Quickhit: Stop funding homeopathy, say British MPs

Diagram of a toilet and plumbing, caption: Does Water Have a Memory?  I sure hope not. (Homeopathy: Sugar and Sewage)

Does Water Have A Memory? I sure hope not.

We conclude that placebos should not be routinely prescribed on the National Health Service

The House of Commons Science and Technology Committee, which released its report on homeopathy on Monday

Categories: medicine, Politics

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46 replies

  1. Yay for parliamentary committee systems! (When they work – which seems to be the case here. When they have some effect – which remains to be seen.)

  2. Yay from me also – Orac at Respectful Insolence linked to a cool page today (an so I did too of course).

  3. Maybe they should keep funding it – the placebo effect is apparently pretty powerful

  4. I tried to copy your comment, but it got eaten by the spaminator as well. Not sure if I’m able to release comments from there. Admins?
    [sorted! ~ tigtog]

  5. @Rebekka: The placebo effect is undeniably powerful. But its efficacy depends on lying to patients about what they’re being given. (Or believing in the Law of Contagion homeopathy, in which case you wouldn’t be lying, just wrong.) It seems a very bad way to run an ethical health care system.

  6. @kaninchenzero: ” its efficacy depends on lying to patients about what they’re being given. ”
    Not really. If the evidence is that placebos have a physical effect, which is what that study suggested, then you’re not lying to the patient if you tell them these pills might help, are you?

  7. @Rebekka Yeah, you are. If you give a patient who is in pain sorbitol instead of hydrocodone you are lying to them even if you say “Here this will help your pain.” It is a lie even if it does have an analgesic effect. (Which clinical trials have shown that it does. In patients who have functioning endogenous analgesic systems; people with chronic pain conditions tend not to.) It’s a lie because they aren’t real meds.
    Also there are laws in many countries that require that meds actually contain the active ingredient claimed on the packaging.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  8. You’ll note I didn’t say the doctor should say “here this WILL help your pain”, as you suggested, which would be a lie, but “these pills might help”, which is in fact true, as you acknowledge.
    The whole ethical issue could be solved, anyway, by getting the person to sign a consent form when they first attend the practice consenting to being given a placebo in situations where it has been shown to be effacious to do so. If the person doesn’t want the possibility of a placebo, they can opt out at that point.
    And the law and ethics are two separate things – if the law mandates that meds have to contain the active ingredient claimed on the packaging, then that makes giving a placebo in packaging that claims to contain an active ingredient illegal, not unethical – and in any case, does not apply to homeopathic medicines, which do not contain an active ingredient.

  9. Rebekka, the problem with your suggestion is that it adds another hoop for patients with chronic illnesses to jump through in their search for decent treatment. It means patients who aren’t susceptible to the placebo effect will be held responsible for the psychological quirk which means they actually need medication, rather than something to distract them while nature takes its course. It means people who are on low incomes (always the most vulnerable group in any health care system) will wind up being disproportionately prescribed and treated with placebos, because it’ll be cheaper in the short term (if you think various practices won’t try to sell placebo therapy to people as a cost saving measure, then I have a bridge in Sydney Harbour I’d like to sell you). If you look at the US health care system (*cough*disaster*cough*) you’ll see the end result of this trend – people on lower incomes in the US die earlier than those on higher incomes, and they’re more likely to die of preventable conditions.
    Placebos might work in some circumstances. But the reason they’re not used as a mainstream therapy is because they *don’t* work in enough circumstances to be therapeutically useful.

  10. The other thing about placebos, is that if you suspect that you may have been given one, it doesn’t work.
    Aside from that, if the government says that prescribing placebos is “just like medicine”, then the issue comes up of whether it is ethical to treat something with a placebo when there are drugs that are efficaious that already exist. It also curtails new drug development that might work much better than placebo, because placebos are cheap, and if they “work”, then people will be reluctant to prescribe something more expensive (especially in countries where health care is not subsidized).
    Placebos should remain in the area of “folk medicine”, if they are used at all. Just because people want a pill for what ails them, doesn’t mean they should be prescribed a sugar pill.
    And as a person with chronic pain, I strongly object to being experimented on by doctors who think a placebo might work. That is another length of time where I would risk being undermedicated and in pain because placebos “might” work. It’s unethical all around, as far as I’m concerned.

  11. On top of all that, beginning to rely on placebos for treatment strikes me as introducing a whole lot of new variables that doctors invested in their own beliefs about their patient and motivations related to that may be influenced by (everything from an altruistic desire to end suffering through to financial motivations or a belief that some patients and/or some diagnoses are annoying) which shouldn’t be left in their own hands.
    Some of this is already bad enough: for example, if the doctor is very invested in the efficacy of a certain drug for whatever reason, or in the frustrating nature of a certain patient, I imagine that at least subconsciously affects their willingness to trust the patient’s account of their experiences or even lab results, and adjust medication to match. Even though the placebo effect is so well-known and universal (although a friend reports second-hand in a book review that it is modified downwards by sufficiently painful medical treatment as a child, and undoubtedly other things) something being “in your mind” is so established as a bad, weak thing that there would probably be a tendency to (a) use placebos disproportionately on patients who one believes are exaggerating or deceiving themselves etc (b) to think less of patients on whom the placebo worked and (c) to over-estimate the effect of the placebo in patients who one believes are exaggerating or deceiving themselves. None of this is controlled in the practice of medicine as it is, the ability to decide that some patients might benefit from a placebo as much as from an active ingredient could and probably would slide very quickly into deciding that some patients only deserve a placebo rather than a real treatment.

  12. @Meg, I did suggest people should be able to opt out.
    @attack_laurel, “The other thing about placebos, is that if you suspect that you may have been given one, it doesn’t work.”
    That can’t be true. In double-blind studies, people know they have a 50/50 chance of having the active drug or a placebo, and the placebo effect is still evident.
    @Mary and @Meg, you’re essentially using a ”slippery slope” argument, of the “once you allow voluntary euthanasia, it’s a short step to non-voluntary euthanasia, Hitler’s Germany, etc” variety.
    Also, as they’ve been doing this already – the article linked to is about the committee thinking they should stop – I would think it self-evident that doing so does not, in fact, cause the NHS to collapse into a US-style health system.

    • @Rebekka,

      @attack_laurel, “The other thing about placebos, is that if you suspect that you may have been given one, it doesn’t work.”
      That can’t be true. In double-blind studies, people know they have a 50/50 chance of having the active drug or a placebo, and the placebo effect is still evident.

      Really? Aren’t most subjects for clinical trials are simply told that they are part of a drug evaluation program and that’s about it? Double-blind merely requires that neither the subject or the medicator knows whether the pill the subject is given is active-agent or placebo – that doesn’t mean that the patients are necessarily told that a placebo is a possibility, does it?

  13. We should not have to opt out. We already have enough to do. It took me fifteen years to find a doctor who believed I was in pain at all. The others — well, nothing turned up on blood tests or imaging scans. There wasn’t anything they could do. I have to be extremely careful to avoid doing anything that would give the appearance of drug-seeking behavior because then I’ll be labeled an addict (I am, unquestionably, physically dependent) and getting relief will become that much harder. I have been extremely careful and still I get lectures from doctors and pharmacists and nurses who see that I am taking opioid narcotics daily for pain management and assume that I really need to be lectured on everything I should be doing to avoid taking opioid analgesia or that I am an addict already. There are sufficient barriers to my — and everyone like me — being able to receive care as things stand thank you. Having to opt out of placebo use at every one of the many medical establishments I interact with is another step I really don’t need. Having to remember to do that is something I don’t need.
    Please stop. It really is harmful.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  14. I can’t find a reference to the interview (timing would seem to indicate its the same person) at the moment but there was a researcher on ABC radio recently talking about how his study had shown that you don’t even really need a pill. Just the act of treating someone (eg the patient knowing someone is doing something) can help.

  15. I’m not sure if this is on or off topic, but in terms of discussing the differences between legitimate treatments and the marketing of nonsense, can anyone point me in the direction of scientifically reputable sites discussing the efficacy of some herbal medications? Because I understand the point being made here that homeopathy is to be put in the dangerous ‘woo’ basket (and am certainly not arguing), but in trying to research which herbal ‘medicines’ are actually legit (and I guess it makes sense to me that some would be given the effects of marijuanan/opium), I find that the vast majority of sites discussing herbal medications *are* self serving ‘woo’ sites, however I don’t know that this in itself means that all herbal medication is not legitimate/is the same as homeopathy and I guess I wanted the opinion of people who are of science backgrounds like yourselves and who have thought a lot about this stuff. Again, if this is off topic then I apologise, but having thought about it, it seems that discussing the boundaries of science/medicine/herbal medicine/homeopathy isn’t really off topic.

  16. you’re essentially using a “slippery slope” argument

    Yes, it’s not a rigorous argument in the formal logic sense, I haven’t conclusively shown anything. But you’re also going from “the placebo effect is demonstrably powerful in clinical trials” and “the placebo effect is undoubtedly at work in existing medical practice, and quite possibly accounts for the primary effect in a number of situations” (neither of which I personally have issue with, and no one else seems to be denying that either) to “deliberate use of placebos should be an option widely available in routine medical practice at the practitioner’s discretion” which is also quite a leap even allowing for consent at some prior time. It doesn’t seem so unreasonable to raise known existing problems some patient populations have with being diagnosed, believed and obtaining effective drugs as it is.

  17. I get that it can be harmful. So can many things in medicine, when they’re not used appropriately. That doesn’t mean it can’t also be helpful for some people.
    The review published in the Lancet, which the article I linked to refers to, suggests that in fact placebos can be highly effective for pain relief:
    “analgesic responses to placebo involve highly specific endogenous opioid release, rather than a more generalised opioid release (such as increased opioid concentration in the cerebrospinal fluid).62 These results have been substantiated and extended by brain imaging techniques such as PET[63] and [64] and functional MRI.[65], [66] and [67] In one PET study, brain changes in response to placebo were reported to be similar to changes seen after treatment with opioid drug.68 Opioid-mediated placebo responses also extend beyond pain pathways. ”
    We’re talking here about doctors prescribing homeopathic “treatments”, i.e. placebos. It’s not like you wouldn’t know if a doctor prescribed a homeopathic treatment. As for opting out, you have to fill out a form when you see a new doctor, all they have to do is add a tick box – I don’t want to receive homeopathic treatments.

  18. Fuckpoliteness, I usually start with searching PubMed: http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed

    for the herb in question to see if any studies have been done of its effectiveness.

  19. @Mary, we’re talking about a specific situation – NHS doctors prescribing homeopathic treatments – not doctors widely being able to prescribe placebos without patients’ knowledge in all circumstances. Your representation of my argument is inaccurate.

  20. How about you maybe listen when disabled people tell you our lives do not need to be any more difficult? Don’t just blow it off with “Oh it’s just another ticky box on the form” it is not. There are social pressures and explicit exhortations and all kinds of stuff. There are doctors who’ll say “I won’t treat patients who check the ticky box.” Those doctors will cost insurers and health services less and there will be pressure on others to do likewise and do not give me any slippery slope shit I live in this. It happens. People who have anaphylactic reactions to substances in generic versions of a med that are not in the named version because the generic manufacturer uses a different process than the big pharma company still cannot get the med that won’t kill them. Because the policy says if there’s a generic, they will only pay for the generic and the sick person cannot afford the drugs on their own. Never mind the medical necessity ticky box at the bottom of the prescription form.
    It is a bad idea. It will harm people. Please. Stop.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  21. Do you live in England and use the NHS?

  22. Why do you need to be right about this? Rather, why do you keep trying to convince us of your rectitude? Badly, I might add. Telling marginalized people that further oppression is good for them and their arguments are insufficiently styled after the manner of the privileged is maybe not the most convincing thing ever. Empathy might be a better way to go here.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  23. The issues you bring up seem to be issues that would occur with a US-style health system, and which would not be issues with the socialised NHS. I don’t “need to be right”, I am discussing it, which is, after all, one way to learn more about something. I note, again, that I was arguing for this in one specific circumstance – the NHS and homeopathy. So I’m wondering whether your arguments against it are because you are thinking from a US-based medical system – which is why I asked you whether you are in England or use the NHS.
    I completely agree that in the US system, this would be problematic.
    But an illogical argument doesn’t become logical because the person making it is oppressed.

  24. @tigtog, I believe that is not the case – my understanding is that consent forms for clinical trials involve informed consent to the possibility that the subject may be treated with a placebo.
    For example:
    “If a placebo is used in a study, the informed consent form must include all of the following information:
    -Subjects must be informed that they may be given a placebo.
    -A clear lay definition of the term “placebo.”
    -The rationale for using a placebo must be explained to the subjects.
    -If applicable, subjects must be informed of any viable medical alternatives to being placed on placebo.
    -The duration of time that a subject will be on a placebo, degree of discomfort, and potential effects of not receiving medication must all be explained.
    -Any consequences of delayed active treatment must be explained to the subjects.
    -A statement in the Risk section of the consent that the subject’s condition may worsen while on placebo.
    -A discussion in the Benefits section that subjects who receive placebo will not receive the same benefit as those who receive active treatment if that treatment is effective.”
    (from http://www.research.uci.edu/ora/hrpp/placebocontrolledstudies.htm#Protocol)
    PS previous comment appears to have disappeared into moderation?

  25. Informed consent laws in at least the US and I am pretty sure at least a few other nations as well require that participants in clinical trials be told that when they are in a placebo trial they be told there is a possibility they will be given the actual med or something that looks like it but does not contain the active ingredient.
    I’ve seen (and signed) the consent forms for one such trial, though I ended up not participating as they were unfond of my blood lipid profile. The forms emphasised that I might get the drug or a placebo though I don’t recall if they gave a probability weighting. The intake person also emphasised this point. They wanted me to be very clear that I knew — or at least that they’d told me. I assured them I understood how double-blind placebo trials worked.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  26. Second, thirded, and fourthed kaninchenzero.
    The return of placebos to general clinical practice, in the manner suggested at comments 6 and 8, would be a disaster for people like us.
    Rebekka, your super cool experiment idea doesn’t trump the lived experiences of PWD, especially PWD with stigmatised conditions.
    For a British-specific cite, see the GMC guidelines on informed consent, where the first paragraph is:

    Successful relationships between doctors and patients depend on trust. To establish that trust you must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention even where a refusal may result in harm to themselves or in their own death1. Patients must be given sufficient information, in a way that they can understand, to enable them to exercise their right to make informed decisions about their care.

    And no, people can’t sign their legal rights away in advance and in perpetuity; especially when there is, often, an element of coercion; but even where there isn’t.
    More from the BMA consent toolkit:

    Consent can also be implied, signalled by the behaviour of an informed patient. Implied consent is not a lesser form of consent but it only has validity if the patient genuinely knows and understands what is being proposed. The provision of sufficient accurate information is an essential part of seeking consent. Acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not ‘consent’.
    Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment.

  27. I am really sorry that I came across as though this idea trumped somebody’s lived experience.
    I would like to reiterate, I was talking about this particular instance, the NHS and homoepathy, and was not suggesting this should be implemented in any other system – the problems being raised seemed very much to be problems with implementing this idea in a US-style system.
    Nor was I suggesting that people should be able to consent in perpetuity to a placebo – only that people should be able to *opt out* of homeopathic treatments being suggested as a possibility. It was an opt out, not a consent.

  28. Rebekka, I’m not speaking from a US point of view, and you know that.
    The problem is this idea being proposed in any world in which there has been, and is, a context of healthcare paternalism and the concealment of information from people who are seeking help. Which is everywhere any commenter here is likely to come from.

  29. Here’s the thing. When you are in a discussion with people who have experienced oppression — and all of us with chronic pain conditions have experienced oppression whether we are currently managing that pain with opioids or not — you really are going to learn a lot more if you stop talking about your neat idea that several people have told you is harmful to them and actually listen. This is a general guideline for discussions with marginalized people, not just this specific one. When you keep talking you make people upset and soon enough people assume that you aren’t listening because you do not care that your neat idea is harmful to us and talking to you is no longer worthwhile. I’m assuming you don’t want that.
    You may not know what to say when someone says, “This thing you have said is harmful to me and people like me.” Sometimes it feels simpler to defend your stated position against all comers. Fortunately there is a script, should you want to follow it. Apologize for causing harm; stop doing what was causing the harm. As a further exercise you could examine the attitudes and assumptions that led you to believe that it was appropriate to cause that harm so but the contents of your mind are ever yours to keep and no business of mine.
    I assure you no one will think any less of you for it. Rather the opposite, in fact.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  30. Ok, if you tell me there are problems I accept that.
    ETA: Not to suggest that I did not accept that the previous problems raised by kaninchenzero were real also, they just seemed to me to be specific to a US-style system – I certainly did not mean to suggest that they were not real problems, or that I did not accept that they were valid.

  31. And that’s not an apology. That’s “I’m sorry if you can’t see how right I am.”
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  32. I apologised for coming across as thinking my idea trumped your experience, I said I accept that it’s problematic – what else do you want me to say?

  33. You had the form of an apology in the first paragraph. Then the next two were justifications for and reiterations of what you’d been saying all along. The thing that which had been causing harm. People representing various kinds of health care systems told you it was harmful. Having an “opt out” option is not sufficient to make it harmless have you not paid attention to the opt-in/opt-out discussion that’s been going on since this web thing got launched? Making a system opt-out means that a considerable segment of the population will not and this is why corporations love them. The compliance rate is much lower with opt-in systems. There are lots of reasons why and they do not matter. Not giving people real medicine when they are expecting real medicine is highly unethical.
    This is not a completely consequence-free discussion. Homeopathy funding by NHS would have inevitably reduced funding for more expensive treatments because funding is finite and fungible. (And alliterative: sorry.) Activists for people like us had to lobby Parliament and get this shit stopped. It cost time and money and effort. The same thing would happen with placebo meds despite your blithe assurances that it will all be just ducky.
    Just talking about it makes us expend energy and time and emotion that costs us more than it does you.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  34. I’ve got nothing further to say – you still seem to think I’m talking about replacing the system that is currently in place in the NHS with some hypothetical system where people are given placebos without their knowledge, which I’m not. I have already apologised, and said that I accept there are issues, and I’m not going to do so twice.

  35. That sounds about right. ‘bye; it’s been unpleasant.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  36. Homeopathic hospitals? Wow, I wonder how many patients had to be transferred to regular hospitals.

  37. Mindy: While I agree that homeopathic medicines shouldn’t be funded in the NHS, homeopathic hospitals in the UK aren’t quite what I think you’re imagining. They offer integrative/complementary medicine, on the whole: regular biomedical services plus complementary practices that include not just homeopathic medicines but acupuncture, osteopathy, massage, relaxation therapies. I can’t swear to the execution, but the idea is not that dissimilar to centres like the Brownes Cancer Centre here at QEII medical centre, which offers a single-location set of services to people with cancer and their families – from massage and meditation to support groups and counselling.
    Re-integrating those evidence-based practices back into general hospital medicine is a non-trivial, but I think useful, task. There could be a big risk of a baby/bathwater situation here.

  38. Thanks for that Lauredhel. I should have googled first before commenting.

    Research carried into the effectiveness of homeopathy includes observational study over a six-year period conducted by Bristol Homeopathic Hospital. It found 70 per cent of follow-up patients reported improved health, with half reporting a major improvement.
    But the report states that the positive results can be explained by the illnesses clearing up on their own, patients choosing homeopathy being more likely to be those who believe in its effectiveness, and the long, empathetic consultations giving patients a positive perception of the treatment. (emphasis added)

    It would seem that they are throwing the baby out with the bathwater by suggesting these hospitals should no longer be funded. Massage therapy and accupuncture have been shown to work. Also the long, empathetic consultations sound brilliant. It would be a shame to lose that.

  39. Yes: there’s value in complementary care. The key is figuring out which of it is valuable and which isn’t. Homeopathy proper — water purported to have medicinal properties — isn’t. Other disciplines can be. Personally I’ve found massage helpful and acupuncture fairly useless, but my anecdotes are worth exactly as much as anyone else’s.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  40. “The key is figuring out which of it is valuable and which isn’t.” Absolutely, and I put homeopathy firmly in the “isn’t” box too. I think they should also come down like an tonne of bricks on practitioners who peddle what really is just expensive water.

  41. I absolutely believe they should be integrated, though, not put into these separate systems, in case that wasn’t clear. People shouldn’t have to choose between empathy/options/effective complementary medicine vs “science”-based (scarequotes-for-a-reason…)/being treated like crap!

  42. Wouldn’t it be nice if you could get effective treatment (of whatever variety works for you) and empathy at the same time.

  43. It would be lovely. I still haven’t managed to find a psychiatrist with much empathy. My therapist is nice — and experienced with gender and sexuality issues so she knew exactly what I meant when I complained about all the psychiatrists asking about my surgical status — and we’re currently working on how to do this without triggering me overmuch. It’s tricky; a lot does right now.
    Other physicians, eh. I have ones who listen to me now so I’ll keep them but they don’t spend a lot of time discussing stuff with me.
    .-= kaninchenzero´s last blog ..Re: Trust Me =-.

  44. Argh. Thanks, kaninchenzero, for shouldering the burden of that argument – conflicting time zones had me off the computer for the majority of it.
    Homeopathy should be kept separate from proven modalities. It’s not an all or nothing issue – after all, if Vioxx is pulled off the market, that doesn’t mean all drugs should be pulled off the market. 🙂
    This is an issue that has huge stakes for chronic pain sufferers, since we’re the ones that doctors love trying placebos on (’cause chronic pain is all in your head, don’tcha know); they don’t pull this crap on heart patients. I’m not someone’s guinea pig – it’s hard enough to get taken seriously as it is, without adding placebo prescription into the mix (and I’m one of those people for whom placebos don’t work, even if you don’t tell me – I can’t be hypnotized either, fwiw). *terrorist fist-bump of solidarity*

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