Tuesday, January 25, 2011

Thoughts on Homeopathy at Non-Homeopathic Volumes

The other day over at Respectful Insolence, a comment from someone by the name of Tim caught my eye. He posted a rather long list of questions regarding homeopathy and opposition to it. Some of the questions seemed clearly meant to provoke (e.g., "Would you consider yourself a member of the church of modern medicine?"), but there were others that really warranted a more serious response.

After the break, I'll post a handful of the questions that I felt were actually not bad questions to ask, the answers to which may help people think a little bit before deciding whether or not to use a homeopathic treatment.

First off, let's get one thing out of the way. Homeopathy is not synonymous with herbal medicine. Herbal medicine actually has some validity to it. Indeed, a significant portion of modern drugs have their origins in plants (e.g., aspirin from willow bark, quinine from cinchona bark, some chemotherapy drugs, etc.). That's not to say that all herbal medicine claims are valid, but there is at least some prior plausibility there. Contrasting to that is homeopathy, where a substance that purportedly causes the same symptoms as a disease in a healthy person can be diluted so that not even a single molecule is likely to remain, and that the resulting solution can cure the disease in a sick patient. A lot of other bloggers and scientists have already shown that homeopathy does not work better than a placebo and discussed how, for homeopathy to work, many, many basic tenets of science would have to be completely wrong. We're talking chemisty, biology, physics and lots of sub-specialties within those.

At any rate, on to the questions.

Why is it important that we inform people that Homeopathy is no better than a placebo?

There are a few reasons. First, there's the ethical considerations around whether it is okay to lie to a patient. This goes against the concept of informed consent and personal autonomy. Without having a reasonable knowledge of the treatment being offered, a person cannot make a well-reasoned decision about their own health care. So, by telling a patient that homeopathy works, the practitioner is stealing the patient's ability to properly weigh their choices. Second, people will not always have the same response to a placebo as someone else. What may work for one person may not work for someone else. Third, for more serious conditions, a person who relies on homeopathy as a real treatment may be delaying proper treatment, which can lead to serious worsening of their condition. This can potentially result in permanent injury (e.g., blindness if a bacterial infection is left untreated by proper medicine) or even death.

Why should anyone care if someone experiences some relief from nothing more than a placebo?

The issue isn't really whether a person gets relief from a placebo or not. If they do, great. And certainly, I would not begrudge a cognitively competent adult choosing, of their own free volition, a treatment that is nothing more than a placebo. I would try to inform them of the reality of what they seek, but it's ultimately their decision. My concern is that they may be inadvertently harmed, as noted above, and the victim of fraud (intentional or otherwise).

If these remedies cost only pennies compared to hundreds of dollars; would the price difference influence your degree of disdain?

Let's take a look at oscillococcinum, a homeopathic preparation that claims to "Reduce duration and severity of flu symptoms." Now, I can get a 12 dose box of this at CVS for about $15-$20. Since the product doesn't actually have any active ingredient and therefore has no real effect on the influenza virus, I am paying $15-$20 for nothing. I could alternatively buy a 4-pack of Tic Tacs for about $4 and get the same results. Or, I could just not spend any money and again have the same results.

Is it the price that offends you or their practice of deception that forms your opinions of homeopathy?

Not really. Certainly it is rather absurd to spend $15-$20 for 12 Tic Tacs, but I am more concerned about the deception. There is quite a lot of effort that goes into this, too. And, to be clear, I do not think that all homeopaths are knowingly deceitful. Many may be honestly deluded that their chosen practice really does work, despite evidence to the contrary. What I mean by the effort into the deception is that not only are claims made that homeopathy works for a wide range of diseases and disorders, despite a lack of high-quality evidence to support those claims, but the very nomenclature of homeopathy is almost totally unique.

For instance, take a standard drug. It may list the active ingredient in terms of grams, milligrams or micrograms. These are measurements that are fairly easily understood by most people. Homeopathic products, on the other hand, list the active ingredients in terms of dilution (2X, 5C, 30C, etc.). That is virtually meaningless, since you have no clue just how much of the substance was in the "mother tincture" (was it 10 g active substance to 90 g sugar or 1 g active to 9 g sugar?). Furthermore, once one gets past about 12C, the chance of finding even a single molecule of the active substance is pretty close to zero. Because of this, it is next to impossible to determine whether the little white pill you have in your hand is a real homeopathic product or an untreated sugar pill.

Next, the active ingredients have a special nomenclature unique to homeopathy. One might find a homeopathic treatment that has as an active ingredient Natrum muriaticum. Sounds impressive, right? That's actually sodium chloride; table salt. The homeopathic name has no relation to either the chemical structure of the substance nor to the common name. Again, let's take a look at oscillococciunum. Its active ingredient is Anas Barbariae Hepatis Et Cordis Extractum. Oooh! It's all Latin-y and sophisticated sounding! It must be a very potent substance, right? Nope. That is ground up duck heart and liver. Don't worry, though. There isn't actually any duck heart or liver in any of those pills you get at CVS, thanks to the ridiculous dilutions.

The worst part, though, is that homeopaths claim all manner of health benefits from their products, some of which can be very dangerous. Homeopathic vaccines? That's a good way to think you're being safe, but really putting yourself at risk of infection. Homeopathy for cancer? Again, relying on water or sugar pills will only rob you of your chance for a better outcome. In short, you're cutting your life shorter. There is no good evidence to back up these claims, and there is no real requirement to do so, unlike with drugs.

Can homeopathy be considered a malign form of health care? Do Homeopaths intend to harm their patients?

As I said, I don't think that all homeopaths intend to harm their patients. In most cases, I would say it is a case of good intentions, unintended consequences. But, just as with actual drugs, there are probably those who know that the snake oil they're selling doesn't do squat.

Would it be better to abolish the whole alternative health practices?

No. Such a sweeping ban would be silly, really. It would cut out potential avenues of improvement in medical and health care research, such as certain herbal remedies. But potential treatments need to be backed by quality evidence. Good science needs to weed out what works, what doesn't work and what needs more investigation. That said, treatments that are shown not to work most certainly should not be used. The interests and well-being of the patient need to be respected, and selling bogus nostrums runs contrary to that.

Is it okay for a Medical Doctor to prescribe a placebo to their patient?

Personally, I would say no. However, this is an area of active research and discussion. When is it right to use a placebo? When is it wrong? As I mentioned before, there are some compelling reasons, largely revolving around patient autonomy, not to prescribe placebos. There are also compelling reasons favoring the use of placebos in treatment. For example, when an illness has a psychological basis, real drugs may provide no real benefit, but have the increased risk of real side effects. In such a case, a placebo may provide the same perceived benefit and provide a solution to the patient's condition. This is a very simplified answer, though, and should not be construed as to endorse either the use or non-use of placebos. The issue is significantly more complex than this.

So, those are my opinions on some of the questions posed by Tim. I am more than willing to change my opinions if I am presented with some high-quality, scientific evidence that counters anything that I've said. To be clear, anecdotes and personal accounts will not convince me. Exhortations to "try it myself" will not convince me, either, since I, like everyone, am prone to biases and mistaken observations, especially when the sample size is 1. What I would need is a placebo-controlled, randomized, double-blinded study with a fairly large number of subjects in both the treatment group and placebo group (at least several hundred each) and where all subjects have the same disease/disorder being treated. The two groups should be as similar as possible, with the only difference being the receipt of the homeopathic treatment or placebo.

Let me close by posing a couple of questions. Suppose that Merck came out with a new pill and claimed that it could treat type 1 diabetes. Keeping in mind that untreated type 1 diabetes can lead to neuropathy, tissue death and, ultimately, patient death:

  • Should Merck be required to show that its pill actually works better than a placebo?
  • Should Merck be required to show that the benefits outweigh the risks?
  • If Merck cannot show either of these, should they still be allowed to market their product, and buyer beware?
  • Finally, if Merck isn't allowed a free pass on these questions, then why should a homeopathy manufacturer be given a free pass?

For further enlightenment, here's a demo of how homeopathy supposedly works:

Disclaimer: This post expresses my opinions and are not intended to libel or malign any individual or group of homeopaths, nor should they be interpreted as statements of fact. If you take offense, sorry, but grow a thicker skin. Furthermore, I am not a physician. Nothing in this post is meant to be taken as medical advice. If you want that, talk to your doctor.

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