July 15, 2015

The BMJ’s head-to-head debate on homeopathy

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Should doctors recommend homeopathy?

That’s the question The BMJ posed to two experts who came out swinging on the volatile issue.

Answering YES is Peter Fisher, Director of Research at the Royal London Hospital for Integrated Medicine, who wrote, “Of all the major forms of complementary medicine, homeopathy is the most misunderstood.” Homeopathy is based on the concept of “treating like with like.” Fisher writes: “The controversial element of homeopathy is that some medicines are highly dilute, including “ultra-molecular” dilutions, in which it is highly unlikely that any of the original material is present. This is a major scientific concern and the source of the view that homeopathy “doesn’t work because it can’t work.”

Excerpts of his arguments:

He questions the methods of a recent review by the Australian National Health and Medical Research Council that concluded that “there are no health conditions for which there is reliable evidence that homeopathy is effective.”
He questioned the methods of a meta-analysis published in the Lancet in 2005 that concluded that there is “weak evidence for a specific effect of homeopathic remedies,” based on the results of just eight trials.
Both these reviews are out of line with the other three systematic reviews and meta-analyses of homeopathy for all conditions published in the peer review literature, all of which have come to essentially positive conclusions, as have several systematic reviews and meta-analyses for specific conditions.
For practical decisions about homeopathy the most relevant evidence is comparative effectiveness research examining effectiveness in real world situations, which the Australian review did not include. Several such studies have compared outcomes in patients attending family physicians who do and do not integrate homeopathy into their practice.
Doctors should put aside bias based on the alleged implausibility of homeopathy.

That last point is impossible for Edzard Ernst emeritus professor, University of Exeter, whose answer to the debate question is NO. His arguments:

Numerous trials have tested the clinical efficacy of homeopathic remedies. Their results depend critically on the study design: uncontrolled studies almost invariably yield positive findings whereas this is not true for the most rigorous of the 250 or so controlled clinical trials (such as a study in headache by Walach and colleagues). The explanation seems obvious: the perceived benefits of homeopathy are caused by non-specific effects. Once these are adequately controlled for in trials, the results tend to show that highly dilute homeopathic remedies are indistinguishable from placebos. Even a former consultant of the Royal London Homeopathic Hospital has agreed, writing, “The great majority . . . of the improvement that patients experience is due to non-specific causes . . . Homeopathy has not been proven to work.”
Homeopathy can harm. As the typical homeopathic remedy is devoid of active molecules, it is unlikely to cause serious adverse effects. However, even a placebo can cause harm, if it replaces an effective therapy; in the words of the Australian report: “People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.”
There are financial costs and opportunity costs. In the European Union, the annual expenditure on homeopathic (and anthroposophic) remedies exceeds one billion dollars. These funds could and should be spent more usefully elsewhere. The notion that the NHS must provide homeopathy for patients who want it is disingenuous: patient choice is, of course, an important principle, but the choice must be evidence based and should not be confused with arbitrariness.
In summary, the axioms of homeopathy are implausible, its benefits do not outweigh its risks, and its costs and opportunity costs are considerable. Therefore, it seems unreasonable, even unethical, for healthcare professionals to recommend its use.

The Telegraph was among those reporting that Peter Fisher, the “yes” proponent above, is the Queen’s physician, and added: “The Royal Family has supported homeopathy for generations and there is still a court homeopath.”

And, in the US, a recent Philly.com physician column asked and tried to answer, “Homeopathic medicine: What’s the potential harm?”

Laughter is often the best medicine. So, after all that, maybe what we need is a good laugh, as provided by this classic Mitchell and Webb spoof.

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