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.”

Posted in: Book & movie reviews

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20 thoughts on “Trick or Treatment

  1. Michelle B says:

    Excellent review and will use as a reference. Thanks.

  2. jonny_eh says:

    “Everyone is entitled to his own opinion, but not his own facts.”

    Wow, gonna have to remember that one.

    Amazon notified me that my copy of this book is on the way, I can’t wait to read it! Harriet, you always pick great books to review.

  3. durvit says:

    Useful review of a useful book.

    Professor Ernst featured in the second part of Dr Ben Goldacre’s discussion of placebo on BBC Radio 4. One of the running strands of the programme was the proposition that if CAM’s effectiveness lies in placebo, is this a justification for its use, if it can be achieved in an ethical manner? However, on the issue of whether it is ethical to use a placebo Professor Edzard Ernst was robust in his stance that the only ethical use of placebos would be if they were used transparently and with fully informed patient consent, in which case he argued that they would not work. Ernst claimed that his clinical training enabled him to form a good, therapeutic alliance with a patient “without being bogus” and without the need for props such as ‘magic pills’.

    There is a running update of the Simon Singh v. the British Chiropractic Association with links to some intersting discussion as to why the BCA might have elected to take this course of action at this time.

  4. superdave says:

    what a great closing quote. Senator Moynihan is certainly missed.

  5. Meadon says:

    Excellent review, thanks.

  6. Joe says:

    I have just begun reading “Trick or Treatment.” As I recall, Ernst was also trained in a form of chiro. Despite his background in that, and homeopathy, sCAM artists are reduced to painting him as their unsympathetic enemy.

    A few years ago, I reviewed the best books on sCAM in general and they mostly dated from the early 1990s (e.g., “The Health Robbers” and Kurt Butler’s “Consumer’s Guide”. At the time, I said they are still quite useful (and they are). It is nice to have a raft of books to add to my list with no need to justify their ages. Ernst has also edited another book on the subject: “Healing, Hype, or Harm” (Societas Imprint Academic, 2008).

    For those interested in the chiro vs Singh case, look here As things stand, the latest word on the subject is well-summarized by Blue Wode (who sometimes posts here).

    The text of the article that got Singh in trouble, along with some annotation, is available here

  7. DBonez says:

    Outstanding book review. Nicely done as always.

    I feel the fundamental problem to overcome with CAM supporters is the element of faith. It seems to me that most people are programmed from a very early age to ask “which”, not “if”. People are raised asking which religion is best, not if religion is real. They are asked which theory of human existence is better; evolution or intelligent design, not if one is more plausible given the physical reality of life and historical evidence.

    So when it comes to medicine, most simply ask which is better, science-based medicine with their cold, “rich” doctors (a six-figure income seems rich to many people), or the warm, natural hand of CAM with their gentle ways and propensity for identifying obscure problems? The real question they should be asking is IF CAM works, IF it is real, IF it is scientifically plausible, IF it is founded on preposterous historical claims, or IF it produces repeatable results. Because so many faith-based propositions start with everything on a level playing field, it is incredibly hard to disprove negatives and even if science-based medicine is proven to work, it’s overlooked as materialistic, toxic, cold, and greedy. To the faithful, repeatability, plausibility, and positive clinical trials are not factors when deciding which alternative method to try or what to integrate with their current medical regiment. I would love to see science and science-based medicine triumph, at least in government, education, and the insurance industry, but fear there is far too much faith-based opposition not to mention highly effective, highly motivated faith and CAM promoting out there.

  8. urology-resident says:

    “However, on the issue of whether it is ethical to use a placebo Professor Edzard Ernst was robust in his stance that the only ethical use of placebos would be if they were used transparently and with fully informed patient consent, in which case he argued that they would not work”

    One of the most common procedures in urology is office cystoscopy. Patients are awake, and a small camara is advanced through the urethra into the bladder.

    Urologist have traditionaly used Lidocaine Jelly (10-20ml injected into the urethra) before passing the camera.

    Meta-Analysis have demostrated that lidocaine jelly does as well as placebo.

    Despite this I keep telling the patients that we have a great numbing jelly that its going to make this procedure less painful. This I think takes the edge off and relaxes them. When a patient is tense, the urinary sphincter tightens making a cystoscopy procedure more painful.

    I don’t think any amount of evidence is going to stop urologists from using Urojet, just because is a great placebo.

    It may not be ethically correct, but I haven’t found a better alternative for the patients or for the person doing the procedure.

  9. durvit says:

    It may not be ethically correct, but I haven’t found a better alternative for the patients or for the person doing the procedure.

    iirc, several of the participants, including Professor Walter Brown, would agree with you. The programme is worth listening to while it is still available but if it isn’t available in some countries then this discusson of the programme covers some of the relevant issues.

    Professor Walter Brown took a somewhat robust attitude and said that some patients would be indifferent to what actually relieved their symptoms, they would just be grateful for the relief. He says that there are times when doctors should feel comfortable with prescribing placebos because it can be done without deceiving patients. Brown offered some forms of words but Goldacre argued that although the sentiments were fine as they stood, in the context of a patient’s expectations of a doctor, there was a reasonable assumption of clinical research to support the recommendation.[a] Brown countered that with the argument that there is good quality research to support the placebo.

    So, Professor Ernst might argue that the physician’s own innate ability to form a therapeutic relationship with the patients should be sufficient, without resorting to stories about ‘numbing gels’ that are economical with the actualité. Professor Brown might well cheer urologists on with the comforting words that if it works then it is in the patient’s best interests and there is a raft of placebo research to provide evidence for such an action and all it takes is a form of words that influences the patient for good without compromising the integrity of the physician/surgeon/health provider.

  10. daedalus2u says:

    A “numbing gel” is a “numbing gel”. If a doctor administers a gel that numbs, does the mechanism matter? Does it numb because it is cold or because it lubricates or because it has a certain composition or because it is delivered in an expert manner?

    If clinical trials have shown a gel without an active pain reliever to be as effective a “numbing gel” as something with active ingredients, the default should be to use the “numbing gel” with the least opportunity for side effects.

    Lidocaine does have side effects in some individuals.

    That lawsuit will be very interesting. My understanding is that in the UK, the loser pays the legal fees of the winner. That is why Wakefield dropped his lawsuit against Brian Deer and paid 100% of Brian Deer’s legal fees up to that time.

  11. AntiVax says:

    Ernst –pharma shill

    Wakefield dropped his lawsuit as Deer’s lawyers requested all his documents he had gathered for his GMC hearing and he diodn’t want to let him have them until that was over. When that is over he will sue the ass of that ass****

    Not fogetting the liar Horton

    Or the other liars like Zuckerman

    I log some of the most obvious pharma propaganda books like Suckers

  12. Blue Wode says:

    An excellent review of an excellent book.

    Harriet Hall wrote: “Prince Charles has called for scientific studies of alternative medicine but has consistently disregarded the results of such studies.”

    So true. He mentioned the need for good scientific evidence for CAM in a speech which he delivered at the 5th Annual Integrated Health Awards in London on 20th March 2008, but seemed oblivious to the fact that the system of healthcare that he was advocating already existed – conventional medicine! Here’s a snippet from the speech:

    “Ladies and Gentlemen, believe it or not I have been advocating the development of a truly integrated health system – one rooted in appropriate regulation and supported by rigorous scientific evidence – for the best part of twenty five years.”

    With regard to Professor Edzard Ernst’s critics, in his editorial in the September 2008 issue of Focus on Alternative and Complementary Therapies (FACT), he gives readers a glimpse of the “bombardment of insults” that he’s received from CAM evangelists in the wake of ‘Trick or Treatment’ going on sale in the UK back in April. It’s well worth a read:

    No doubt the authors at Science Based Medicine (and several others) will easily relate to what he’s written.

  13. Versus says:

    Trick or Treatment (nicely reviewed by Dr. Hall) presents an opportunity to do what most of us who read Science-Based Medicine long for: educating the public about alternative medicine. So let’s use this opportunity! Some suggestions:
    1. buy the book and read it, then loan it to friends and family with your recommendation;
    2. buy copies for your local or school librar(ies);
    3. suggest that your local paper, a national newspaper, a national magazine, or a medical journal, review this book, or offer to write a review yourself;
    4. recommend it for your book club;
    5. go on amazon, Barnes and Noble, and Borders websites (after you’ve read the book, of course) and write a review.
    (Such is my faith in this book that I do not hesitate to recommend reviews.)
    Don’t just complain about pseudoscience — do something about it!

  14. overshoot says:

    Ernst –pharma shill

    That’s the wonderful thing about you, John. You’re so consistent. Anyone who disagrees with you is a “pharmashill,” no matter the details. In the present instance, we have someone who practiced homeopathy for years and was headed towards a programme in chiropractic, who was chosen by HRH as the champion who would bring the final proof of AltMed to academia, and who spent fifteen years trying to do just that.

    When that failed, he retroactively becomes a “pharmashill.”

    When all else fails, we can count on you.

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