Ben Goldacre’s excellent piece in the Guardian this weekend outlines clearly why it is that we can’t trust much of the data we have about pharmaceuticals. Data gets buried, the wrong questions get asked about what works, and we end up prescribing things that are later shown not to be useful, or even harmful.
Meantime, Des Spence wrote in the BMJ that homepathy is ‘bad science but good medicine’. While making it clear that homeopathy doesn’t work at a cellular level, he said that “The homeopathic doctors I know are caring people, disillusioned with the crudeness of conventional medicine, not your typical aggressive alpha medical type. They are not in the pay of big pharma, whose drugs potentially kill 100 000 people a year in the United States alone.1 They listen, spend time, and offer some explanation for the unexplainable—and their patients like them. The effect of homeopathy is the positive effect of a therapeutic relationship that is reassuring, accepting, and supportive. Society should never underestimate the healing effect of a kind word or the value of a holistic approach. These consultations genuinely improve wellbeing. Homeopathic pills are placebos, but the placebo response is great, maybe even as high as 80%.”
Here we have the crux; the massive dilemma in modern medicine. We have pharmaceuticals which we hope are evidence based but may, if we take into account the poor quality of the evidence, actually not be. Then we have doctors saying that actually, the drugs won’t work for a subset of people anyway; homeopaths are not prone to the excesses of Pharma, and thus homeopathy, with it’s kindness and concern, works. In other words, homeopathy is the best way to protect patients and care for them.
I think this is wrong, hugely and utterly and inescapably wrong.
First: it would be a scandal if the homeopathic consultation were the only way to talk, listen, support and be kind. But it’s not. It is true that the GP consultation has become owned, via the GP contract, to politicians more than patients (the whole of the last bit in The Patient Paradox is all about this.) The answer to this is not homeopathy, but in making the GP consultation about the patient, not about ticking boxes via the GP staring at the computer screen. We must address the GP contract, not add an unethical placebo like homeopathy. As I’ve written about before, there are many things which good general practice can ethically offer that improve outcomes for patients – like continuity of care – and which are not unethical deception.
Second: Some drugs do work. Treatments for HIV, meningitis, organ transplantation, heart failure, stroke. Ben knows this, he writes about this; he is certainly not arguing for non evidence based medicine (like homeopathy). The answer is not to give up on pharmaceuticals. It is to make the way we test and research treatments better. We have to make the questions researchers ask more useful to patients. This is already happening. The James Lind Alliance works to do just this – to make sure that patients are telling researchers are asking the questions which are important to them, and then taking part in trials which they have ownership of. We need legislation to ensure that clinical trial results are not hidden. This can be done.
Third; It is of huge importance that we get back to the importance of unbiased assessments of the evidence. This is what Cochrane was set up to do. Biased, bad evidence should be dismissed – which is how Cochrane operates – but good evidence stops us killing people – and here’s the crux -not just by prescribing, but also by not prescribing. So we know that MMR saves lives. But we also know that paroxetine prescribed to young people raises the risk of suicide.
More than ever, doctors, patients, carers, citizens and researchers have to work together. We have to acknowledge and reduce uncertainties about treatments when we can. But we also have to do this ethically; and caring well for patients without deception can and should be our priority.