Science-Based Medicine

Get your facts first, and then you can distort them as much as you please.

—- Mark Twain

I use a Mac, so I know I think different. I also coexist on an alternative parallel world where people live on the same planet as me, but have such a radically different way of thinking that I wonder if we have the same ability to evaluate reality (1).

The best example of different ways of seeing the same thing is homeopathy. Homeopathy is utterly and completely ridiculous with zero plausibility or efficacy. Only therapeutic touch is its rival. Yet homeopath Louise Mclean can suggest there are 50 facts that validate homeopathy (2). These facts were presented as an attempt to counter criticism that homeopathy is only water with no therapeutic effects.

Lets evaluate each fact. There are two parts to the evaluations: whether the fact is true and what, if any, logical fallacy is being used. Deciding on which logical fallacy is being used is not my strong point, feel free to correct me in the comments, and I will add to the text later.
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In Parts I and II of this series* we saw that from 2000 to 2002, key members of the Harvard Medical School “CAM” program, including the Director, had promoted quackery to the legislature of the Commonwealth of Massachusetts. We also saw other explicit or tacit promotions by Harvard institutions and professors, and embarrassing examples of such promotions on InteliHealth, a consumer health website ostensibly committed to “providing credible information from the most trusted sources, including Harvard Medical School….”

Those points were made in an essay that I sent in the spring of 2002 to Daniel Federman, the Senior Dean for Alumni Relations and Clinical Teaching at Harvard Medical School (HMS). I also sent Dr. Federman a treatise on homeopathy, including several examples of credulous Harvard professors and misrepresentations aimed at students, patients, and the public. Much of the content of that treatise has been covered by the series on homeopathy† with which I began my stint here on SBM, so here I’ll post only the parts relevant to promotions by academic physicians, including those at Harvard. There is a bit of redundancy involving InteliHealth, but please bear with me if you’ve made it this far; the discussion will be meatier than the short summary in Part II.

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Is it ever ethical to provide a placebo treatment? What about when that placebo is homeopathy? Last month I blogged about the frequency of placebo prescribing by physicians.  I admitted my personal discomfort, stating I’d refuse to dispense any prescription that would require me to deceive the patient. The discussion continued in the comments, where opinions seemed to range from (I’m paraphrasing)  “autonomy, shmatonomy, placebos works” to the more critical who likened placebo use to “treating adults like children.”  Harriet Hall noted,  “We should have rules but we should be willing to break them when it would be kinder to the patient, and would do no harm.” And on reflection, Harriet’s perspective was one that I could see myself accepting should I be in a situation like the one  she described. It’s far easier to be dogmatic when you don’t have a patient standing in front of you. But the comments led me to consider possible situations where a placebo might actually be the most desirable treatment option. If I find some, should I be as dogmatic about homeopathy as I am about other placebos?

Nicely, Kevin Smith, writing in the journal Bioethics, examines the ethics of placebos, based on an analysis of homeopathy. Homeopathy is the ultimate placebo in routine use — most remedies contain only sugar and water, lacking a single molecule of any potentially medicinal ingredient. Smith’s paper, Against Homeopathy — A Utilitarian Perspective, is sadly behind a paywall.  So I’ll try to summarize his analysis, and add my perspective as a health care worker who regularly encounters homeopathy.
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Homeopathy amuses me.

Well, actually it both amuses me and appalls me. The amusement comes from just how utterly ridiculous the concepts behind homeopathy are. Think about it. It is nothing but pure magical thinking. Indeed, at the very core of homeopathy is a concept that can only be considered to be magic. In homeopathy, the main principles are that “like heals like” and that dilution increases potency. Thus, in homeopathy, to cure an illness, you pick something that causes symptoms similar to those of that illness and then dilute it from 20C to 30C, where each “C” represents a 1:100 dilution. Given that such levels of dilution exceed Avagaddro’s number by many orders of magnitude, even if any sort of active medicine was used, there is no active ingredient left after a series of homeopathic dilutions. Indeed, this was known as far back as the mid-1800′s. Of course, this doesn’t stop homeopaths, who argue that water somehow retains the “essence” of whatever homeopathic remedy it has been in contact with, and that’s how homeopathy “works.” Add to that the mystical need to “succuss” (vigorously shake) the homeopathic remedy at each dilution (I’ve been told by homeopaths, with all seriousness, that if each dilution isn’t properly succussed then the homeopathic remedy will not attain its potency), and it’s magic all the way down, just as creationism has been described as “turtles all the way down.” Even more amusing are the contortions of science and logic that are used by otherwise intelligent people to make arguments for homeopathy. For example, just read some of Lionel Milgrom‘s inappropriate invocations of quantum theory at the macroscopic level for some of the most amazing woo you’ve ever seen, or Rustum Roy‘s claims for the “memory of water.” Indeed, if you want to find out just how scientifically bankrupt everything about homepathy is, my co-blogger Dr. Kimball Atwood started his tenure on Science-Based Medicine with a five part series on homeopathy.

At the same time, homeopathy appalls me. There are many reasons for this, not the least of which is how anyone claiming to have a rational or scientific viewpoint can fall so far as to twist science brutally to justify magic. Worse, homepaths and physicians sucked into belief into the sorcery that his homeopathy are driven by their belief to carry out unethical clinical trials in Third World countries, even on children. Meanwhile, time, resources, and precious cash are wasted chasing after pixie dust by our own government through the National Center for Complementary and Alternative Medicine (NCCAM). So while I laugh at the antics of homeopaths going on and on about the “memory of water” or quantum gyroscopic models” in order to justify homeopathy as anything more than an elaborate placebo, I’m crying a little inside as I watch.

The Lancet, meta-analysis, and homeopathy

If there’s one thing that homepaths hate–I mean really, really, really hate–it’s a meta-analysis of high quality homeopathy trials published by Professor Matthias Egger in the Department of Social and Preventative Medicine at the University of Berne in Switzerland, entitled Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy.
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On Friday, you might have noticed that Mark Crislip hinted at a foreshadowing of a blog post to come. This is that blog post. He knew it was coming because when I saw the article that inspired it, I sent an e-mail to my fellow bloggers marking out my territory like a dog peeing on every tree or protecting my newfound topic like a mother bear protecting her cubs. In other words, I was telling them all to back off. This article is mine.

Mine! Mine! Mine! I tell you!

My extreme territorial tendencies (even towards my friends and colleagues) notwithstanding on this issue aside, if you read Mark’s post (and if you didn’t go back and read it now—seriously, go now), you might also remember that he was discussing a “reality bias” in science-based medicine (SBM), a bias that we like to call prior plausibility. In brief, positive randomized clinical trials (RCTs) testing highly implausible treatments are far more likely to be false positives than RCTs testing more plausible treatments. That is the lesson that John Ioannidis has taught us and that I’ve written about multiple times before, as have other SBM bloggers, most prominently Kimball Atwood, although nearly all of us have chimed in at one time or another about this issue.

Apparently a homeopath disagrees and expressed his disagreement in an article published last week online in Medicine, Health Care, and Philosophy entitled Plausibility and evidence: the case of homeopathy. You’ll get an idea of what it is that affected us at SBM like the proverbial matador waving his cape in front of a bull by reading this brief passage from the abstract:

Prior disbelief in homeopathy is rooted in the perceived implausibility of any conceivable mechanism of action. Using the ‘crossword analogy’, we demonstrate that plausibility bias impedes assessment of the clinical evidence. Sweeping statements about the scientific impossibility of homeopathy are themselves unscientific: scientific statements must be precise and testable.

Scientific. You keep using that word. I do not think it means what you think it means. Of course, his being a homeopath is about as close to a guarantee as I can think of that a person doesn’t have the first clue what is and is not scientific. If he did, he wouldn’t be a homeopath. Still, this particular line of attack is often effective, whether yielded by a homeopath or other CAM apologist. After all, why not test these therapies in human beings and see if they work? What’s wrong with that? Isn’t it “close-minded” to claim that scientific considerations of prior plausibility consign homeopathy to the eternal dustbin of pseudoscience?

Not at all. There’s a difference between being open-minded and being so “open-minded” that your brains threaten to fall out. Guess which category homeopaths like Rutten fall into. But to hear them tell it, homeopathy is rejected because because we scientists have a “negative plausibility bias” towards it. At least, that’s what Rutten and some other homeopaths have been trying to convince us. This article seems to be an attempt to put some meat on the bones of their initial trial balloon of this argument published last summer, which Steve Novella duly deconstructed.

Before I dig in, however, I think it’s necessary for me to “confess” my bias and why I think it should be your bias too.
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Over the weekend, my wife and I happened to be in the pharmacy section of our local Target store. We happened to be looking for one of our favorite cold remedies, because both of us have been suffering from rather annoying colds, which have plagued both of us for the last week or two. As we perused the Cold and Flu section of the pharmacy, we were struck at how much shelf space was taken up by Airborne (which was “invented by a schoolteacher“). Nearly three years ago Airborne had to settle a case brought against it alleging false advertising to the tune of $23 million. Despite that, Airborne is still being sold, and there are even a whole bunch of knock-off products copying it. Then, as we continued to look for our favored cold remedy, we noted that, sitting right next to the extensive shelf space devoted to the various flavors and types of Airborne supplements, I saw Boiron’s homeopathic remedy for colds containing oscillococcinum, which is derived from duck liver and heart and diluted to 200C (a 10⁴⁰⁰-fold dilution).

Yes, I was a bit depressed after that. Now I know what my skeptical friends in the U.K. go through every time they walk into a Boots pharmacy.
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It can be frustrating, and sometimes even a little depressing, to be a skeptic. Promoting reason and science-based medicine often feels like a Sisyphean effort that garners lots of hostility and ad hominem attacks from proponents of pseudoscience and few concrete victories. But once in a while, something happens to give a little hope and inspiration.

In 2010, for example, the House of Commons Science and Technology Committee report on homeopathy came out, clearly unmasking homeopathy for the vitalist 18^th century relic it is (though, sadly, politics is complicated and often unmoved by mere scientific truth, and the government didn’t eagerly embrace the findings or recommendations of the committee). About the same time, the British Medical Association called homeopathy “witchcraft,” and recommended it no longer be supported by the National Health Service. More recently, the Chief Medical Officer in Britain openly acknowledged homeopathy is “rubbish.” Perhaps there has been a shift in the winds? Maybe there is hope that the institutions of government and organized mainstream medicine here in the U.S. might be willing to start taking a stand against pseudoscience in the way they used to in the days before Wilk vs American Medical Association?

As a veterinarian, I was particularly delighted and inspired in March, 2012 when the Australian Veterinary Association (AVA) joined in this movement and took  a firm and public stand on unscientific therapies, in particular washing its hands of homeopathy:

Australian Veterinary Association (AVA) resources will not be used to promote therapies that, in the Board’s opinion, are not compatible with current understanding of physiology and pathophysiology and have been demonstrated to be ineffective by the current accumulated body of knowledge.

That the Board agreed that the veterinary therapies of homeopathy and homotoxicology are considered ineffective therapies in accordance with the AVA promotion of ineffective therapies Board resolution.

This echoed the policies of the British Veterinary Association, and other national veterinary groups in Sweden, Denmark, and elsewhere in Europe. The idea that the central player in organized veterinary medicine in the U.S., the American Veterinary Medical Association (AVMA), which has as members more than 80% of the licensed veterinarians in the country, could be moved to take a similar stand started to seem like a realistic possibility.

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The House of Commons Science and Technology Committee (STC) has released a report, Evidence Check 2: Homeopathy, in which they recommend that the NHS stop funding homeopathy. The report is a rare commodity – a thoroughly science-based political document.

The committee went beyond simply stating that homeopathy does not work, and revealed impressive insight into the ethical, practical, and scientific problems caused by NHS support for an implausible and ineffective pseudoscience.

The STC formed in October of 2009, and this is their second report. The goals of the STC itself are significant step forward:

The purpose of Evidence Check is to examine how the Government uses evidence to formulate and review its policies.

We certainly can use more of that.

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Naturopathy has been a recurrent topic on this blog. The reasons should be obvious. Although homeopathy is the one woo to rule them all in the U.K. and much of Europe, here in the U.S. homeopathy is not nearly as big a deal. Arguably, some flavor of naturopathy is the second most prevalent “alternative medical system” here, after chiropractic of course, and perhaps duking it out with traditional Chinese medicine, although naturopathy does embrace TCM as part of the armamentarium of dubious medical systems that it uses. In any case, some sixteen states and five Canadian provinces license naturopaths in some form, and in some states naturopaths are fighting for–and in some cases winning–the power to prescribe certain real pharmaceutical medications and order real medical tests. For instance, in California, naturopaths can order laboratory tests and X-rays, which reminds me of a conversation I had with a mammographer from California at TAM last summer. He told me a tale of the dilemma he had when naturopaths and other “alt-med” practitioners ordered tests at his facilities. Specifically, the dilemma came about because he doubted that the naturopath knew what to do with the results. Meanwhile, in Oregon, naturopaths can prescribe certain types of pharmaceutical drugs (as opposed to the usual supplements, herbs, or homeopathic remedies they normally prescribe). Meanwhile, moves are under way to expand the prescribing privileges of naturopaths in Canada, as Ontario (which is, remember, just across the Detroit River, less than two and a half miles as the crow flies from my cancer center—a truly frightening thought to me).

Unfortunately, naturopathy is a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to “pick one from column A and one from column B” when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine. Despite their affinity for non-science-based medical systems, naturopaths crave the imprimatur of science. As a result, they desperately try to represent what they do as being science-based, and they’ve even set up research institutes, much like the departments, divisions, and institutes devoted to “complementary and alternative medicine” (CAM) that have cropped up on the campuses of legitimate medical schools and academic medical centers like so many weeds poking through the cracks in the edifice of science-based medicine. Naturopaths also really, really don’t like it when they encounter criticism that their “discipline” is not science-based. Indeed, the president of the American Association of Naturopathic Physicians, Carl Hangee-Bauer, ND, LAc (he’s an acupuncturist, too!), wrote a revealing post on the official AANP blog entitled Science and Naturopathic Medicine.

Science. You keep using that word. I do not think it means what you think it means.

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I realize that I’ve said it many times before, but it bears repeating. Homeopathy is the perfect quackery. The reason that homeopathy is so perfect as a form of quackery is because it is quite literally nothing. On second thought, I suppose that it’s not exactly nothing. It is, after all, water or whatever other diluent that homeopaths use (usually ethanol). However, thanks to some basic laws of physics and chemistry and a little thing known as Avogadro’s number, any homeopathic dilution greater than 12C (twelve serial 100-fold dilutions) is incredibly unlikely to contain even a single molecule of starting compound. That unlikeliness reaches truly astonishing levels as we reach the common homeopathic dilution of 30C, which is the equivalent of a 10⁶⁰-fold dilution. Given that that little thing known as Avogadro’s number, which describes how many molecules of a compound are in a mole, is only approximately 6 x 10²³, a 30C dilution is on the order of 10³⁶- to 10³⁷-fold higher than Avogadro’s number. Even assuming that a homeopath started with a mole of remedy before diluting (unlikely, given the high molecular weight of most of the organic compounds that can serve as homeopathic remedies), the odds that a single molecule could remain behind after the serial dilution and succussion process is infinitesimal. Appropriately enough, the “law” in homeopathy that states that diluting a remedy will make it stronger is the law of infinitesimals.

It is also the reason that homeopathy is nothing.

Homeopaths have known these facts for many decades. Anyone who is any sort of a scientist or has an understanding of science, when confronted with these simple, well-established physical laws, might—just might—start to rethink his belief in something that is so utterly implausible from a scientific standpoint. Indeed, homeopathy is about as close to impossible as anything I can imagine, because for it to “work” multiple well-established laws of physics and chemistry would have to be not just wrong, but spectacularly wrong. Yet, as Richard Dawkins famously put it, undeterred, homeopaths bravely paddle up the river of pseudoscience and invent explanations to “explain” how homeopathy could work, the most famous of which is the so-called “memory of water,” in which the water in the homeopathic remedy remembers all the good bits meant to heal but, as Tim Minchin so famously put it, somehow forgets all the poo that’s been in it. Homeopathy is truly magical thinking, which is why I love to use it as an illustrative example of quackery. Not only is it magical thinking, but because it is nothing but water, it’s a very useful educational example for placebo effects and the general types of fallacious arguments quacks and pseudoscientists make. Apparently it’s time for another one.
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