I have successfully and exclusively used Homeopathy for more than forty years.

There’s a difference between anecdote and data – and we’re not told why homeopathy has been used.  It’s quite possible to go 40 years without being seriously ill; and there’re even some serious illnesses that’ll sort themselves out with a bit of luck.  But, with my ethicist’s hat on, there’s a problem here with importance.  Patients are important to medicine because without patients there would be no need for medicine.  Patients might also be important in terms of being the proper primary concern of medics.  But it doesn’t follow from that that patients’ views are the most important things to consider when it comes to deciding what doctors should prescribe.  Why would they be?

I find it insulting and demeaning to have my own experience of Homeopathy [sic] downgraded to an “anecdote” as do the hundreds of thousands of other patients who regularly use Homeopathy. Edzard Ernst has no mandate to speak for anyone other than himself; he is neither my physical nor my mental guardian.

This is the bit about being upset by the wrong thing.  What is insulting or demeaning about someone saying that your preferred treatment doesn’t work, can’t work, and shouldn’t be prescribed?  That’s not a personal attack – not even on homeopaths.  It’s just a scientific criticism.  (Imagine a mainstream scientist whose technique for some procedure is generally held to be misguided; if her colleagues tell her that, she might feel as though she’s being got at – but there’s no reason to suppose that she is.  If her integrity is impugned, that’s a different matter.  But simply being told you’ve got something wrong is neither here nor there; and while it might smart, that isn’t the fault of the person who tries to put her right.)

If you have evidence for homeopathy, then present it.  Being upset because someone has rejected it isn’t evidence.  Oh – and if Edzard Ernst has no mandate to speak for hundreds of thousands of other patients, why does this correspondent?  Curious.

I am more than capable of making my own decisions, based on my own intelligence, research and experiences. Simply put, he should mind his own business.

The question posed was whether doctors should prescribe homeopathy.  Minding one’s own business has nothing to do with it.  And, of course, what’s sauce for Ernst is sauce for the pro-homeopathy Peter Fisher.  tu quoque.  (While we’re at it… didn’t I warn of the “I’ve done my research” response a couple of weeks ago?  Why, yes: I did.)

It is high time that due respect was given to the voice of the patient as accorded in Human Right Law and the Equality Act and attention paid to the basic Right on Informed Consent.

Informed consent doesn’t mean you get a right to particular treatments: only that you get to refuse ones you don’t want.  Sorry.  Ditto human rights law.  As for the Equality Act (2010): I searched for the word “patient”, and it doesn’t appear once.

GP’s trained only in allopathic medicine who have neither training nor experience of Homeopathy simply do not have the ability to influence patients’ decisions.

Yeah, they do.  The whole point of medical training is to be able to look at the evidence for what works and work out how best to administer it.  Honestly, if homeopathy worked, it’d be taught.  You don’t even get to play the Big Pharma Shill conspiracy card here, because if homeopathy worked, Big Pharma would be pushing that, too.

I strongly resent anyone who has nothing more than their personal bias and prejudice

– and evidence!  Don’t forget evidence –

refusing to give me what I and my family have found to be the most efficacious treatment available.  There is a very simple financial argument to this question as well. Patients would not continue to pay for Homeopathy privately if it did not work. Patients are not fools. They clearly understand value for money which is why Homeopathy continues to flourish.

People pay for things that don’t work all the time.  The fact that they’ve paid for it might actually make them more likely to think that what they’ve bought works, because they have an interest in not believing that they’ve been sold a pup.  (I used those Vibram Five Finger things for ages, on the basis that I’d paid a bloody fortune for them.  That was fallacious, too.)  But, still: if someone wants to go on buying homeopathic remedies, then that’s up to them, just so long as noone else is harmed.  It doesn’t follow from that that doctors ought to help out.  In just the same way, if I happen to believe that nailing a carrot to my wall as a smoke detector is a good way to protect my home, then that’s fine and dandy.  That doesn’t mean that the Fire Brigade should lend me a hammer.

GPs would do well to consider the cost savings to be gained from integrating Homeopathy in to their practices.

Well, there’d be fewer people with costly illnesses of old age, for sure.

There’re three points to make here.  The first is that insults may be morally important, but a perceived insult doesn’t have to be.

The second has to do with consent and patients’ rights.  However important you think that consent is, we should perhaps be wary of thinking that this means that the patient is wholly in charge.  Admitting that the patient has a veto on a given medical decision doesn’t mean that he has a right to propose or insist on certain courses of action.  The medic is still the gatekeeper – and, I’d’ve thought, for fairly good reasons.  While doctors can make mistakes – sometimes big ones – and while patients might be better informed in some cases, the odds are still in favour of the medic’s judgement being more finely honed than the patient’s.  More: when it comes to decisions about whether doctors should use such-and-such a procedure, there is nothing improper about the terms of any debate being medical: asking patients what they’d like isn’t necessarily a good move, and patients have not, by that token, been wronged by their voices not being given a platform.  In one sense, patients were omitted from the BMJ piece.  But it doesn’t follow that anyone was wronged by that.

Finally, that allows us to put flesh on the bones of Ernst’s contribution.  It seems reasonable to say that, in the absence of evidence, doctors should not recommend homeopathy.  That doesn’t commit us to the belief that it doesn’t work; there’s always room for a mismatch between our best account of the world, and the world as it is in itself.  Maybe homeopathy does work.  Still, that is in a sense irrelevant: it’s the evidence that’s relevant, and right now, what little evidence there is in favour of homeopathy is massively outweighed by the evidence that (a) homeopathy doesn’t work, and (b) conventional medicine works far better.  Of course, there might be outliers; but the general shape is clear.  The current state of the evidence shouldn’t be ignored: and when it comes to treatment decisions, what the evidence does suggest is, I’d’ve thought, the proper foundation for treatment options.  Patients can decide whether they want to accept what the evidence supports; that’s not the same as giving the option of what it doesn’t.

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