Apr 24 2014

Ernst on Homeopathy

Edzard Ernst is one of my intellectual heroes. If you are a skeptic, you need to know who he is. He began his career amenable to the claims of alternative medicine. He became the world’s first professor of complementary and alternative medicine, and set about to do the one thing that no other CAM proponent (to my knowledge) has truly ever done – he wanted to use rigorous scientific research to find out if any specific CAM modality worked. Most proponents use research to prove that CAM does work, or simply to describe how it is used or how it can best be implemented.

Throughout the publication of his more than a thousand scientific articles, Edzard became increasingly convinced that most CAM methods simply do not work. Further, he learned what happens to people who point to the scientific truth about CAM, they are vilified by true believers.

I have to admire anyone who changes their world-view significantly in the face of scientific evidence. His intellectual honesty is refreshing.

It is interesting that Edzard was trained as a homeopath, the one CAM treatment that is perhaps the most at odds with science. He has written a recent summary of the various views on homeopathy. While he admits these three views are caricatures (meant for emphasis) he feels they capture the basic situation.

He describes the skeptic, who reject homeopathy on plausibility grounds. Then there is the true-believer, who accepts homeopathy because of personal anecdotal experience, and resists science and logic. Finally there is the evidence-based medicine (EBM) advocate, who cares not for plausibility, but looks only at the clinical evidence.

He concludes:

The arguments and counter-arguments originating from the various perspectives would surely continue for another 200 years - unless, of course, two of the three perspectives merge and arrive at the same or very similar conclusions. And this is precisely what has now happened. As I have pointed out in a recent post, the most thorough and independent evaluation of homeopathy according to rigorous EBM-standards has concluded that “the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.”

He ends on a hopeful note that perhaps now homeopathy will finally fade, and this 200 year old error can be corrected. He is referring to the recent Australian report on homeopathy that I also wrote about here. Like the UK report before it, the exhaustive analysis concludes that the clinical evidence shows homeopathy has no effects beyond placebo. So, whether you take a skeptical or EBM approach to homeopathy, it cannot and does not work.

I would add two further categories to Edzard’s description. The first is simply the misinformed public, who are not even aware of the true nature of homeopathy or that it is such horrible pseudoscience. Many in the public think homeopathy is herbal or natural medicine, rather than the magical potions it really is.

The final category, the one to which I belong, is the science-based medicine (SBM) approach. Edzard’s description of the EBM approach is spot on, and in fact is one of the major reasons for SBM, as a fix to the deficiencies of EBM. EBM looks at clinical evidence as if that is all there is. They give too little (if any) consideration to prior plausibility, which is really just an expression of the existing basic science and clinical science. Plausibility, in other words, is also about evidence. The worst of EBM puts blinders on, narrowly focusing on clinical evidence and ignoring basic science or science from other disciplines.

The SBM approach looks at the clinical evidence in the context of all other scientific evidence, expressed as prior probability or plausibility. The plausibility of homeopathy approaches zero, and so it is not shocking that the clinical evidence also shows homeopathy does not work. While I am glad to have the clinical evidence to drive this point home, skeptics have a point when they argue that it is likely a waste of resources to fund extensive clinical trials into magical notions that cannot possibly work.

SBM also takes a thorough look at the nature of science itself, specifically medical science – the limitations and abuses of clinical trials, the nature of self-deception, statistical misadventures, and outright pseudoscience. We study the process of science and the scientific literature itself, so as best to interpret the evidence. EBM, in my opinion, takes an often naive approach to the clinical literature.

One of the missions of SBM as an organized effort is to educate those who are already scientifically or skeptically minded toward the SBM view. Edzard’s description of the skeptical position (and again, to be fair, he admitted this was a caricature) only captures one aspect of this view. SBM is essentially the fusion of Edzard’s skeptical and EBM approach, which actually is the true skeptical approach.

I do feel compelled to point this out because the notion that skeptics only consider plausibility, and then dismiss claims out-of-hand because of lack of plausibility, is a common but inaccurate description of what is happening in mainstream skepticism. (Of course I can’t account for what every self-identified skeptic says or does, but I am referring to the skeptical literature.)

Read SBM articles on homeopathy or any other pseudoscientific topic – you will find a detailed discussion of plausibility, but also an in-depth and nuanced analysis of the clinical evidence. Skeptics do explore issues in depth and look at the evidence, that’s what we do.

What about Edzard’s conclusion? Will this latest blow to homeopathy finally put us on a path to end two centuries of pseudoscience? That would be nice, but I am not hopeful.

As Edzard himself points out, homeopathy true believers are immune to logic and evidence. If they can maintain belief in the magic of homeopathy, no amount of further evidence is likely to have an impact. At best we can marginalize the true believers, we will likely never eradicate them.

I do think there are some concrete goals that can be achieved. Homeopathy currently enjoys regulatory legitimacy in many industrialized nations, including the US, UK, Canada, Australia, and all of Europe. A public discussion of the evidence should lead to withdrawal of official support for homeopathy. Homeopathic potions should not be approved by the FDA, homeopathy hospitals in the UK should be repurposed, and no government should provide a dime for further research into homeopathy.

These are achievable goals, but it will be difficult to translate scientific reality into political will. We will also be coming up against the will of the true believers and those who make money from the scam of homeopathy. The power and will of people who have a vested interest in persistently lobbying the government should not be underestimated. Boiron will not give up its multi-million dollar industry in selling water and sugar pills easily.

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12 responses so far

12 Responses to “Ernst on Homeopathy”

  1. TomJLon 24 Apr 2014 at 9:47 am

    Great article. I think the distinction between science-based medicine (SBM) and evidence-based medicine (EBM) is an important one. As you have described here and elsewhere, EBM is associated with a variety of issues, in particular the emphasis on more research (‘more well designed large RCTs needed’ etc.) which is often unnecessary purely on the grounds of non-existent prior plausibility. This is expensive, time consuming and doesn’t take into account the likelihood of false positives from poorly and even well-designed trials muddying the waters.

    However, anyone I know who is actively involved in research either has not heard of SBM or is typically unaware of the distinction between SBM and EBM. For example, searching for ‘science based medicine’ on google or pubmed doesn’t really bring up any results for published academic articles, apart from those about EBM.

    Is there any intention to outline the position of science based medicine in the academic literature in the same way as Sackett and colleagues influential articles did for EBM (eg. Evidence based medicine: what it is and what it isn’t, (1996) BMJ) or is this not a plausible option? I personally think a position statement which outlines the theoretical and methodological goals of SBM and how they build upon and correct upon some of the limitations of EBM would be a valuable contribution to the research literature.

  2. carbonUniton 24 Apr 2014 at 12:02 pm

    I think many consider “homeopathy” = “home remedy”. I think there’s deliberate marketing to exploit this.

  3. Teaseron 24 Apr 2014 at 2:01 pm

    Great entry and thanks for talking about Ernst. I will add his blog to my regular reading list.

    I have found this graphic very useful in regards to supplements and other “health foods”.

    Scientific evidence for popular health supplements
    Showing tangible human health benefits when taken orally by an adult with a healthy diet

    http://www.informationisbeautiful.net/play/snake-oil-supplements/

  4. grabulaon 24 Apr 2014 at 10:44 pm

    I have to agree with carbon unit, part of what’s muddying the water these days is the fact that homeopathy is replacing “natural” when it comes to certain products. I notice on occasion a lot of products using the label that obviously aren’t just water.

  5. Eric Tergersonon 28 Apr 2014 at 3:57 pm

    I know this is an old quibble that gets trotted out time after time, but once again, my eye twitched a little bit when I saw the term “skeptic” being used to describe someone “rejecting” something for one reason or another.
    I realize these anecdotes confirm my own bias, but that bias is that the term skeptic only describes the very first part of what skepticism really entails: Don’t buy into a claim before looking into it. Then you go through all of the steps you need to in order to evaluate evidence, plausibility, ect ect.

    I know there have been other attempts at finding a different name… but gah!

  6. Eric Tergersonon 28 Apr 2014 at 3:59 pm

    Specifically, the term skeptic being confused with contrarian, or, a hater, basically.

  7. Nitpickingon 29 Apr 2014 at 7:26 am

    How does one nominate for the Macarthur Foundation grants? I think it’s time Ernst got one.

  8. BillyJoe7on 29 Apr 2014 at 7:47 am

    Sometimes “sceptic” means “denier” as in “climate change sceptic”
    By this definition, even sonic is a sceptic (:

  9. Bill Openthalton 29 Apr 2014 at 7:49 am

    There is a thin line between a doubter and a denier, especially when one is surrounded by bullshit.

  10. Kevin Duganon 29 Apr 2014 at 2:45 pm

    I now use “Bayesian Skeptic” or “Bayesian Rationalist”. This leads into a discussion of Bayes theorem and how prior probability feeds into evaluating dubious claims in the context of other explanations.

  11. Thomas_Kunderaon 29 Apr 2014 at 5:21 pm

    Three interesting points to consider about homeopathy: it is a “medicine” that is unlikely to be harmful due to the dilution method, very cheap to produce (99.9999…% of sugar), and effective, in the sense that a placebo one believes in is effective for many medical problems peoples have.

    I wonder, if, at least in France, homeopathy hasn’t been officially approved as a medicine just to give a cheap and inoffensive answer to public request for “alternative” medicine, a placebo that is as effective as any other, but cheaper and less dangerous than many. Even if it cost a bit of public money, it’s likely a better option than misuse of “conventional” drugs or many other “alternative” stuff, that could cost far more in consequences.

    Could that be?

  12. grabulaon 01 May 2014 at 11:10 pm

    @thomas

    “I wonder, if, at least in France, homeopathy hasn’t been officially approved as a medicine just to give a cheap and inoffensive answer to public request for “alternative” medicine, a placebo that is as effective as any other, but cheaper and less dangerous than many. Even if it cost a bit of public money, it’s likely a better option than misuse of “conventional” drugs or many other “alternative” stuff, that could cost far more in consequences.”

    That’s most likely the case just about everywhere. I’ve seen interviews and articles where directors literally say we’re bringing it in because of the money it generates. No discussion about efficacy. The important thing to understand here is that in the end it’s the wrong answer. Unproven, or methodologies proven not useful should not be part of a legitimate healthcare system.

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