January 2010 Archives

Homeopaths who are perhaps feeling the pressure of the 10:23 campaign have recently been taking to declaring that those of us supporting it are against freedom of speech or freedom of choice.

This is not true. It's explicitly clear on the 10:23 site's FAQ page, so anyone spouting this nonsense hasn't bothered to read the site properly.

Anyway, I wanted to go in to the question of freedom of speech a bit, and why I'm quite happy to say that in certain cases homeopathy needs to be reined in.

Let's start by considering freedom of speech - this is widely regarded, fairly correctly, as a human right. If you look at the freedom of speech wikipedia page you'll see right up front why.

But scroll down a little further, and you'll see the justifiable limitations upon freedom of speech. One has a certain right to express opinions freely, but not to say absolutely anything you like in all circumstances.

These do naturally vary from country to country, as laws vary. I'll leave it to more expert legal opinion to discuss how that plays into this matter, but suffice to say when, for example, someone shouts "fire" in a crowded theatre, but there is no fire, there are limitations on freedom of speech that can come into play.

One might also expect to find your freedom of speech in certain countries to be limited when it comes to hate speech, or that you can't go round freely claiming to cure cancer. If you wish to run a business you may find your freedom of speech doesn't extend to making false claims when advertising it, or you may find you aren't able to go round freely telling everyone you are a policeman or a doctor.

In short, freedom of speech is one of those things most people agree is a good idea, but when you start pointing out certain exceptions that should be made to it, it's actually quite hard to find someone who thinks everyone should be able to go around stringing together any words in any order they please, when some of those orderings of words can be dangerously misleading or incite criminal behaviour.

As I expressed in my last blog post, I think certain privileges come at a certain cost in freedoms. If you wish to claim you are a pharmacist, you must also take on the responsibilities of a pharmacist, such as ensuring the safety of your patients and providing them with the kinds of information they can reasonably expect a pharmacist to provide on a professional level.

Where certain lines are drawn are a matter of personal preference. I have no wish to stop a Catholic priest from using holy water and telling his congregation that it is holy because it has been blessed, even if it's not any different from before by any test I can come up with. If someone comes along and offers sugar pills that have been through some special ritual, and someone who is fully informed about the evidence base for it still wishes to buy it, you would be hard pushed to find me arguing it has to be banned. I don't think the freedoms of the seller of that product should extend to them being able to lie about the product or misinform, or fail to provide certain kinds of information when asked about it. This goes both ways - as I said last time if you want to sell those sugar pills that have gone through a special ritual, the buyer has a right to expect that they really have gone through that special ritual. I think most people that have benefited one way or the other from the scam protection services of Trading Standards or the like can see why I might think this.

Those using conventional medication also benefit from some kind of restriction on freedom of speech. Doctors have certain ethical obligations in informing their patients on things like the risks of the treatments they offer, and drugs do not hit the market straight off the bat with drugs companies able to make any claim whatsoever regarding them - the licensing of drugs means a drug company can't just sell anything and make any claim regarding it.

The 10:23 campaign seems to be, as a whole, rather liberal on this point, actually, and I think when people consider what they say on it properly, most people can see why simply asking for a proper informed choice, and asking that pharmacies take a bit more responsibility is quite reasonable.

Myself - I'm fairly liberal when it comes to people choosing how to spend their money. If you want to buy snake oil, it's your money. I'm not so liberal when it comes to how people choose to earn money. I'm not so willing to let you earn money in a number of unethical ways, and one of those ways is by being in the healthcare industry and not treating your patients with the proper respect, and providing them with proper, accurate information about their own healthcare, even if you don't happen to agree with that proper and accurate information.

Personally, I don't think you should be able to claim that vaccines cause autism, that homeopathy can prevent malaria or that some whackjob in Brazil can magic the cancer out of you, any more than you should be able to shout "fire" in a crowded theatre. I'm still fairly liberal if you happen to be a model who is dangerously misguided - I think there are better ways for society to protect itself from dangerous ideas than criminalising everyday people, even if I might colloquially describe them as criminally stupid. I do think that anyone setting themselves up as a business in the area, or as some kind of professional, does have a more serious responsibility though, and when they stray from that they need to be held to account. Freedom of speech just does not go that far.

If you follow me on Twitter (and chances are if you read this you do) you'll maybe have seen me use the hashtag #ten23 or mention www.1023.org.uk. This is a recent campaign to raise awareness of what homeopathy is, and what evidence there is for it. I wanted to expand on that a little, and explain why I think this campaign is important. As a warning, this will be a long post. I'll start off explaining briefly what homeopathy is (which many readers can skip), why I think the evidence is insufficient for it (without directly discussing any analyses in detail) and then why I have an issue with it, and I'll also tackle a few common arguments that seem to come up.

There's a fairly common misconception that homeopathy is herbal medicine. It isn't. For one thing, a lot of homeopathic remedies are based upon non-herbal materials (minerals for example), and secondly while a specific material is used in the preparation of a homeopathic remedy, the final product contains none (or almost none) of that material. In a lot of cases, a homeopathic remedy is literally just water or just a sugar pill.

Homeopathy was invented by Samuel Hahnemann a couple of hundred years ago. He put it forward with a few simple principles behind it.

• Like cures like - the 'Law of Similars'. He figured that giving someone a small amount of something that prompted similar symptoms in a person would cause their body to heal itself of the problem.
• Dilution - obviously giving someone a large dose of something that causes the same symptoms isn't exactly going to help. So Hahnemann figured he'd dilute the substance. Repeatedly. A lot.
• Potentisation - Hahnemann also figured that a special ritual of shaking at each repetition of the dilution made the homeopathic medicine work. This is called 'succussion' - his original idea was something like striking the container against a board ten times.

This is not the foundation of an effective system of medicine. I don't think it takes a rocket scientist to figure out that the dilution idea is implausible. The succussion is borderline implausible - clearly shaking some materials does have an effect on them, but the use of it in this repeated dilution process is quite bizarre. There's no reason to think (as homeopaths do) that somehow this imparts a memory of the material into the water, and that doing this repeatedly somehow makes the memory stronger. The 'like cures like' is also fairly implausible, although it has similarities to vaccinations, where giving someone a weakened or dead dose of a pathogen provokes a lasting and protective immune response. The reason I'd say homeopathy is particularly implausible is that it looks for something producing similar symptoms, not for the actual cause (in striking contrast to a common criticism by alternative medicine types that conventional medicine only treats the symptoms). With vaccines, it can even be the case that a particular strain of a pathogen (the H1N1 strain of the influenza virus for example) has to be used and won't protect against closely similar pathogens producing near-identical symptoms (other strains of influenza).

Homeopathy is a deeply implausible system of medicine. However, sometimes deeply implausible things turn out to be true - and obviously the way you find out when this is happening is by looking at evidence. Unfortunately for homeopaths there is no strong evidence. They'll sometimes claim there is evidence, but (referring back to my past blogs) while this is technically true in some cases, a small amount of low quality evidence is not enough. Extraordinary claims require extraordinary evidence, and you need a lot of good evidence to justify homeopathy. Furthermore, homeopathy has long been at the edge of detectability - for 200 years the support for it has been tenuous and weak, when for real effects one can expect the accumulation of evidence, and the improvements in methods for accumulating evidence to increase support for ideas that are true. It's telling that homeopaths scrabble around for tiny effects on white blood cell responses or whatever that Hahnemann couldn't possibly have been able to observe. If Hahnemann had real evidence for homeopathy it should be demonstrable completely beyond any doubt by such sensitive laboratory techniques as are available today.

I'm not going to go into any of the evidence for homeopathy or criticise it, and equally, if you're reading this blog as a supporter of homeopathy and are thinking of posting some - don't bother. The a priori likelihood that you have sufficiently convincing evidence for something as dramatically implausible as homeopathy, but that I've not heard of it through a more reputable source than a comment on my blog is zero, so I'm not even going to bother clicking your link. You might criticise me for not bothering to assess your evidence, but I can be pretty confident that if your evidence is really that good it will make itself known to me some other way, and at that point I will carve fancy that on my happily admit I was wrong all along. I've changed my views about certain elements of nature fairly profoundly before, and I'm more than happy to do it again, given the evidence.

So, why is homeopathy a bad thing? Clearly, if it attracts people and they use homeopathic medication in place of proven treatments that do work, then people suffer. People die, and innocent people die. That alone is argument enough for campaigning against homeopathy, and for raising awareness of what it really is.

Homeopaths will sometimes claim that they will never tell people not to see their doctor or whatever, but there is (as is clear as day if you know where to look on Twitter for example) a concerted campaign by homeopaths against conventional medicine (which they term allopathy). This is dangerous to people. Homeopaths have been shown in the past to give bad advice on malaria prophylaxis, and I don't doubt that it's easy to find similar examples of bad practice by them. And I have no doubt that if it were not for people like James Randi and a host of vocal skeptics like those involved in 10:23 they would quite happily continue spouting bullshit at the expense of people's lives.

The excellent whatstheharm.net has further examples. The marvellous Simon Singh has just posted this on the 1023 site too, explaining the harm of homeopathy.

Homeopathy runs counter to well-established and important scientific facts. It operates at dilutions so low that there is no ingredient left - that this is the case is a result of the atomic theory of matter. You can't keep on dividing matter indefinitely - you reach the level of single molecules or atoms of substance.

The atomic theory of matter is pretty widely known today by people, but there's a reason so much time is devoted to it in schools. It's behind all of chemistry, a lot of biology, a vast proportion of physics, a myriad forms of technology and engineering, materials science - this list is vast. Richard Feynman was, beyond a shadow of a doubt, one of the finest physicists mankind ever produced. He was a chief architect behind the most successful theory of physics ever, and a wealth of other stuff besides. This is something he once said:

If, in some cataclysm, all scientific knowledge were to be destroyed, and only one sentence passed on to the next generation of creatures, what statement would contain the most information in the fewest words? I believe it is the atomic hypothesis (or atomic fact, or whatever you wish to call it) that all things are made of atoms -- little particles that move around in perpetual motion, attracting each other when they are a little distance apart, but repelling upon being squeezed into one another. In that one sentence you will see an enormous amount of information about the world, if just a little imagination and thinking are applied.

It's maybe not the sentence I would choose (I might choose a sentence that points more to the methodology of science than the results), but it emphasises the fact that this is a truely core idea of modern science.

Homeopathy, with its repeated dilutions exponentially reducing the amount of material in its remedies (public misunderstanding of the power of exponential functions is another complaint), encourages a misunderstanding of biology and chemistry and the crucial role the concepts of atoms and molecules play within them.

In addition, certain sectors of the homeopathic community like to put forward ideas for mechanisms by which it might work (because clearly it can't be the material ingredient itself at work - there isn't any). These are almost universally poppycock. The now-classic example is "Homeopathy with Dr. Werner" - it's just a hideous murdering of concept in physics, and it's shocking that anyone would stand up and spout such utter crap as if they knew what they were talking about. Homeopathy is damaging the public understanding of science. By putting forward ridiculous woo explanations for its mechanism when the existence of the effect has not been demonstrated, it also encourages other bad ideas. The belief that water might harbour some kind of energy or 'vibration' from past contact with other materials might, for example, lead someone to lend more credence to the idea that particular crystals harbour some kind of energy or vibration specific to them, that can also have a health effect.

Essentially, science is an important part of our society and how it develops, how we improve technology, medicine and our lifestyles. Attacks upon it are attacks upon us all.

I want to make clear I don't think homeopaths and alternative medicine supporters are at all stupid. They simply have latched on to incorrect ideas, and this is something everyone does. Homeopathy even has, or has had, some level of support from a Nobel Prize-winning physicist. We need to educate ourselves about the mistakes we make in how we perceive the world, understand the world and assess evidence. It's a pervasive difficulty, and why many skeptics like myself think that the teaching of critical thinking skills is so important. For further reading, Michael Shermer has an excellent book "Why People Believe Weird Things", and the late Carl Sagan wrote the brilliant "Demon-Haunted World", which I consider required reading for anyone.

This predilection for people to make mistakes is precisely why scientists go to great lengths to operate proper scientifically controlled studies, to perform proper statistics on the results, and to critically appraise each others' work. It's why we skeptics push homeopaths to provide real evidence in the form of randomised controlled trials. These are trials that try to remove all the confusing and confounding effects (such as the placebo effect) in order to highlight the evidence for something. @endless_psych provided a great blog post on this just recently.

Homeopaths will frequently complain about RCTs. I would like to emphasise that the value of an RCT is not that it is stricter and makes it more difficult for an effect to become visible. It is that it removes other effects and essentially increases the contrast by which you might detect any true effect from the thing you are studying.

Another complaint is that homeopaths produce too-specific a prescription to be subject to an RCT. While one might test the latest antidepressant by giving it to 100 people and comparing against a control group, how would one do this if every one of the 100 needed a different remedy?

Well, it's still fairly straightforward. One normally does a double-blind study by splitting a group in two, and randomly (and without the patient or doctor concerned knowing who was in which group) give them either the drug or an inactive treatment (like a sugar pill). One can still do this with a specific treatment for each patient. You let everyone see the homeopath (repeatedly if needs be) and still supply each of them with either their actual homeopathic remedy or the control substance. It works just as well - you're just testing a collection of remedies, not one.

Finally I have seen homeopaths linking to examples of where RCTs are inappropriate. It's absolutely true that in some cases RCTs are inappropriate, even unethical. These are cases when something has a dramatic effect, often lifesaving. A classic example is insulin. This is a disturbing image. The person on the left is a type I diabetic before insulin was around - the weight loss is notable. Without insulin, a type I diabetic dies in short order - you could sometimes drag it out a bit longer on a diet of boiled cabbage and black tea, but you'd live the last months of your life as an exhausted skeleton. With insulin, a diabetic lives a practically normal and active life. When you start doing a trial on insulin, you see practically instantly that this is no placebo effect, and you roll the stuff out worldwide and save countless lives. An RCT then would be unethical. In the case of homeopathy, RCTs are appropriate. You're looking for effects that are not that pronounced, for something whose entire foundation and means of mechanism are utterly implausible. Arguing that because RCTs are not appropriate forms of trial in some circumstances does not absolve homeopathy of the requirement to produce a proper level of evidence - a proper level of evidence that is most easily obtained for something that has a real effect through the means of the RCT.

Homeopaths also like to attack 'big pharma', or other aspects of 'allopathic' medicine. They repeatedly pollute the #ten23 hashtag with articles unrelated to homeopathy, but attacking conventional medicine. Conventional medicine does have its flaws, and the commercial mechanisms behind the production of many new drugs through large companies investing money in that direction does lead to problems. Surprisingly enough, the medical community is aware of this (that was my sarcastic voice). You only have to flick through Ben Goldacre's writings to see considerable criticism of a number of pharmaceutical companies or conventional treatments, but the great thing is that doctors and scientists like him can try to spot when this happens and put that criticism out there. Conventional medicine is not perfect for sure, and if you have a great idea for how to regulate it better or fund it better then I'm sure someone would like to hear from you, but that does not somehow constitute proof of the effectiveness of homeopathy. One also wonders why you so rarely see homeopaths attacking other forms of treatment, such as reflexology, acupuncture or most particularly herbal medicine (which in some forms is simply conventional pharmacology minus the controlled trials, purification of active substances, detailed information sheets on potential side effects and what to do and not to do while on the medication, and properly controlled doses - things I generally suspect are actually quite a good idea). Pretty clearly its because they don't like to be criticised for their lack of an evidence base, and this is a form of attack on those of us that do support the use of evidence in making our decisions, and attacking other groups that don't particularly care much for fact-checking doesn't really serve their aims.

There is a mistaken belief amongst some parts of the 'opposing camp' that we skeptics are against a freedom for people to choose their medical treatments, or that we wish to silence homeopaths. This is wrong.

We want people to have a right to proper information about their treatments so that their freely exercised choices can be fully informed. Equally, I at least don't wish to curtail freedom of speech - but I do not believe that freedom of speech extends to anything. The classic example is that freedom of speech does not extend to causing panic and risking injury by shouting "Fire!" in a crowded theatre, and I do not believe freedom of speech extends to allowing people to advertise nutty claims about how they can cure your mother of terminal cancer by waving a magic crystal around, if you'll just give them a few hundred quid.

If you go off and research homeopathy and decide to go for it, I will not stop you. I will argue that if you go into a pharmacist, you have the right to see a bottle of water on the shelf not labelled as a treatment or preventative for flu, but as something that contains no active ingredient but has gone through a magic ritual that some people think gives it that property, but for which no good clinical evidence has been found to support its efficacy. I will also argue that pharmacists have a duty to properly inform those going into their shop, and that by implicitly endorsing certain products with no efficacy by stocking them they are failing that duty. This doesn't impact your ability to go and buy sugar pills or water off a shelf that has gone through some special ritual, any more than I wish to ban churches from using holy water during baptisms.

So, to finish, I support the 10:23 campaign because I think homeopathy is a danger, a danger to the individual and a danger to society. I think people are often poorly informed about what it is, and when people are properly informed they often make better decisions about their health, their childrens' health, and it can serve as a starting point for applying critical thinking to other areas, not just alternative medicines but topics that come up in all sorts of areas in our society.

I don't want to ban homeopaths from having peculiar beliefs, but I have no shame in pointing out ideas I think are ridiculous. I might also want to protect their children from those beliefs when they become lethal.

I think homeopathy is utterly without foundation, that there is no good argument to support it. It does not deserve government funding, and we have a right to expect that healthcare professionals, particularly pharmacists, are their to support our ability to make informed choices about our health.

And if you made it to the end of this blog, thanks, and well done!