EASAC statement on Homeopathy

Here, dated September 2017:

http://www.easac.eu/fileadmin/PDF_s/reports_statements/EASAC_Homepathy_statement_web_final.pdf

EASAC – the European Academies' Science Advisory Council – is formed by the national science academies of the EU Member States to enable them to collaborate with each other in giving advice to European policy-makers. It thus provides a means for the collective voice of European science to be heard.

Extracts:

EASAC, the European Academies’ Science Advisory Council, is publishing this Statement to build on recent work by its member academies to reinforce criticism of the health and scientific claims made for homeopathic products. The analysis and conclusions are based on the excellent science-based assessments already published by authoritative and impartial bodies. The fundamental importance of allowing and supporting consumer choice requires that consumers and patients are supplied with evidence-based, accurate and clear information. It is, therefore, essential to implement a standardised, knowledge-based regulatory framework to cover product efficacy, safety and quality, and accurate advertising practices, across the European Union (EU).

Our Statement examines the following issues:

Scientific mechanisms of action—where we conclude that the claims for homeopathy are implausible and inconsistent with established scientific concepts.
Clinical efficacy—we acknowledge that a placebo effect may appear in individual patients but we agree with previous extensive evaluations concluding that there are no known diseases for which there is robust, reproducible evidence that homeopathy is effective beyond the placebo effect. There are related concerns for patient-informed consent and for safety, the latter associated with poor quality control in preparing homeopathic remedies.
Promotion of homeopathy—we note that this may pose significant harm to the patient if incurring delay in seeking evidence-based medical care and that there is a more general risk of undermining public confidence in the nature and value of scientific evidence.
Veterinary practice—we conclude similarly that there is no rigorous evidence to substantiate the use of homeopathy in veterinary medicine and it is particularly worrying when such products are used in preference to evidence-based medicinal products to treat livestock infections.

We make the following recommendations.

1. There should be consistent regulatory requirements to demonstrate efficacy, safety and quality of all products for human and veterinary medicine, to be based on verifiable and objective evidence, commensurate with the nature of the claims being made. In the absence of this evidence, a product should be neither approvable nor registrable by national regulatory agencies for the designation medicinal product.
2. Evidence-based public health systems should not reimburse homeopathic products and practices unless they are demonstrated to be efficacious and safe by rigorous testing.
3. The composition of homeopathic remedies should be labelled in a similar way to other health products available: that is, there should be an accurate, clear and simple description of the ingredients and their amounts present in the formulation.
4. Advertising and marketing of homeopathic products and services must conform to established standards of accuracy and clarity. Promotional claims for efficacy, safety and quality should not be made without demonstrable and reproducible evidence.

Our purpose is not to seek the prohibition of homeopathic products, and we recognise the fundamental importance of allowing and supporting consumer choice. Rather, we aim to explore the policy dimensions for ensuring informed patient choice with the emphasis on ‘appropriately informed’, and for achieving a standardised knowledge-based, robust regulatory framework and sound advertising practices across the EU, which can apply equitably to all medicinal products, whatever their origins and whatever their mechanisms.

The continuing popularity of homeopathic products worldwide might be taken as demonstrating an unfortunate point – that scientific evidence is not always relevant to the policy maker nor understood by the public-at-large. In this eventuality, there might be only limited room for optimism that EASAC and others – in reiterating that homeopathic products and practices lack proof of efficacy– could influence the present situation. 

Any claimed efficacy of homeopathic products in clinical use can be explained by the placebo effect or attributed to poor study design, random variation, regression towards the mean, or publication bias. Among these, the placebo effect can be of value to the patient but there are no known diseases for which there is robust, reproducible evidence that homeopathy is effective beyond the placebo effect.

• Homeopathy raises issues of concern for patient-informed consent if health practitioners recommend products that they know are biologically ineffective.

• There are also potential safety concerns for homeopathic preparations because of poorly monitored production methods, and these require greater attention to quality control and assessment of adverse effects.

• The scientific claims made for homeopathy are implausible and inconsistent with established concepts from chemistry and physics. In particular, the memory effects of water are too short-range and transient (occurring within the nanometre and nanosecond range) to account for any claimed efficacy.

• The promotion and use of homeopathic products risks significant harms. First, by incurring delay in the patient seeking appropriate, evidence-based, medical attention or, even worse, deterring the patient from ever doing so. Secondly, by generally undermining patient and public confidence in the nature and value of scientific evidence for decision making in health care and other societal priorities.

• In the absence of similarly robust evidence for homeopathic products in veterinary medicine, it is an error to require organic farmers to use these products in preference to prevention or treatment for which there is demonstrable efficacy and an established mode of action.

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Homeopathy sent to Room 101

Which is nice.

Sadly, BBC iPlayer does not allow embedding, so I can only give you this link and this screenshot:

Comedian Ben Miller, a physics graduate, opted to send homeopathy to Room 101, in the BBC program based on Orwell's dystopian vision of the future:

You asked me once, what was in Room 101. I told you that you knew the answer already. Everyone knows it. The thing that is in Room 101 is the worst thing in the world. (O'Brien in 1984)

Presenter Frank Skinner said that no-one on the (production) team knew what it meant, and everyone on set appeared surprised by its stupidity and implausibility once Miller explained it to them. Comedian Jo Brand (a nurse in a former life, for goodness sake!) said "Are you rubbishing the whole of homeopathy?". To his eternal credit, Miller replied:

No, I'm not rubbishing it; it is rubbish.

Cue a round of applause. To his eternal credit, Skinner chose to put homeopathy into Room 101. (Skinner is an excellent comedian with a gift for wordplay, but sadly has a history of woo-mongering himself.)

Cheers all round!

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Merdophilia

Stephen Law linked to a curious review of his book Believing Bullshit in THE, by Martin Cohen. I've not read Law's book, but I may well do - I've enjoyed some of the snippets he's posted from it, and his blog is full of useful philosophy. So I was interested to read what Cohen, Editor of The Philosopher, the journal of The Philosophical Society of England, had to say. According to the Society's blurb:

The Society aligns itself with no particular school of philosophy, nor is it a cover for any political, ideological, religious or esoteric movement or interests.

Sounds good. The review presents Law's book as an uncompromising attack on religion, alternative medicine and anti-science. Doesn't sound too bad to me, but I'm aware that Law's philosophy is rarely so absolute, so it surprised me. Then he says that Law thinks the scientific method:

...was invented about 400 years ago and is this: "Scientists collect data by observation and experiment. They formulate theories to explain what they observe and where possible, subject these theories to tests." Now that's what I call bullshit!

Eh? It's a simplistic summary, for sure, but 'bullshit'? How so?

Cohen complains that there is no mention of Thomas Kuhn and Paul Feyerabend, and so the alarm bells start ringing. No doubt their contribution to philosophy of science is considerable, but is it possible the reviewer is in thrall to unworkable post modern social science theories? Then Cohen says:

Law is one of the militant English atheists, led by His Holiness, Richard Dawkins.

Oh boy, the hallmark of the shallow thinker; 'cleverly' equating Richard Dawkins with a religious leader. Ironically, in a review of a book about believing bullshit, we are given a stream of classic examples from Cohen:

Take homeopaths, for example. Law complains that they swap anecdotes with each other about people who got better after taking the little sugar pills. No doubt this happens, yet if homeopathic remedies work for some people, then why the censorship?

Is it possible that this is some elaborate ruse by Law and Cohen to manufacture a review that highlights the problems detailed in the book? I mean, homeopathy? No harm? To the story covered at that link, Cohen says:

An "undercover" BBC reporter once asked homeopaths if they had alternatives to malaria pills. And they did! Scarcely surprising nor, I would say, particularly culpable.

The prospect of people using pills that don't work instead of pills that do doesn't raise any issues of blame for any resulting illness? Bizarre.

Stephen Law comments on the review a few times, and unsurprisingly is pretty livid at what appear to be misrepresentations. Cohen makes a risible defence of his statements, which in no way supports his review. And during the course of one point, in which he defends his accusation that Law is uncritical of the theory of natural selection by quoting Law on the theory of evolution (!), he says:

I argue that Law's book is uncritical of the theory of Natural Selection, which there are good arguments for considering to be unsupported by the 'evidence', whatever one may think about religious explanations for the universe.

This prompted me to berate him for commenting irresponsibly, as an academic (the use of scare quotes around 'evidence'). Water off a duck's back. The evidence for the overall theory is legion, even if many details are still debated. Law posts a comment detailing Cohen's completely inadequate response:

In short, I am baffled how Martin Cohen thinks any of the above supports his bizarre characterization of my views. As others have already spotted, it *very obviously* doesn't.

... which even Cohen can plainly see, since he posts a feeble follow-up:

You say the quotes don't show that you consdier (arguments for) belief in God to be 'bullshit', but I think it is reasonable to read this in. The second quote clearly implies Dawkins' work to be 'intellectually rigorous' and the views of 'theists' to be silly = you use value=laden terms to lead the reader into dismissing the 'theists' as people who use 'immunizing tricks'.

The quote he refers to has had Law's questioning of Dawkins' argument removed! Anyone's ghast should be flabbered by Cohen's effrontery.

Cohen's entirely inadequate data collection does rather point to the problems of folk who don't think that data collection in support of a theory (the very basics of science) has any value. What a sorry state we would be in if scientists like, say, Simon Singh, Christopher French and Richard Dawkins never bothered to check their data, and simply wrote about the impressions they, somehow, culled from the world, just as Cohen wrote about the impressions he, somehow, culled from Law's book.

But according to Cohen, that would be fascistic. Yes, in a masterful piece of Godwining even before the writing starts, Cohen is partly responsible for the website Philosophical Investigations, on which a page called British Science Fascists is prominent. Why Fascists?

But do they deserve to be called 'Fascists', after the 20th century political movement? The term is bandied about carelessly elsewhere. But we use it very, ah 'scientifically', as these reactionary thinkers share with the original fascists:

• a superficial and ideological commitment to Darwin's Theory of Natural Selection, which they attempt to adopt for political ends
• an inappropriate and dangerous reverence for scientific 'progress', coupled with an unwillingness to accept an ethical dimension to science
• an objectionable version of the history of science
• an even more objectionable distinction between 'Rational Man' and 'irrational deviants', with an often vicious antipathy towards the latter.
• hair on their arms and legs

So far, so brainless (and so straw filled, apart from the hair on the arms and legs). Here are slagged off, in order:

Chris French: "In an article for... (where else) The Guardian he trots out merrily the usual scientifically ignorant and politically dangerous call for 'rational' thought to eliminate 'emotional' biases."

Ben Goldacre: "...when confronted with the self-evident notion that his belief system (clinical epidemiology, now pretentiously called 'evidence-based medicine' or EBM), a statistics-based hierarchy of facts, is exclusionary..."

Julian Baggini: "Baggini speaks down to the ignorami from his perch at... the Guardian."

Madeleine Bunting (!): "She has also argued that the Enlightenment is a ‘made-up’ pseudo concept, which it is. In fact, she doesn’t belong in this list, but just fell in her because of her popping up regularly to support her ‘colleagues’." (phew, that's better - didn't think this was right!)

Nick Cohen: "Columnist for the Observer... guess what! part of the Guardian newspaper group."

Richard Dawkins (about time): "Richard Dawkins has successfully combined his day job, Professor of the Public Understanding of Science at Oxford University, with being the prophet of a new religion, the sole deity of which is Charles Darwin."

George Monbiot: "A columnist for the Guardian."

Simon Singh: "In a laughably bad 'investigation', Singh and others contacted homeopathic quacks, told them they suffered dangerous side effects from malaria tablets, and then asked what they should do? The homeopaths advised homeopathic treatments... Shame on them!"

Jeremy Stangroom (!): "Less influential, but tries to make up for it by the sheer venom of his pronouncements. Fails miserably."

Mark Lynas: "Guardian regular"

They don't like American scientists either! A number of themes appear. A paranoid distrust of science, so that one wonders how the compilers manage in everyday life. An antipathy to The Guardian! Well, it's not my cup of tea either, but I don't immediately consign its contributors to the bin. A slight obsession with CAM and climate change denial. They are keen to call into question the expertise of those mentioned, but it's not clear what expertise they have to talk about climate change, evidence based medicine and homeopathy. The website lists Samuel Hahnemann as a key thinker, for goodness sake!

All in all, the sort of sloppy thinking exemplified on the site plays out in Cohen's review and comments, as we see above. If this demonstrates the best thinking of the anti-science faction, then they are good examples of the unworkability of some theories of post-modernism and social science. I guess I'm in favour of science fascism.

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Government cares more for Tiddles than for You

Image via Wikipedia

A little while back I published some correspondence with Francis Maude, my MP and now Minister for the Cabinet Office and Paymaster General, discussing the report on homeopathy by the House of Commons Science and Technology Committee. I urged him to back their conclusions and to stop allowing public money to be spent on a treatment that hasn't been shown to work. In his reply he said:

Where a doctor and a patient believe that a homeopathic treatment may be of benefit to the patient, I believe doctors should be free to prescribe that medicine. All therapies should be considered equally, and decisions on whether or not to provide them on the NHS should be evidence-based, as is the case with all other conventional medicines and treatments.

He took the approach that patient choice was an important aspect in the provision of homeopathy. One wonders, if someone requested hoodoo, or sexual healing, would he be so keen to support patient choice? I wrote back to him pointing out this paragraph from the report:

The Government’s position on homeopathy is confused. On the one hand, it accepts that homeopathy is a placebo treatment. This is an evidence-based view. On the other hand, it funds homeopathy on the NHS without taking a view on the ethics of providing placebo treatments. We argue that this undermines the relationship between NHS doctors and their patients, reduces real patient choice and puts patients’ health at risk. The Government should stop allowing the funding of homeopathy on the NHS.

...noting that the Committee's position was that homeopathy reduced patient choice. He replied:

I think this argument you refer to is flawed. The argument goes that patient choice is meaningless when patients are not properly informed about the implications of the treatments they are selecting, and thus diminishes "real" patient choice.

In arguing this, the Select Committee pass judgement on homeopathic treatments, labelling them a "phoney" or "fake" choice. I am not a medical expert, and would not like to make judgements of this kind in the place of experienced medical professionals. GPs rightly should provide information to patients about different treatments, and must be held to account for the decisions they and their patients make under their advisement. I would not seek to undermine this critically important relationship in this way.

It is difficult to see how taking this choice away from GPs and patients could constitute an increase in choice; in my opinion this is simply taking choice away.

Should patients also be supported by the NHS if they choose urine therapy too? Or would that be taking the piss? Of course, the major flaw here is that GPs are in no position to judge the efficacy of any particular treatment either; that is determined by peer-reviewed clinical trials. Despite not being a medical expert himself, and apparently unacquainted with the science, he still sees fit to support public funding of a treatment that hasn't been shown to work. So far, so inconsistent.

But now the government has decided to add another layer of inconsistency on top of this watered down approach. DEFRA have clamped down on the use of homeopathic remedies for animals:

Some herbal and homeopathic products are claiming medicinal benefits without scientific proof, meaning they may not properly treat or prevent serious diseases, leaving pets at risk.

The Veterinary Medicines Directorate’s (VMD) Director of Operations, John FitzGerald, said:

“Some of these products are claiming to be effective and safe when no scientific evidence has been presented to us to show they are.

“Animal owners have a right to know if a product does what it claims. The products claim to treat diseases which can cause serious welfare problems and in some circumstances kill animals if not properly treated. So in some cases owners are giving remedies to their pets which don’t treat the problem.”

Bizarre; so these are the Government's current recommendations:

• Animal owners cannot choose a homeopathic remedy in conjunction with their vet, because no scientific evidence has been presented to show they are effective and safe, but...
• Patients can choose a homeopathic remedy in conjunction with their doctor, even though no scientific evidence has been presented to show they are effective and safe.

The government clearly doesn't care about our welfare as much as our pets'.


And note that they even allow us the freedom of choice to catch malaria; oh, sweet liberty!

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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.

...and:

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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Correspondence with Francis Maude on Homeopathy

Succussion

After the House of Commons Select Committee report on Homeopathy, recommending that the Government stops funding homeopathic treatments, I emailed my MP, Francis Maude, asking him to support its conclusions. He replied by letter:

24th February

Dear Mr Jones

Thank you for your recent e-mail about homeopathy, following the report produced by the House of Commons Select Committee on Science and Technology.

I am aware that there are differing views on the provision of homeopathic remedies, with some arguing that there is not enough evidence to support their availability via the NHS, while others argue that greater access to complementary therapies in the NHS might lead to widespread benefits.

Conservatives believe that the NHS should not rule out providing alternative therapies. Homeopathy and alternative treatments are a valuable resource for doctors to be able to draw upon when offering treatments. Where a doctor and a patient believe that a homeopathic treatment may be of benefit to the patient, I believe doctors should be free to prescribe that medicine. All therapies should be considered equally, and decisions on whether or not to provide them on the NHS should be evidence-based, as is the case with all other conventional medicines and treatments.

Once again, thank you for taking the time to write to me on this issue.

Francis Maude

Noting his liking for patient choice, I quizzed him on the suggestion by the Committee that homeopathy actually *reduced* patient choice (para 101):

Dear Rt Hon Francis Maude,

Thank you for your letter of 24th February.

You say that you want doctors free to prescribe a homeopathic treatment, where the doctor and the patient believe it may be of benefit. But as the Select Committee reported,

"The Government’s position on homeopathy is confused. On the one hand, it accepts that homeopathy is a placebo treatment. This is an evidence-based view. On the other hand, it funds homeopathy on the NHS without taking a view on the ethics of providing placebo treatments. We argue that this undermines the relationship between NHS doctors and their patients, reduces real patient choice and puts patients’ health at risk. The Government should stop allowing the funding of homeopathy on the NHS."

So, you seem to be arguing for patient choice, but the Select Committee think you are in fact arguing for less patient choice. Could you explain why you are right, and the Select Committee wrong?

Perhaps you could also confirm you are happy for this correspondence to be made public; if I don't receive a reply, I'll assume that is the case.

Yours sincerely,

Mark Jones

He replied and said that he disagreed with the committee's argument:

9 March 2010

Dear Mr Jones

Thank you for contacting me again about homeopathy.

I think this argument you refer to is flawed. The argument goes that patient choice is meaningless when patients are not properly informed about the implications of the treatments they are selecting, and thus diminishes "real" patient choice.

In arguing this, the Select Committee pass judgement on homeopathic treatments, labelling them a "phoney" or "fake" choice. I am not a medical expert, and would not like to make judgements of this kind in the place of experienced medical professionals. GPs rightly should provide information to patients about different treatments, and must be held to account for the decisions they and their patients make under their advisement. I would not seek to undermine this critically important relationship in this way.

It is difficult to see how taking this choice away from GPs and patients could constitute an increase in choice; in my opinion this is simply taking choice away.

Once again, thank you for taking the time to contact me.

Francis Maude

These letters are a cause for concern. The first says that Conservatives think that public money can be spent on alternative therapies. Just to be clear what that means; the Tories are happy for public money to be spent on treatments whose efficacy has not been shown. Mr Maude then couches this support for CAM in terms designed to make it look like support for doctor/patient choice. This is irrelevant, I feel. The Tories would surely not back with public money *any* treatment that a doctor and patient feel would help? No, a line has to be drawn; and where should that line be drawn? Between medicines that are shown to be efficacious and those that aren't. That's why CAM treatments should not be publicly funded. Doctor/patient choice is fine, at their own expense.

The second letter suggests that medical professionals decide what treatments should be provided. This is true, of course, but restricted to treatments that have been licensed for use by the MHRA. Doctors are in no position to determine the state of the science on some pretty complex subjects. That is why the MHRA should not allow homeopathic treatment; because the science says it doesn't work better than placebo. The *science* says that homeopathy is a fake choice, not the Select Committee. This is a vital distinction.

So it's clear that he is in favour of homeopathy (and other alternative medicine) on the NHS, but also of evidence-based medicine *only* for the NHS, which is either a contradiction, or he thinks homeopathy *is* evidence-based. In light of that, I emailed again:

Dear Rt Hon Francis Maude,

Many thanks again for taking the time to respond to me in your letter of 24th February (email response is quite all right, incidentally). I'll take that as a 'No', you won't be supporting the Select Committee's conclusions; at least, not whole-heartedly.

I note, however, that you haven't signed David Tredinnick's EDM expressing concern at the Committee's conclusions, so I'm thankful for small mercies. The idea that MPs should allow public money to be spent on treatments that are no better than placebos astonishes me, but we live in a strange world. For Conservatives intent on making savings in public expenditure it seems doubly odd.

Yours sincerely,

Mark Jones

I shall update again if I get a further reply.

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