A homeopathic “debate” in BMJ?

Homeopathy is quackery.

There, I’ve said it for the hundredth or even thousandth time, but I don’t care if it’s repetitive because it can’t be emphasized enough times that homeopathy is The One Quackery To Rule Them All, with the possible exception of reiki and other “energy therapies.” I also find it useful to make it clear right where I’m coming from right off the bat. If you’re a homeopath and are offended, quite frankly, I don’t care. Any “medicine” whose very precepts break multiple laws of physics and chemistry, laws that wouuld have to be proven not just wrong but spectacularly wrong for homeopathy to work deserves only ridicule.

Think of it this way. There are two “laws” of homeopathy, neither of which has any basis in reality. First, there is the law that states “like cures like” and asserts that, to relieve a symptom, you need to use a substance that causes that same symptom in healthy adults. There is, of course, no evidence that this is a general principle of medicine. For instance, we don’t generally treat fever by administering something that causes fever or treat vomiting with something that causes vomiting. The second law, however, is the one that’s completely ridiculous. Basically, it’s the law of infinitesimals. This law states that a homeopathic remedy is made stronger with dilution, specifically serial dilutions with vigorous shaking between each dilution step to “potentize” the remedy. That’s ridiculous enough, but homeopaths, never satisfied with the merely ridiculous have to turn the ridiculous up to 11 and beyond by using this principle to assert that dilutions far beyond the point where there is likely even to be a single molecule of the original remedy left are effective and become more so with more dilution. For instance, a 30C dilution is 30 one hundred-fold dilutions (C=100, get it?), or a 10-60 dilution. Avogadro’s number is only on the order of 6 x 1023, or more than 1036-fold less than the dilution. The simple mathematics of homeopathy just doesn’t work, although this doesn’t stop homeopaths from coming up with some truly spectacular flights of pseudoscience (like the “memory of water”) to try to “explain” how it can work.

For this reason and many others, there is no good reason for a reputable scientific journal to publish anything about homeopathy, and certainly there is no reason to publish a “debate” about homeopathy, any more than there is a reason to publish a debate over whether creationism, intelligent design or young earth, has validity compared to evolution. Unfortunately, that’s exactly what a prestigious medical journal, The BMJ, has done, asking Should doctors recommend homeopathy? On the “yes” side there is Peter Fisher, director of research, Royal London Hospital for Integrated Medicine. Note that “integrated medicine” seems to be a British variant of “integrative medicine,” the oft-criticized (on this blog at least) of integrating quackery with real medicine. Note also that the Royal London Hospital for Integrated Medicine used to be called the Royal London Homeopathic Hospital. Indeed, the last time I was in London (alas, eight years ago!), I made it a point to have my picture taken in front of its sign. In any case, Fisher is a homeopath, and a rather famous one at that. On the “no” side, we have Edzard Ernst. Now, I have no idea why Ernst agreed to this, but I wish he hadn’t. His debating a homeopath would be not unlike an evolutionary biologist debating a young earth creationist. There’s no point, and all it does is to elevate the stature of the crank by association. In fact, it’s even more like a creationist debate than you might think in that Fisher proves himself adept at doing the old Gish Gallop.

Hilariously, this is how Fisher chooses to begin:

Of all the major forms of complementary medicine, homeopathy is the most misunderstood. Based on the concept of “treating like with like,” homeopathy originated with the German physician Samuel Hahnemann (1755-1843). But similar ideas are found in the Hippocratic Corpus, in the work of Paracelsus, and in the medical traditions of several Asian countries.

Homeopathy is part of a family of toxicological and pharmacological phenomena that are attracting growing interest, characterised by secondary, reverse, or paradoxical reactions to drugs or toxins as a function of dose or time or both. These include hormesis (the paradoxical, stimulatory, or beneficial effect of low doses of toxins), paradoxical pharmacology, and rebound effects.

The controversial element of homeopathy is that some medicines are highly dilute, including “ultra-molecular” dilutions, in which it is highly unlikely that any of the original material is present. This is a major scientific concern and the source of the view that homeopathy “doesn’t work because it can’t work.”

First off, the problem with homeopathy is not that it is misunderstood. The problem with homeopathy, for homeopaths at least, is that it is understood all too well by scientists who have looked into it and become its critics, and that understanding is that it is quackery. Even though Fisher correctly points out the central problem with homeopathy, notice how he rebrands it in terms favored by homeopaths. Whenever you see “ultra-molecular dilutions” used as a term, it’s an almost certain bet that you are dealing with a homeopath. The term sounds all science-y and important, but it is utterly meaningless. Notice how he also attacks a straw man. Yes, we skeptics do say that homeopathy can’t work, because for homeopathy to work, our understanding of some long-established bedrock principles of chemistry and physics would have to be not just wrong but spectacularly wrong. But that’s not the only reason why we say homeopathy doesn’t work. We also look at the clinical evidence, which, when aggregated, is most consistent with the effects of homeopathy being nothing more than placebo effects. That’s not surprising, given that homeopathy can’t work, but in this case the science and the clinical observations we have both agree: Homeopathy doesn’t work.

Fisher’s also trotted out a veritable Gish gallop’s worth of homeopathy tropes, many of which I’ve written about here before, as well as on my not-so-secret other blog. Similar ideas are found in Hippocratic writings? So what? Hippocrates’s followers also believed in the four humors and that illness was caused by imbalances in the four humors. Yes, Hippocrates and those who followed made some significant contributions to medicine, not the least of which was the idea that diseases were natural and not caused by gods and evil spirits, but much of what they taught was based on prescientific beliefs about biology and physiology. Paracelsus, too, made great contributions to medicine, but he was also an alchemist, astrologer, and occultist. In fact, it is true that the ideas of homeopathy do resemble those of various ancients. Unfortunately for homeopaths the ancient ideas that homeopathy most resembles come from sympathetic magic, namely Frazier’s Law of Similarity (“like cures like”) and the Law of Contagion or “contagious magic” (the memory of water).

Last up, there’s the usual nonsense about hormesis and paradoxical drug effects. Repeat after me: Hormesis does not justify homeopathy. It’s an analogy that homeopaths love because it’s a hypothesis that states that some substances that are toxic at high doses might be benign or even beneficial at lower doses. That hormesis has anything to do with homeopathy is, of course, wishful thinking on the part of homeopaths, representing extreme over-extrapolation. Hormesis might apply to low doses, but much of homeopathy involves no dose; i.e., dilution far, far beyond the point where it is highly unlikely that even a single molecule of the original remedy remains. Not that this stops Fisher:

However, recent in vitro research shows repeatable effects (for instance, inhibition of basophil degranulation by highly dilute histamine1) while basic physical research shows that the homeopathic manufacturing process changes the structure of the diluent, including the formation of nanoparticles of silica and gas.2 The physical research is of little clinical relevance but provides a possible mechanism of action for the controversial high dilutions.

He’s referring to Jacques Benveniste’s study, which he claimed to have found evidence for the “memory of water.” Basically, Benveniste diluted allergens down to homeopathic dilutions and showed that they could trigger basophils to activate. The then editor of Nature, Sir John Maddox, agreed to publish Benveniste’s paper—but only on one condition. Benveniste was required to open his laboratory to a team of independent referees, who would observe and evaluate his techniques. Among that team was James Randi. Indeed, the Benveniste affair was, from my perspective, one of Randi’s greatest achievements in skepticism. Basically, Randi and the team of referees asked Benveniste to repeat the experiment, but went to extraordinary lengths to make sure that the people carrying out the experiments didn’t know what groups were the control groups and which groups were the ultradilute samples. Under these conditions, Benveniste’s results were not replicable. Basically, Randi showed how critical proper blinding was to experiments involving homeopathy. Indeed, this is a lesson that anyone doing lab work could take to heart, because blinding is actually uncommon in basic lab research for most experiments.

As for the bit on “nanoparticles,” that’s just the latest pseudoscientific “explanation” for homeopathy. It’s one particularly favored by a rather vocal proponent of homeopathy whom we’ve met before, Dana Ullman. it’s nonsense, of course, just like every “explanation” of homeopathy other than that it “works” solely through placebo effects.

It also turns out that Fisher is—surprise, surprise!— very unhappy with some systemic reviews and meta-analyses of homeopathy that show it to have no specific effects above and beyond placebo effects, as one would expect given what homeopathy is. As is usual for homeopaths, he attacks the 2005 Lancet meta-analysis by Shang et al, but worse, he misrepresents its findings. Contrary to Fisher’s characterization of the meta-analysis, Shang et al did not find that there was “weak evidence for a specific effect of homeopathic remedies.” That’s a cherry-picked quote. Actually, Shang et al concluded quite the opposite:

We acknowledge that to prove a negative is impossible, but we have shown that the effects seen in placebocontrolled trials of homoeopathy are compatible with the placebo hypothesis. By contrast, with identical methods, we found that the benefits of conventional medicine are unlikely to be explained by unspecific effects.

Then, as homeopaths are wont to do, Fisher picks crappy or old meta-analyses. Incredibly, this leads to a discussion of comparative effectiveness research involving homeopathy! Here’s a hint: Doing comparative effectiveness research is only appropriate to compare the effectiveness of treatments already shown in clinical trials to be efficacious. Such is not the case for homeopathy. One study he cites is an old study looking at comparing homeopathy to conventional therapy for a self-limited condition. It’s not randomized (of course), and the two groups (conventional treatment and homeopathy) are ridiculously poorly matched in terms of age and location. Sure, they had, as an aggregate, well-matched health scores, but demographically the groups are so different as to be uncomparable, making the study basically uninterpretable. Other studies referenced are all basically unrandomized and relied heavily on interviews, with the possibility of recall bias. Indeed, what the two studies suggest is not so much that homeopathy works rather than that general practitioners tend to overprescribe antibiotics for upper respiratory infections and nonsteroidal anti-inflammatory drugs for musculoskeletal pain.

All of this leads Fisher to conclude:

Doctors should put aside bias based on the alleged implausibility of homeopathy. When integrated with standard care homeopathy is safe, popular with patients, improves clinical outcomes without increasing costs, and reduces the use of potentially hazardous drugs, including antimicrobials. Health professionals trained in homeopathy do not oppose the use of conventional treatments, including immunisation (www.facultyofhomeopathy.org/media/position-statements/immunisation). Doctors should recommend the use of homeopathy in an integrated manner.

I’m so relieved that a bunch of homeopaths grudgingly recommend vaccination. No, I’m not, given that if you go to the link, you’ll note that in the case of patients for whom there is a medical contraindication to being vaccinated it “may be appropriate to consider the use of the relevant homeoprophylactic preparation applicable to that disease.” It is most definitely not appropriate.

Finally, contrary to Fisher’s plea to ignore the inconvenient science that shows how ridiculously implausible homeopathy is, doctors should most definitely not put aside “bias” regarding its implausibility because homeopathy has plausibility that is as close to zero as it is possible to get. In other words, Fisher doesn’t think that “plausibility bias“—or, as I like to call it sometimes, “reality bias“—is a good thing. Indeed, the only reason I don’t give homeopathy zero plausibility is more philosophical than anything else. I always leave open the possibility, however small, that maybe several laws of physics are not just wrong, but spectacularly wrong. Whether that is being too “open minded” or not, I leave to the reader. In practice, the difference is negligible, undetectable even. Using Bayesian methods, which take into account the plausibility (or lack thereof) of the remedy being tested, equivocal tiny “results” plus extreme implausibility of the method equal negative results. Basically, in clinical trials of homeopathy what is being observed is statistical noise and publication bias.

I don’t feel a need to go over Edzard Ernst’s response. It’s just Ernst doing what Ernst does best and, of course, mentioning some of the dangerous things homeopaths recommend, such as homeopathy for Ebola. I encourage you to read it. What I do feel obligated to do is to ask once again what the hell the editors of BMJ were thinking when they decided to publish this “point-counterpoint” in their journal. If they were looking for page views, no doubt they’ll get it. After all, I linked to the article, and so will, I predict, a lot of skeptical bloggers, to mock and criticize. All I can ask the editors is this: Were the page views worth the ridicule?