Memorandum submitted by Dr Ben Goldacre
Sugar pills which have been prepared in accordance with the principles or rituals of homeopaths are physically indistinguishable from untreated or "placebo" sugar pills, and these homeopathy pills have overall been shown, repeatedly, in summaries of fair clinical trials, to perform no better than dummy placebo sugar pills. Any claims to the contrary rely on cherry picking the evidence to selectively reference only positive findings, to reference poorer quality studies which are not "fair tests" of the pills, and so on. Almost any ineffective medical treatment could be made to appear effective using these strategies: they simply reflect misleading and partisan scholarship. These sugar pills are not physically harmful, nor do they physically confer benefit on patients. Where there are benefits (and indeed harms) from these sugar pills, it is only in how they are presented. I assume that this basic territory will be covered by others, and confine my submission to issues that interest me particularly.
Licensing of homeopathic pills:
The MHRA approved label on homeopathy sugar pills is misleading. A great deal of effort has gone into making patient literature, leaflets, and labels more easily understood, explaining the benefits and risks of treatments clearly, so it seems perverse and anomalous that the MHRA have settled on a plainly misleading convention for labelling these homeopathic sugar pills. The MHRA may deploy sophistry, or invoke technical readings of the statements, but the public read these labels as saying that the homeopathic sugar pills are effective for the conditions listed. They are not effective, and the MHRA know they are not. The confused wording of the labels is compounded by the fact that the government medicines regulator is giving licenses to pills sold in pharmacies which have not been shown to be effective, something few would expect a government regulator to do, so this unusual state of affairs requires even more explicit clarity than normal. As things stand, this labelling system is misleading, ignores the evidence on best practise in communicating risks and benefits to the public, and should be changed.
The MHRA approval reinforces an unwelcome situation in which pharmacists are misleading patients. Patients and doctors should be entitled to trust pharmacists as a valuable source of evidence-based information on the treatments they deal in. Pharmacists hold themselves out as a valuable community resource in this regard, for example in the RPSGB's "Scientist In The High Street" campaign. Now they are selling placebo sugar pills to sick people by misleading them. Each profession should be free to make its own decisions, but it may be worth ensuring that the public are told that pharmacists have abandoned their previous principles, so that they are not trusted in error.
Homeopathy on the NHS:
The obvious argument is that homeopathy, since it works no better than placebo, should not be funded by the NHS. Although homeopathy is certainly not the biggest example of resources being wasted on an ineffective treatment, a recession should be a time for rational disinvestment, homeopathy is a clear example, and the NHS should be scanning its activities for other good candidates.
Although it is clear that homeopathy works no better than placebo, I do however accept that circumstances might occur in which it could arguably be desirable to have the option of prescribing a placebo. There are often situations where an individual may want treatment, for example, but where medicine has little to offer - lots of back pain, stress at work, medically unexplained fatigue, and most common colds, to give just a few examples. Going through a "theatre" of medical treatment, and trying every medication in the book, will only risk side-effects. A harmless sugar pill in these circumstances may seem to be the sensible option.
However the limited benefits must be weighed up against the risks:
1. Prescribing a placebo requires that a healthcare practitioner misleads their patient, which is unethical, paternalistic, and undermines the current emphasis on shared decision making in medicine. It also undermines the credibility of healthcare professionals' utterances, when it is widely known that doctors and others will lie to you about a treatment.
2. Even if we accepted that it was desirable and cost effective to prescribe a placebo, and responsible healthcare practitioners could be found who were willing to work around the ethical issues and do so, homeopathy may not be the best model for delivering placeboes, for a number of reasons:
a. It is routine marketing practice for homeopaths to denigrate mainstream medicine, for example campaigning against vaccination programmes, advising against medical treatments, undermining treatments such as chemotherapy which are distressing - but overall confer benefit - by overstating the side effects, and so on. One study found that more than half of all homeopaths approached advised a client against the MMR vaccine for their child. A BBC Newsnight investigation found that almost all the homeopaths approached recommended ineffective homeopathic pills to protect against malaria, and advised against medical malaria prophylactics, while not even giving basic advice on bite prevention.
b. Homeopaths who are not medically qualified can miss fatal diagnoses, actively disregard them, advise patients to avoid beneficial medications, and so on.
c. Senior and respected homeopaths, and homeopathic membership groups, promote irresponsible and extreme quackery. One example of many is the Society of Homeopaths' symposium on the treatment of Aids, featuring the work of Peter Chappell (a man who claims to have found a homeopathic solution to the Aids epidemic involving homeopathic remedies which are broadcast over the radio). The state should not be encouraging the public to trust people and organisations which go anywhere near such plainly foolish ideas.
d. The endorsement of these sugar pills by the NHS is used by homeopaths as evidence that they work, and this further misleads the public. There are also more specific examples. Visitors to everyday NHS medicine clinics which happen to be held in the building of the Royal London Homeopathic Hospital in Queen's Square, walk past adverts proclaiming that homeopathy sugar pills are effective for a range of childhood and adult conditions, in an NHS setting. This is misleading and an abuse of the good faith that people have in the NHS.
e. Homeopaths - and the marketing activity around homeopathy - mislead the public by sending out false messages on evidence in the name of marketing their pills, for example making prominent arguments in popular media claiming incorrectly that fair trials of homeopathy sugar pills cannot be done, or that systematic reviews of the literature are biased. This is corrosive. Ideally we would be encouraging patients to have a greater understanding of evidence based medicine, of how we know what is good for us and bad for us, to improve engagement in shared decision making with doctors, and to encourage participation in clinical trials.
f. Homeopaths have cut themselves off from normal academic discourse on evidence based medicine by threatening critics with legal action to silence them, failing to engage with criticisms adequately in their literature, and shrouding their university teaching in secrecy. I can find no evidence that any of the plain criticisms I have outlined above with regard to the practise of homeopathy are seriously discussed by homeopaths. This would be unusual in other healthcare professions.
1. It is my view that the MHRA labelling system is misleading, not evidence based, and should be overhauled so that it unambiguously and explicitly states that homeopathy sugar pills have not been shown to be effective.
2. If the government believes that prescribing placebo sugar pills is a cost-effective strategy to manage a sub-population of treatment-resistant patients, then they should specify the characteristics of this population and commission a pragmatic cost-effectiveness analysis, comparing "GP treatment-as-usual" against "GP treatment-as-usual plus homeopathy". There is no need for any further trials comparing homeopathy sugar pills against untreated "placebo" sugar pills, as we already know the answer to that question, and we know that homeopaths ignore the results, so any further trials of that design are wasteful and uninformative.
Dr Ben Goldacre