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Should doctors recommend homeopathy?
Should doctors recommend homeopathy? Two experts debate the issue in The BMJ this week.
Peter Fisher, Director of Research at the Royal London Hospital for Integrated Medicine, says that of all the major forms of complementary medicine, homeopathy is the most misunderstood.
He questions the methods used to review the evidence for homeopathy. For example, in a recent report by the Australian National Health and Medical Research Council which stated that "there are no health conditions for which there is reliable evidence that homeopathy is effective."
"The fact that one homeopathic treatment for a condition is ineffective doesn't mean that another is also ineffective." The review also unaccountably omitted several key pieces of evidence, he argues.
Most overviews have had more favourable conclusions, he says, including a Health Technology Assessment commissioned by the Swiss federal government which concluded that homeopathy is "probably" effective for upper respiratory tract infections and allergies - and several meta-analyses of homeopathy as a whole and for specific conditions have been positive
He also points to several studies comparing treatment outcomes of conventional family doctors with those who integrate homeopathy in their practice, showing better outcomes at equivalent cost in a range of conditions with reduced use of hazardous drugs including antibiotics.
He concludes that "Doctors should put aside bias based on the alleged implausibility of homeopathy. When integrated with standard care homeopathy is safe, popular with patients, improves clinical outcomes without increasing costs, and reduces the use of potentially hazardous drugs, including antimicrobials. Health professionals trained in homeopathy do not oppose the use of conventional treatments, including immunisation."
But Edzard Ernst, Emeritus Professor at the University of Exeter, says most independent systematic reviews of randomised controlled trials "have failed to show that homeopathy is effective" and reviews with positive conclusions "usually have serious methodological flaws."
The assumptions underlying homeopathy "fly in the face of science" he says "and critics have long pointed out that unless our understanding of the laws of nature is incorrect, homeopathy's mode of action has no rational explanation."
He also argues that homeopathy can harm "if it replaces an effective therapy" and says he knows of "several deaths that have occurred in this unnecessary way."
Finally, he questions Europe's €1bn annual spend on such remedies, saying these funds "could and should be spent more usefully elsewhere."
In summary, he says, "the axioms of homeopathy are implausible, it's 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."
Expert Reaction
These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.
Dr Shaun Holt is an Adjunct Professorial Research Fellow, Victoria University of Wellington, and Director of HoneyLab
"A survey found that around that 1 in 8 New Zealand GPs either practice homeopathy or refer patients to homeopaths. However this is not consistent with either the ethical or regulatory requirements of practicing medicine whereby healthcare professionals should manage patients with treatments that are likely to be effective according to medical research.
"The practice involves diluting substances to such a degree that not a single molecule remains. Some people mistakenly think that homeopathic products work but are fooled by factors such as the placebo effect, the natural history of the condition and not attributing benefits to other treatments or lifestyle changes.
"A survey found that 93% of people in NZ do not actually know what it involves, and most mistakenly think that it is the use of low doses of natural products.The British Medical Association has rightly described it as witchcraft, as to claim that a product with no active ingredients can produce beneficial health effects is the same as saying that it has magical powers.
"The lunacy of homeopathy can be summed up by the following real product that is available from a main UK supplier : "Berlin Wall" - consists of dust from the Berlin Wall, diluted until none remains, sold to people to help them stop feeling repressed.
"Other products available include koala, vaginal ultrasound, light from Saturn, dog testes, dolphin song and jet fuel.
"Although homeopathic products themselves do no harm, as they do not contain any active ingredients, there can be serious problems when people use them instead of real medicines. An example is the death of an Australian baby from eczema after her parents treated her with homeopathic remedies."
Assoc Prof Joanne Barnes is Associate Professor in Herbal Medicines, School of Pharmacy, University of Auckland
"Many users of homoeopathy report beneficial effects, likely due to ‘placebo’ effects or simply the natural course of the symptom or condition, but the evidence for efficacy of specific homoeopathic products to treat or prevent specific symptoms and conditions is not convincing. Yes, there are examples of robust clinical trials that have reported positive results for certain homoeopathic products, including when selected on an ‘individualised’ basis (as is advocated by homoeopaths,) and there are some systematic reviews or meta-analyses of all placebo-controlled clinical trials indicating that, collectively, homoeopathic treatment is better than a placebo.
"However, the evidence is not consistent – there are also trials and systematic reviews with negative results - and does not provide a definitive body of evidence to support the efficacy of specific homoeopathic products for specific medical conditions.
"This, together with the lack of a plausible mechanism of action for homoeopathy, and other claims, such as dilution effects, that are inconsistent with current scientific fact, preclude supporting that health professionals should actively recommend homoeopathy.
"This does not mean that health professionals should be dismissive if asked about homoeopathy by their patients. Patients are free to choose to use homoeopathic products and it is desirable and important that they are able to have respectful, non-judgemental and open conversations about this with health professionals responsible for their care. Highly dilute homoeopathic remedies are unlikely to cause adverse reactions or to have interactions with conventional (pharmaceutical) medicines if used concurrently.
"However, patients should not stop taking conventional medicines without seeking advice from the prescriber of those medicines. If patients choose to use homoeopathic products, they should be advised only to use products that are manufactured according to the principles of good manufacturing practice, which is the pharmaceutical industry standard for quality of medicines."
Dr Nik Zeps is a research scientist at UWA and a member of the NHMRC Homeopathy Working Committee
Peter Fisher makes several incorrect assertions about the methodology used in the NHMRC report which undermine his conclusions. The report was based upon a review of systematic reviews of clinical trials involving the use of homeopathy. As such it was the least biased evaluation of the current evidence that is possible and no important reviews were omitted to our knowledge. The quality of the reviews and the trials they were based upon found that most studies were unreliable due to the possibility of bias or poor design.
He also incorrectly suggests that the Swiss commissioned a report that was favourable for homeopathy. As highlighted in the NHMRC report this was a public submission from a call for submissions made by the Swiss government and to imply it is a government sanctioned report is a misrepresentation of its status that appears to be commonly made by proponents of homeopathy.
Peter fisher refers to in vitro (laboratory) experiments that demonstrate a physiological action. Whilst this was not the focus of the NHMRC report it is important to remind the public to examine 'evidence' carefully and to note that these experiments have not been reproducible and remain controversial within the scientific community.
The NHMRC report examined claims for effect in many conditions and did not focus on a particular form of homeopathy, rather it examined the evidence provided in the literature for claims of effect. Peter Fisher claims that evidence did not take into account an integrated approach when in fact it did.
Many of the conditions outlined in the additional evidence he quotes are self-limiting (eg,. respiratory infections) and people get better regardless of their treatments. The report of benefits for those who had homeopathy needs to be assessed in the light of their overall health and the reliability of the studies also needs to be independently assessed, as was done for each study in the NHMRC report. Quoting from single studies without such an evaluation is not a reliable way to assess the data.
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