Trick or Treatment (35 page)

It was misguided at best, irresponsible at worst, for the Prince of Wales to suggest publicly that Gerson therapy might be able to treat cancer, when the evidence is to the contrary. And it would be arguably reckless for him to continue promoting alternative medicine in general when we have demonstrated in this book that very little benefit is derived from therapies such as acupuncture, homeopathy, chiropractic therapy and herbal medicine.

In short, the Prince of Wales ought to start listening to scientists rather than allowing himself to be guided by his own prejudices. Or, as Professor Michael Baum, a cancer specialist at University College, London, put it: ‘The power of my authority comes with a knowledge built on 40 years of study and 25 years of active involvement in cancer research. Your power and authority rest on an accident of birth.’

Placebos – little white lies or fraudulent falsehoods?

We have shown that the majority of alternative treatments are wholly or largely ineffective in treating the majority of conditions. The term ‘ineffective’, however, does not mean that such remedies are of no benefit to patients, because there is always the placebo effect, which we know can offer varying levels of relief. So, should doctors encourage the use of disproven alternative treatments, which on the one hand are nothing more than fake remedies, but which on the other hand can help those patients who have sufficient faith in them? Can large parts of the alternative-medicine industry justify their existence by offering relief through belief?

Of course, patients with life-threatening conditions cannot rely on the placebo effect to rescue them, but for patients with less serious conditions the issues are more complicated. Because of this complexity, we will explore the value of placebos by focusing on homeopathy, but everything that follows is also applicable to the placebo effect in the context of other alternative therapies.

Homeopaths will argue that their remedies are genuinely effective, but we know that the best scientific evidence concludes that homeopathic remedies are bogus and rely wholly on the placebo effect in order to benefit patients. For example, rubbing homeopathic Arnica cream on a bruise works only at a psychological level, so that a patient merely feels that a bruise is healing faster and that the pain is subsiding. Or a person with high blood pressure might take a homeopathic remedy, and the resulting sense of optimism might normalize his blood pressure. Similarly, a patient who uses homeopathy to deal with hay fever will expect the remedy to be helpful, hence the placebo effect may actually reduce the hayfever symptoms, or perhaps the patient tolerates the same symptoms with more fortitude – either way, the patient is happier. Some patients take homeopathy for self-limiting conditions, such as colds, which will clear up regardless after a week or so – in these sorts of cases, the placebo effect makes the patient feel better because he or she is given the illusion of taking control of the illness. For some conditions, such as back pain, conventional medicine struggles to offer a reasonably good solution, which means that a homeopathic remedy might be as good as anything else. After all, it will garner whatever psychological strengths the patient can bring to bear.

With all these undoubted benefits, it might seem that the use of homeopathy as a placebo is an obviously good thing, because it gives patients hope and relief. Many people might even argue that this is sufficient justification for homeopathy to be embraced by conventional doctors.

However, we take a different view. Despite the allure of the placebo effect, which is often (but not always) cheap, safe and helpful for patients, we strongly believe that it would be wrong for doctors and other healthcare practitioners to use homeopathic pills in this way. We base this stance on a variety of arguments.

One of our main reasons for discouraging the use of placebo-based alternative medicine is the desire for honesty between doctor and patient. For the last few decades, the consensus in medicine has moved very decidedly towards encouraging a doctor–patient relationship based on openness and fully informed consent. This has involved doctors using the principles of evidence-based medicine to offer patients those treatments that hold out the greatest likelihood of success. Any reliance on placebo treatments would undermine all these goals.

Doctors who studied the research into, say, homeopathy would soon realize that it is bogus and that any benefit to the patient is due to the placebo effect. If a doctor nevertheless decided to prescribe homeopathy, then he or she would be forced to lie to the patient in order for the placebo to be effective. In short, the doctor would have to reinforce the patient’s misplaced faith in the extraordinary power of homeopathy or perhaps even instil such a false belief. The question is simple – do we want our healthcare to consist of honest, evidence-based treatments or do we want it built upon a foundation of lies and deceit?

In fact, the best way to exploit the placebo effect is to lie excessively in order to make the treatment seem extra special. A doctor could use statements such as ‘this remedy has been imported from Timbuktu’, ‘you’re receiving the last supplies’, ‘the remedy has had a 100% success rate so far this year’, ‘this remedy neutralizes the most evil anti-matter in each of your cells’. Such statements will raise a patient’s expectations, thereby increasing the likelihood and extent of the placebo response. In short, for maximum-strength homeopathy, the doctor would need to tell the biggest pork pies imaginable.

Doctors regularly exploited placebos in the past, as they had little else to offer patients, but modern medicine now has real treatments that have been tested and shown to be effective. We strongly feel that there should be no return to a medical system that relies on placebos – a view shared by the doctor and journalist Ben Goldacre:

Our position – that the routine use of placebos is unacceptable because doctors should never lie to their patients – might seem draconian. Indeed, those who oppose our view would argue that the benefits of lying outweigh our ivory-tower ethical arguments. These opponents would feel that white lies are acceptable if they improve the health of patients. We would counter that routine peddling of placebos would lead to a widespread culture of deception in medicine, which would in turn result in a series of corrosive consequences for the medical profession. Imagine what healthcare would be like if doctors routinely prescribed placebo-based treatments, such as homeopathy:

1. Doctors would have to establish a conspiracy of silence and agree not to reveal the bogus nature of homeopathy. None of them would be allowed to point out the truth about the Emperor’s New Clothes, as this would undermine homeopathy’s placebo effect.
   
 

2. Medical researchers would not sign up to this pact, as their mission is to understand disease, its causes and its cures. In the name of progress, they would be honour bound to point out that existing research fails to support homeopathy. This would lead to scientists and doctors giving conflicting messages.
   
 

3. Homeopathic prescriptions would act as a gateway drug, encouraging patients to experiment with other irrational treatments. Professor David Colquhoun has neatly summarized the insidious dangers of homeopathic remedies: ‘Their sugar pills contain nothing and they won’t poison your body. The greater danger is that they poison your mind.’
   
 

4. Parents might ignore scientists who promote life-saving interventions such as vaccination, and instead they might listen to homeopaths promoting alternative (and ineffective) ways to protect children. After two centuries of progress since the beginnings of the Age of Enlightenment, a decision to move away from evidence-based medicine could usher in a New Age of Endarkenment.
   
 

5. Pharmaceutical companies would be in a strong position to argue that they too could promote placebo remedies. Why should they bother with the expensive process of proper drug development when they could make bigger profits by marketing a placebo sugar pill and pretending that it was a panacea?
   
 

Finally, there is one more reason why placebo treatments should be avoided. In fact, this particular reason is so powerful that it will soon become obvious that it is completely unnecessary and unjustifiable to use placebos routinely to treat patients. Everyone agrees that the placebo effect can be very beneficial, but the truth is that we do not need a placebo in order to evoke a placebo effect. Although this sounds paradoxical at first, it actually makes perfect sense if we explain what we mean in more detail.

Whenever a doctor prescribes a proven treatment, then the patient hopefully experiences a biochemical and physiological benefit. However, it is important to remember that the impact of a proven treatment is always enhanced by the placebo effect. Not only will the treatment deliver a standard benefit, but it should also deliver an added benefit because the patient has an expectation that the treatment will be effective. In other words, patients receiving proven treatments already receive the placebo effect as a free bonus, so why on Earth would a patient take a placebo on its own which delivers only a placebo effect? And why on Earth would a therapist prescribe just a placebo? This would simply short-change the patient.

Doctors are well aware that all their treatments come with a placebo effect, the extent of which depends on a whole host of factors. These include the doctor’s clothing, confidence and general attitude. The best doctors fully exploit the placebo impact, while the worst ones add only a minimal placebo enhancement to their treatments; this explains why the neurologist J. N. Blau suggested, ‘The doctor who fails to have a placebo effect on his patients should become a pathologist.’

Earlier we outlined a list of conditions that homeopaths might treat which would improve due to the placebo effect. Returning to these same conditions, we can see that conventional doctors will generally advise a more reliable medical treatment that will not only offer a direct benefit to the patient, but will also offer an indirect benefit via the placebo effect. So, instead of recommending homeopathic Arnica for a severe bruise, a doctor might suggest a cold compress within the first day of the injury and then a damp, warm cloth thereafter. Instead of homeopathy for high blood pressure, a doctor might suggest a change in diet, or less alcohol consumption or fewer cigarettes, and if this does not work then the condition can also be treated with effective drugs. Similarly, for patients suffering from hay fever, a non-drowsy antihistamine that has been proved to work, plus its inevitable placebo effect, would be a much better option than a homeopathic placebo on its own. A cure for the common cold still eludes science, so conventional medicine can only treat this condition in terms of addressing the accompanying symptoms, but even this is more than homeopathy can achieve. The proven benefits of conventional cold tablets plus their placebo effect are, again, better than just the placebo effect of homeopathic tablets.

For the hardest problems, such as back pain, doctors have a limited arsenal of truly effective options, but these are still more powerful than anything that homeopathy or any placebo-based alternative therapy can offer. In 2006, B. W. Koes and his Dutch colleagues published a clinical review entitled ‘Diagnosis and treatment of low back pain’ in the
British Medical Journal
:

As we approach the end of this book, it becomes increasingly clear that much of alternative medicine is ineffective and should not be encouraged, even at the level of being a benign placebo. In many ways, today’s alternative medicine is a modern version of the snake-oil remedies that were sold widely in America a century ago, such as Tex Bailey’s Rattlesnake Oil and Monster Brand Snake Oil. They offered no medical benefit to patients, but they made plenty of profits for the huxters who sold them. One of the most famous snake-oil salesmen was Clark Stanley, who promoted his product as ‘A Liniment that penetrates Muscle, Membrane and Tissue to the very bone itself, and banishing pain with a power that has astonished the Medical Profession’. Of course, it offered no such benefit, and when his Snake Oil Liniment was tested in 1916 it was found to be devoid of any actual snake oil. Instead, it consisted of ‘principally a light mineral oil mixed with about 1 percent of fatty oil, probably beef fat, capsicum and possibly a trace of camphor and turpentine.’

Both snake oil and ultra-diluted homeopathic remedies contain no active ingredient, and both also offer nothing but a placebo effect. Yet the former is now mocked and seen only in Hollywood cowboy films, and the latter is still sold in every pharmacy. If anything, homeopathy is even more absurd than snake oil, as demonstrated by a homeopath who wrote a letter outlining a particularly bizarre homeopathic remedy: ‘This patient continues to have multiple symptoms of lumps on scalp and has had a flu-like illness. Overall her mood has improved, however, I have given her a dose of Carcinosin Nosode 30C over the day followed by Berlin Wall 30C one a day in the morning…’ A response in the
Medical Monitor
emphasized the ridiculous nature of Berlin Wall as a homeopathic remedy: ‘What therapeutic advantages does Berlin Wall have over ordinary garden wall or Spaghetti Junction concrete? And do Scottish homeopaths use microdoses of that historic nostrum, Hadrian’s Wall? I think we should be told.’