Trick or Treatment

I’ve just finished reading Trick or Treatment: The Undeniable Facts about Alternative Medicine by Simon Singh and Edzard Ernst. I’d been looking forward to the publication of this book, and it exceeded my expectations.

Edzard Ernst, based at the University of Exeter in England, is the world’s first professor of complementary medicine, a post he has held for 15 years. An MD and a PhD, he also embraced alternative medicine and used to practice homeopathy. He has done extensive research and published widely. His stated objective is “to apply the principles of evidence-based medicine to the field of complementary medicine such that those treatments which demonstrably do generate more good than harm become part of conventional medicine and those which fail to meet this criterion become obsolete.” His most important accomplishment has been to “demonstrate that complementary medicine can be scientifically investigated which, in turn, brought about a change in attitude both in the way the medical establishment looks upon complementary medicine and in the way complementary medicine looks upon scientific investigation.”

Simon Singh is a science writer with a PhD in particle physics. As a team, he and Ernst are uniquely qualified to ferret out the truth about alternative medicine and explain it to the public.

The book is ironically dedicated to HRH The Prince of Wales, who is infamous for encouraging unproven treatments. Prince Charles has called for scientific studies of alternative medicine but has consistently disregarded the results of such studies.

The first chapter asks “how do you determine the truth?” and explains the scientific method. Four chapters address the scientific evidence for the 4 major alternative therapies: acupuncture, homeopathy, chiropractic, and herbal medicine (36 lesser therapies are covered in an appendix). The final chapter asks “does the truth matter?”

They give an example that beautifully illustrates the value of rigorous science. Dr. Bill Silverman was frustrated by seeing premature babies go blind with retinopathy of prematurity (ROP). He tried treating them with ACTH and had astounding success: only 2 out of 31 infants lost their sight. In another hospital where ACTH was not used, 6 out of 7 babies lost their sight. Most doctors would have simply continued using ACTH treatments and would have recommended them to everyone, but Silverman was a true scientist. He recognized that it might not be fair to compare babies in two different hospitals and that a proper randomized controlled trial was needed. When he did such a trial, 70% of the babies on ACTH recovered, but 80% of the untreated babies recovered, and more babies in the ACTH group died. A followup study confirmed these results. If Silverman had not had the integrity to question his own hypothesis, a useless and possibly harmful treatment might have become standard, and more babies might have ended up blind or dead.

Singh and Ernst provide many other memorable examples of good and not-so-good science, from Lind’s experiments on British sailors with scurvy to Benveniste’s discredited homeopathy study in Nature. They debunk many of the fallacies of alternative medicine: the “natural” fallacy, the “traditional” fallacy, the “holistic” fallacy, the “science can’t test alternative medicine” fallacy, the “science doesn’t understand alternative medicine” fallacy, and the “science is biased against alternative ideas” fallacy. They discuss placebos and explain why they don’t condone using them. They name ten classes of culprit in the promotion of unproven and disproven medicine, from the media to alternative gurus to the World Health Organization.

They discuss the role of prior plausibility in deciding directions for future research. They quote Carl Sagan:

It seems to me what is called for is an exquisite balance between two conflicting needs: the most skeptical scrutiny of all hypotheses that are served up to us and at the same time a great openness to new ideas… [I]f you are open to the point of gullibility… then you cannot distinguish useful ideas from worthless ones. If all ideas have equal validity then you are lost, because then it seems to me, no ideas have any validity at all.

They review all the published evidence for alternative medicine, and their conclusions are not very favorable:

While there is tentative evidence that acupuncture might be effective for some forms of pain relief and nausea, it fails to deliver any medical benefit in any other situations and its underlying concepts are meaningless. With respect to homeopathy, the evidence points towards a bogus industry that offers patients nothing more than a fantasy. Chiropractors, on the other hand, might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks. Herbal medicine undoubtedly offers some interesting remedies, but they are significantly outnumbered by the unproven, disproven and downright dangerous herbal medicines on the market.

These are strong words, and they have met with understandable hostility from the alternative community. Simon Singh has already been sued by the British Chiropractic Association for libel because of an article saying that chiropractors knowingly promoted bogus treatments for illnesses including asthma and ear infections.

Criticisms of Trick or Treatment reveal an appalling poverty of thought. No one can seriously question the facts and the reasoning in the book, so opponents resort to other tactics. A homeopathy website resorts to denying that science is a useful tool. It essentially calls evidence-based medicine quackery! Other critics simply criticize every defect of conventional science-based medicine, as if imperfections in applied science somehow proved that a nonscientific approach was better! They misrepresent what the book says and use ad hominem insults, ridiculously attacking Ernst as “desperate to find ANYTHING to discredit CAM.” I haven’t found any critics who have even tried to cogently address the points the book makes.

It’s easy to criticize with generalizations. Emily Rosa’s therapeutic touch study was accused of “poor design and methodology,” but as Singh and Ernst point out, “[her] protocol was simple and clear and her conclusion was hard to fault. Moreover, nobody has ever come up with an experiment that has overturned her findings.” If proponents of alternative medicine come up with good experiments that overturn the present findings, Singh and Ernst have made it clear that they will gladly accept them. In fact, Ernst has offered a prize of £10,000 to be given to the first person who can show homeopathy is better than a placebo in a scientifically controlled trial. No one has applied to take his money.

Trick or Treatment is well worth reading. I highly recommend it. It ought to have more credibility than other books critiquing alternative medicine, simply because it is harder to accuse Dr. Ernst of bias. He is an avowed supporter of everything in alternative medicine that can be shown to work. He has used homeopathic remedies himself. He accepts herbal medicine claims that many of us reject (for instance, Echinacea to prevent and treat the common cold). He has demonstrated his ability to change his mind and follow the evidence. He has no ax to grind; his only agenda is to find the truth.

I wonder if the tide is starting to turn. We’ve recently seen a number of books critiquing complementary and alternative medicine. Natural Causes, Snake Oil Science, Suckers, and now this. People are no longer trying to be “politically correct” but are freely calling most of CAM a scam and a sign of the “Endarkenment.” They are calling for a return to scientific medicine and to one standard for judging all treatments. Just as we are doing on this blog.

Singh and Ernst are not attacking alternative medicine; they are attacking overblown claims for unproven treatments. As Ernst says, “People must not confuse the perceived benefits of so-called alternative medicine with the medical facts.” Or as Daniel Patrick Moynihan put it, “Everyone is entitled to his own opinion, but not his own facts.”

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