Thursday, 29 July 2010

Does the Government Actually Do Good, or Just Create the Feeling It Does?

The Government response to the House of Commons Science and Technology Committee report on Homeopathy has been published, and is a masterpiece of dodging the issue. Congratulations to the author, Sir Humphrey Appleby.

In short, they refuse to stop NHS funding of homeopathy, preferring to abdicate responsibility to the PCTs; see here:
(Committee conclusion)
By providing homeopathy on the NHS and allowing MHRA licensing of products which subsequently appear on pharmacy shelves, the Government runs the risk of endorsing homeopathy as an efficacious system of medicine. To maintain patient trust, choice and safety, the Government should not endorse the use of placebo treatments, including homeopathy. Homeopathy should not be funded on the NHS and the MHRA should stop licensing homeopathic products. (Paragraph 157)
(Government response)
We note the Committee’s view that allowing for the provision of homeopathy may risk seeming to endorse it, and we will keep the position under review. However, we do not believe that this risk amounts to a risk to patient trust, choice or safety, nor do we believe that the risk is significant enough for the Department to take the unusual step of removing PCTs’ flexibility to make their own decisions. We believe that providing appropriate information for commissioners, clinicians and the public, and ensuring a strong ethical code for clinicians, remain the most effective ways to ensure quality outcomes, patient satisfaction and the appropriate use of NHS funding.
They do say something about placebo. In response to the Committee's observation that:
We would expect the Government to have a proper understanding of the power and complexities of the placebo effect and the ethical issues surrounding its use in a clinical setting; otherwise it cannot hope to make good decisions relating to patients and public health.
...the Government says:
The Government agrees that, when looking at the evidence base for efficacy, it is important to focus on the most scientifically robust studies and evidence. We note, however, that a “proper understanding of the power and complexities of the placebo effect” is difficult to achieve, since we are not aware of any scientific consensus at present on the mechanisms by which placebos have an effect. We note also that it is not for the Department of Health to comment on the ethics of the use of a particular treatment in a particular setting. 
So they've decided that the Government should have no ethical view on placebo use.

The difficulty is obvious. The way is open for any number of placebo effect treatments to be given Government funding; how could they be stopped, if patients are demanding them and saying that they feel better thanks to them?

As Steven Novella points out:
...for any objective outcome, there is no important placebo effect. For outcomes that are subjectively reported by patients, there is a highly variable placebo effect. It is plausible that the expectation of benefit could result in the release of dopamine and endorphins and produce a physiological decrease in pain, for example, in a subset of people, and there is some evidence for this. But this is, at best, a transient symptomatic effect – not therapeutic.
Such effects are also non-specific – meaning they do not derive from the intervention itself, but from the therapeutic ritual surrounding the intervention. Even treatments that do not work may therefore provide these non-specific benefit. My opinion is that the non-specific benefits of the ritual of treatment should be combined with an actually effective treatment, not magic pretending to be medicine.
Or, if no actual treatment is available, any placebo should be delivered for the minimum cost. That would certainly exclude comparatively complicated treatments such as homeopathy and acupuncture.

The major problem with such Government indecision is the patina of respectability it gives these purveyors of *nothing*; they are free to pretend they are being efficacious, and this adds to the totality of woo in this supposedly civilised society. The more woo we can eliminate the better informed our citizens will be, and the more likely they are to lead healthy lives, in my opinion.

Further, a Government that condones treatments that just make people *feel* better, rather than *actually* better, might be tempted to extend that principle to other policy areas; would they prefer policies that work, or policies that make people think they work?


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    Anonymous says:
    30 July 2010 at 23:09

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    5 August 2010 at 22:51

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