Issue 39 / 20 October 2014

YOU don’t see the word “gentle” in the title of a scientific paper all that often.

But there it is atop a paper coauthored by two homeopaths and two prominent Australian medical ethicists, Associate Professor Ian Kerridge and Professor Paul Komesaroff: “A gentle ethical defence of homeopathy”.

Homeopathy doesn’t usually keep that kind of company. Medical leaders are generally more likely to lambast the alternative health practice than to defend it.

These authors, however, suggest those who criticise homeopathy as unethical have “an impoverished idea of ethics — one that fails to account for either the moral worth of care and of relationships or for the perspectives, values, and preferences of patients”.

“The choice to seek care from a homeopath can be just as valid and as ethically sound as any other health care choice that a patient or consumer makes, and the notion that consent or agency is untenable in respect to homeopathy is deeply paternalistic and challenges the very idea of moral autonomy”, they write.

I can’t help gently suggesting that perhaps the authors are setting up a bit of a straw man here.

I’m not sure that even the most virulent critics of homeopathy would argue an adult seeking homeopathic care was acting unethically, though they might criticise that choice on other grounds.

But what of the homeopaths? Is it unethical to provide a treatment that comprehensively fails to meet the normal standards of evidence-based medicine (EBM) (see this MJA review)?

The authors of the current paper argue the EBM approach alone is not enough, but that we need “a more sophisticated approach to evidence in medicine” in this and every other field of health care.

“This approach would recognise that what constitutes evidence can be defined and measured in different ways by different people or groups and that judgements about competing epistemes are ultimately statements about the ‘value’ of particular data or outcomes”, they write.

“When looked at in this way, it then seems completely appropriate that congruence with patients’ values, goals and preferences as well as their reported experiences and outcomes from homeopathic interventions should be included in any comprehensive evaluation of the efficacy of homeopathy.”

That’s all getting a bit postmodern for me.

I have no doubt many patients experience benefit from seeing a homeopath, and I support their right to keep doing it. I also don’t doubt the vast majority of homeopaths hold a sincere belief in the value of what they do.

But I don’t believe their medicines “work”, other than by triggering a sometimes powerful placebo effect, and I am disturbed when claims are made for them that go beyond that.

I wrote last year, for example, about homeopathic remedies being sold in pharmacies with claims they were effective against fever and other symptoms in children, claims that were withdrawn after a successful complaint to the Therapeutic Products Advertising Complaints Resolution Panel.

Randomised controlled trials (RCTs) are far from perfect but, as Winston Churchill famously said about democracy, they’re the worst system we have, except for all the others.

I’d certainly rather base my decisions about health care on RCTs than on a bunch of patient anecdotes.

Others have different values and different decision-making processes and that’s fine. I have friends who attest to the mental health benefits of past-life regression and tarot readings and I respect that.

My own ethical concerns about homeopathy arise when attempts are made to place it in contexts where it doesn’t belong, when the public purse subsidises it through private health insurance rebates, for example (something that may come to an end next year).

And I think it’s fundamentally misleading for a practice without a conventional evidence base to be promoted in a scientific context — as happens when pharmacists endorse homeopathic products or universities teach homeopathy as part of a science degree.

The ethics of that, I’d gently suggest, are troubling.

 

Jane McCredie is a Sydney-based science and medicine writer.
 


Poll

Should the medical profession accept a patient’s choice to seek care from a homeopath?
  • Yes – but reveal concerns (59%, 110 Votes)
  • No – it’s harmful (24%, 44 Votes)
  • Yes – unreservedly (17%, 32 Votes)

Total Voters: 186

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26 thoughts on “Jane McCredie: A gentle reproach

  1. daman langguth says:

    Here here Jane.

    If you know something is a falsehood, or neglect (like in mandatory chid abuse reporting) then it is unethical to pretend that it might help. Homeopathy is so ridiculous as to actually be a joke. Those that perpetuate it as treatment deny the tenets of physics and chemistry.

    I think this tacit acceptance is likely due to rthe authors religious beliefs, ie if one can challenge homeopathy then one can challenge religion, after all they are both non-fact, non-science, non-evidence belied systems, that ignore scientific fact.

  2. Mick Vagg says:

    Having downloaded and read this article, I can only surmise that they are arguing that determining efficacy is irrelevant to whether a treatment is ethical. If I convince you I have a flying carpet, and sell you my flying carpet on that basis, the ACCC will still say it’s fraud because flying carpets aren’t a thing. Doesn’t matter a damn whether both parties are sincerely deluded or not. That is why homeopathy is unethical for practitioners of medicine to offer or endorse. It’s not about respecting autonomy because there is no fair choice between medicine and homeopathy.

  3. Sue Ieraci says:

    Thanks for the article, Jane. All therapeutic relationships and remedies have the potential for placebo effect, including what we know as ‘medicine’ – but medicine works BEYOND placebo. It is not considered ethical for doctors to use deception – even for benign reasons. Why defend this paternalistic style when used by others?

     

  4. Cathryn Hester says:

    Patients can certainly make their own mind up, but any ethical evaluation of homeopathy (or any other CAM diagnostics/treatment) should evaluate whether a patient has given their informed consent.

    For homeopathy this would sound something like “this treatment has been comprehensively shown to be of no more benefit than a placebo. It may, however, be financially costly, and could also delay significant diagnoses and the use of (actually) efficacious management options. Would you still like to proceed?”  

    I think it is unethical (perhaps negligent and self-serving) for a practitioner to omit this discussion with a patient seeking these types of treatment.

  5. q402681@amamember says:

    Indeed Mick & Daman,

    Indeed we now do seem to be infected with a secular post-modern version of the very ethical idiot ‘Peripatetic’ philosophers and ethicists of 15th/16th century Catholic Church infamy who put Galileo on trial, had him recant and effectively stopped all rational scientific endevour in Italy in its tracks for centuries. Also the fact that scientifically trained chemists, who themselves have benefited from 500 years of brilliant enlightened European scientifc progress, are now actively pedalling this crap on the altar of cynical crass capitalism seems to indicate something of a major malaise in 21st century Western Democracies. The chemists clearly have taken Barnham & Bailey’s advice to heart: ”Never give a mug an even break” and “You never go broke underestimating taste or intelligence of your audience”.

    Also, please, will everyone stop being ”gentle” with “Big Vitamin” and its retinue of illiterate idiots.

    ps. Please read the NEJM Oct 16 about irrational testing (PSA & Mammograms), emotional factors and individuals preferences for an interesting and balanced view on a topic not dissimilar to this one.

     

  6. James Dando says:

    Nail on the head. Criticism of homeopathy may reveal ‘ethical poverty’ but it’s quite a leap from that acknowledgement to including patient anecdotes in an assessment of treatment efficacy. Homeopathy has its place – and that place is far, far from evidence-based medicine. East is east and west is west and never the twain shall meet.

  7. Dr Phil Watters says:

    As health professionals we deal with patients of all mindsets, including a significant number who choose to have faith in ideologies with no evidence base in rational scientific analysis. As eminent scholars such as Bertrand Russell and Richard Dawkins can attest, dealing with that is a truly Sysiphean task. Cognitive dissonance and confirmation bias are the devils of rational science.

  8. Dr Ken Harvey says:

    I agree with Jane. I have no problem with consumers utilising “natural therapies” such as homeopathy, iridology and reflexology as long as practitioners of these modalities abide by State Codes of Conduct for Unregistered Health Practitioners (currently under discussion to become a National Code).  These ethical Codes (like those for registered practitioners) include clauses such as “a health care worker must not make claims either directly to clients or in advertising or promotional materials about the efficacy of treatment or services he or she provides if those claims cannot be substantiated”.

    Whether or not such therapies should be subsidised by the taxpayer, either for patients through the private health insurance rebate or for students through FEE-HELP, is a question about the allocation of scarce resources. The Review of the Australian Government Rebate on Private Health Insurance for Natural Therapiesused the NHMRC level of evidence approach. This has caused much angst to proponents of “natural therapies” but at least it provides a consistent basis for decision-making (like the choice of medicines on the PBS).

    If “evidence” is defined by the “values” of different people or groups, as the authors of “A Gentle Ethical Defence of Homeopathy” suggest, then horoscope reading and water-divining would appear equally valid for public subsidy and university degrees. 

  9. stephen sonneveld says:

    I wonder if the real reason we are reluctant to disuade patients away from homeopathy is the threat of a letter from the Health Complaints Commission or AHPRA.  If the patient wishes to waste money  and effort on homeopathy, they sometimes have a delusional belief in their benefits. Any comment by the medical profession will be ignored. One can only hope the patient gets some placebo benefit either physical or psychological.  

    I prefer to comment only if I perceive the alternative medicines may have a detrimental effect or completely disuade a patient from effective standard medical therapy – how often to no benefit.

     

  10. Chris Guest says:

    Yes, I plead guilty of having a utilitarian, “diminished episteme” that “excludes the value and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy.” The Levy et al paper makes for a very funny read. More like a lost chapter from Gulliver’s Travels, but I don’t think that the satire is intentional.

  11. Meryl Broughton says:

    The rise of homeopathy and related hypotheses, including Darwinism, has come along with the Enlightenment. “The first effect of not believing in God is to believe in anything”.

  12. Marcus Aylward says:

    Several things are evident from the Levy et al article. Firstly, that while most areas of rigorous thought have blown away the value-less miasma of postmodernism, limited areas of academe are still to be ventilated; second, that this sort of soft-headed defence of homeopathy represents a regression to pre-Enlightenment thinking from the very sources that are meant to epitomise Enlightenment thinking itself; and third, that these authors are in serious need of some psychotherapy, as their crisis of confidence in modern medicine verges on self-loathing.

    Perhaps the article was more for attention than for rigour?

  13. Paul Komesaroff says:

    Part 1 of comment

    We are two of the authors of the article in question and are pleased that it has generated some informed comment. We are, however, disappointed that it has also provoked exactly the kind of inflamed dogmatism that we had hoped to move beyond through careful, measured discussion.

    The key argument of the paper should not be difficult to understand for anyone familiar with the Enlightenment tradition of thought: that epistemology and ethics refer to different, albeit interconnected, domains of thought. There is nothing postmodern about this claim, despite the beliefs of three of the contributors to the discussion; nor is it inconsistent with the ethos of science itself, which – at least since Galileo – has been identified with a commitment to scepticism and openness to contrary points of view.

    Even a cursory reading of our paper will reveal that we make no claims about the truth-values of statements about the biological effects of homeopathy, we do not argue for state subsidies for homeopathy in preference to conventional medicine (of which we are ourselves practitioners), and we do not propose insurance rebates for homeopathy or the inclusion of homeopathy in universities.

  14. Paul Komesaroff says:

    Part 2 of comment

    Rather, we argue that “the contention that the evidence-base for homeopathy is insufficient does not mean that homeopathy is – by definition – unethical. We suggest that the majority of professional homeopaths behave ethically, work for the good of patients, practice virtuously, have integrity, privilege their clinical interactions with patients and that their care provides valued outcomes for the people who seek their care and expertise.” This would seem a rather mild claim, certainly in comparison with the allegation of one of the erudite commentators that we are “actively pedalling… crap on the altar of cynical crass capitalism” (?). Also, it is more intelligible than the claims of other commentators, including the one who argued that our arguments were motivated by belief in religion and the other who concluded that they were the effect of a lack of belief in God!

    For the sake of clarity, let us state our main point once again: the fact that something lacks one particular kind of evidence does not make it unethical. The words “ethical” and “unethical” are not just vague terms of admiration or abuse that one uses in polemical argument. If you don’t like homeopathy, don’t use it, but don’t debase the concepts and traditions of science by misusing and distorting its most fundamental precepts. 

    Paul Komesaroff and Ian Kerridge

  15. Cathy Nolan says:

    I find it both appalling and interesting that the first two authors on this paper being reviewed are referred to merely as “two homeopaths”  and not afforded the same respect shown to their co-authors who were appropriately introduced as “two prominent Australian medical ethicists, Associate Professor Ian Kerridge and Professor Paul Komeseroff”. By introducing and singling out these two authors are you suggesting that no “self-respecting”  ethicist would support homeopathy, or even co-author papers with them? For those that haven’t read the article the two “nameless” homeopaths are David Levy MHSc (Ed) AdHom ND, PhD scholar and Ben Gadd BA(Hons) BSc(Hom) MSc(Hom) RN LFHom(Nurse) MF(Hom).

  16. q402681@amamember says:

    Ethics and epistomology are intimately interdependent and whilst it is certainly theoretically possible to mount a philosophical argument for an individual, depending on one’s belief systems, to be ethical as well as stupidly deluded (eg a gravity or holocaust denier), it is simply not acceptable for ”intelligent” academics to attempt an ethical defense for a cynical massive industry that is nothing but a ‘placebo’ based snake oil spruiker. Kerridge and Komeroff’s arguments are equally valid for workers in cigarette producer factories and even the poor farmers caught up in the cocaine and heroin drug trades. It appears to me that they are being played for mugs by the British homeopathic lobby who have successfully subverted the NHS and are looking further afield to expand their funding avenues.

  17. University of Sydney says:

    Wow, such a lot comments but a fascinating discussion. Presumably, the patient still has a right to evaluate the evidence for homeopathy themself (ie at least to seek an opinion) rather than a Big Brother approach denying patients the right to even see one. Nonetheless the lack of government funding for certain services on the basis of ineffectiveness can reasonably be identified in advance to prospective patients/clients. For me, patient anecdotes reminds me of learning by induction ie it worked for this patient so it will for you too. The anecdotes of other patients may be somewhat different and of course all should also be presented rather than only the favourable stories. On the other hand, RCTs and other trials of course can and have been fudged too. There are many interventions and devices that have turned out to be far less effective, if at all, than initially suggested. I also agree that for some, the placebo (and nocebo) effects of (non-) interventions are substantial. Interestingly, there is a well-conducted RCT showing that placebo acupuncture is more effective than placebo pills ie surgery is better than medicine even both don’t work! I remember Homer Simpson at Arpoo’s seeking flu relief and when told that a particular pills was no better than placebo, replied “I’ll have some of them (the placebo) too”!

  18. Marcus Aylward says:

    Let us give homeopathy the benefit of the doubt for a moment, and imagine that they are not cynically trying to milk gullible ‘consumers’, but are dedicated practitioners aspiring to treat patients responsibly. 

    Let us also acknowledge that whilst it is a pleasant indulgence to be able to spend time thinking about thinking and weighing relatives virtues, it becomes necessary to say eventually that there are in fact some ultimate truths in the universe. One of these is that a dilution to nothing – the essence of homeopathic treatments – can leave no active ingredient, and any effect must be placebo based. 

    Once this fact is declared, ongoing practise in the face of it is either malicious exploitation or wilful, active delusion. Neither represents an ethical choice.

  19. Camilla Gold says:

    “[Evidence based medicine]requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice…External evidence can inform, but never replace, individual clinical expertise that decides whether external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. ..any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patients’ clinical state, predicament, and preferences, and thus whether it should be applied…Clinicians who fear top down cookbooks will find the advocates of evidence based medicine joining them at the barricades.” David L Sacked

    Based on the views expressed in this article re post-modern interpretations of EBM I feel the time may have come for true proponents of EBM to start joining us at the proposed barricades.

  20. Richard Gordon says:

    Thank you Jane McCredie, David De Leacy and Marcus Aylward for your comments. I wholly agree.

    Why did these ethicists write an article about the ethical use of non-evidence based therapies and only discuss homeopathy? Why not include faith healiing, astrology, rolfing, therapeutic touch etc., all of which have the same benefit as homeopathy?

    Doctors who practise homeopathy who believe it is beneficial do not understand evidence based medicine.  Their fitness to practise may be in dispute. Those who practise homeopathy and do understand evidence based medicine are practising unethically.

     

  21. Jenny Heywood says:

    Hi Jane, If you are looking for RCTs look no further than the NHMRC investigation into homeopathy which is due by the end of this year. There are many high quality RCTs referenced there. So why don’t you hear about them? Because the NHMRC review created criteria for assessment which specifically excluded the large body of high-quality RCTs.  Unethical and illogical at best.

    If the medical profession, as represented by the NHMRC, is serious about finding out if homeopathy is effective, a good start would be to fund the kind of trials they find acceptable, and stop ignoring the ones already done which meet their criteria for reliable science. We need a more open perspective on alternatives, not more suppression of information.

    As for anecdotal evidence, what are RCTs but a gathering and and analysis of anecdotal evidence on a large scale? If the evidence of 10 human beings is unreliable then the evidence of 10,000 is still unreliable.

     

  22. Elliot Rubinstein says:

    There is a vast difference between RCT’s and collections of anecdotal reports. I think any support for homeopathy from medical practitoners is scandalous and we should have no part in it. This must be the best restaurant in Melbourne. 20,000 flies can’t be wrong!

  23. daman langguth says:

    My apologies to the authors about being dogmatic about science. As Neil de Grasse Tyson says: The best thing about science is that it is true wether you believe in it or not. Komesaroff seems to imply there are types of evidence and that irrational flights of delusion need to be considered along side actuallly unrefutable science. I agree that i the acceptance of this drivel allows a modern malaise in medicine; integrative medicine.

    Science is dogmatic about things that are true. It however seeks further truths and tests its theorems.

    Homeopathy is religion in healthcare form.

  24. q402681@amamember says:

    Amen

  25. Paddy Hanrahan says:

    I had a similar problem when I spoke at a meeting about what I thought was the complete disregard by orthopedic surgeons for both an evidence base for what they do, and the natural history of diease and injury. Some thought I was suggesting that they were unethical, and I wasn’t suggesting that at all – rather I thought they were practising ethically under inappropriate paradigms. The same could be said for homeopathy, they are possibly practising ethically under an at best erroneous belief system, at worst a delusional belief system. But orthopedic surgery has much other going for it, and there is no doubt that orthopedic surgeons achieve a considerable amount of good, through their practice of orthopedic surgery. Whatever good homeopaths cause is independant of homeopathy. An erroneous belief system is not, in itself immoral or unethical, but then to profit from it and tacitly cause others to believe that it will improve their health is simply wrong. Homeopaths may not be unethical, but the practice of homeopathy clearly is, despite any philosophical flourishes in the debate about it. The article by Komesaroff et al is no more than sophistry.

  26. George Dimitriadis says:

    I think the authors of “A Gentle Ethical Defence of Homeopathy” remain true to their title, and are clear and consistent in their content, in rightly separating “ethics” from efficacy. Well done to the authors for a dispassionate treatment in a most ethical manner.

    Ethics (Gr. ηθική (Ithiky), virtue, moral). Virtue refers to any beneficial quality, and given the user of Homœopathy has the right to deem they derive the benefit they perceive (irrespective of any external assessment), then, by extension, Homœopathy is rightly held as virtuous, hence ethical. For virtue is not a inherent quality, rather, a quality perceived, and for this reason, the same thing may be (rightly) held as virtuous by one, yet deleterious and even harmful, by another; and in the same way a substance may be of virtue in one disease, yet without virtue or even hurtful in another. One cannot ethically contend the experience of others expressed in favour of Homœopathy is in any way invalidated by their own inexperience in observing the same. Or would they also extend their ill-reasoning to suggest that the losing party in an election must now be declared unethical for the majority did not agree with their view?

    What is of note is that would-be “ethicists” themselves have so little regard for the position of thinking and highly educated adults in favouring Homoeopathy (in almost every corner of the globe), that they most unethically infer such people must be ignorant, deceived, or lack a mental capacity for proper reason.

    Lastly, let us also not confuse the indefinite quality of “truth” as some would venture to mention, with “scientific method” or the (methodical post-Baconian, inductive) pursuit of knowledge.

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