Taking a political placebo
The radical backlash against alternative medicine allows liberals to imagine a return to their glory days of fighting against ‘menaces to civilisation’. But it sheds little light on the real problem with the politics of health today.
These are hard times for old radicals and even for younger liberals.
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After 40 years, the dreams of world revolution in 1968 have turned into the disillusionment of the global capitalist new world order. Those who put their hopes in Tony Blair a decade ago felt betrayed over Iraq and have already lost faith in Gordon Brown. The transatlantic choice between Barack Obama and Hillary Clinton provides no inspiration. The radical embrace of the gospel of apocalyptic environmentalism reflects the prevailing misanthropic outlook.
Despairing of their capacity to engage with serious adversaries or big issues, former left-wingers are inclined to re-fight the battles of the past and to seek out soft targets for their invective: current favourites include neo-fascists, creationists and conservative religionists. Though any small success of these forces is trumpeted as a menace to civilisation, in reality they are as marginal as they have ever been. Exaggerating these threats enables liberals to imagine a return to their glory days, and allows them to evade the real problems of the present.
Alternative medicine, the focus of a new critique titled Trick or Treatment? by the science writer Simon Singh and Edzard Ernst, ‘the world’s first professor of complementary medicine’, has become another target of the radical backlash. Following the spectacular success of a series of works promoting militant secularism, a spate of books and blogs now signals a new crusade against alternative medicine.
I should declare that I share some of the instinctive hostilities of the old left. I am a veteran of anti-racist campaigns that sometimes involved confrontations with more vicious right-wing groups than today’s respectable British National Party. I have run summer school courses endorsing evolutionary biology and atheism – and denouncing alternative medicine. I have contributed a chapter to another book edited by Professor Ernst due to be published shortly, titled Healing, Hype or Harm: The Debate About Complementary Medicine (and a new book of my own is a critique of alternative treatments in autism). Though it may seem curmudgeonly not to extend a welcome to others taking up causes that I have long espoused, bear with me while I indicate some reservations about the terms of the radical critique of alternative medicine presented by Singh and Ernst.
I should first make clear that Trick or Treatment? contains much of value. It provides a comprehensive exposure of the lack of scientific evidence for the efficacy (and indeed safety) of acupuncture, homeopathy, chiropractic therapy and herbalism (and an appendix offers brief evaluations of more than 30 further brands of alternative therapy). Singh’s rare skill for making science comprehensible to a lay readership (evident in his earlier works on Fermat’s theorem and the Big Bang) is displayed in the presentation of the methods of study and systematic review of alternative therapies, in which Ernst has played a pioneering role. The result is a book which is readable, entertaining and rigorous in its appraisals (it is light on references, but provides details of key readings in an appendix).
‘The bottom line’, the authors conclude, ‘is that none of the above treatments is backed by the sort of evidence that would be considered impressive by the current standards of medical research’. They acknowledge that acupuncture may be of some benefit for some types of pain and nausea; manipulation may help some people with back pain (though carrying a significant risk of stroke); and some herbs may be beneficial (though many are toxic). Homeopathy, however, is without redeeming features. The conclusion drawn from 4,000 studies conducted since 2000 (when the House of Lords Committee on Science and Technology demanded further investigation of alternative therapies) is that ‘those benefits that might exist are simply too small, too inconsistent and too contentious’.
My reservations about Trick or Treatment? concern its uncritical endorsement of what the health policy expert Rudolph Klein has characterised as the ‘new scientism’ of ‘evidence-based medicine’ (1), its incoherent advice to doctors on telling the truth and its curiously paternalistic approach towards patients.
According to Singh and Ernst, ‘evidence-based medicine’, a term coined by the epidemiologist David Sackett in 1992, has ‘revolutionised medical practice’. They acknowledge that ‘prior to the development of evidence-based medicine, doctors were spectacularly ineffective’. However, ‘once the medical establishment had adopted such simple ideas as the clinical trial, then progress became swift’. As a result, ‘today’, less than two decades later, according to this remarkable telescoping of the familiar narrative of progress from darkness to enlightenment, ‘the clinical trial is routine in the development of new treatments and medical experts agree that evidence-based medicine is the key to effective health care’.
While it is true that evidence-based medicine (EBM) has made some useful contributions to contemporary medical practice, notably in the systematic use of randomised controlled trials in the study of therapeutic interventions, it is nonsense to claim that it has played a major role in the successes of modern medicine (such as vaccines, antibiotics, steroids, anaesthetics, surgical techniques) which arose from developments in the basic medical sciences. The authors’ claim that Florence Nightingale was ‘one of the earliest advocates of evidence-based medicine’ illustrates their method of ‘reading history backwards’. To some of its critics, in its disparagement of theory and its crude number-crunching, EBM marks a return to ’empiricist quackery’ in medical practice (2). Its main appeal, as Singh and Ernst suggest, is to health economists, policymakers and managers, to whom it appears useful for measuring performance and rationing resources.
‘Why are so many GPs tolerating, promoting or even using bogus treatments?’ is the provocative question posed by Singh and Ernst to my colleagues in primary health care. They consider various possibilities (though they do not seem to apply their commitment to an evidence-based approach to their speculations in this area). Could it be that GPs are simply ignorant of the facts that alternative medicine is useless? They raise the possibility that some GPs may be true believers in alternative therapies, but – understandably – find this too terrifying a subject to investigate further. They believe that many GPs are so inconsiderate towards their patients that this drives them into the sympathetic, empathetic arms of alternative therapists. But for them the most likely explanation is that GPs are simply lazy and respond to their patients’ relentless minor complaints by ‘fobbing them off with placebos’, in the form of ‘bogus remedies’ and referrals to alternative therapists.
In an earlier chapter, Singh and Ernst ask, in relation to the use of alternative therapies as placebos, ‘does the truth matter?’. They conclude that it does matter and that deception violates the honesty required in the doctor-patient relationship and has wider corrosive consequences for trust. Yet, when they come to considering how doctors should respond to patient demands, they offer a third way: instead of either being ‘more honest’ or offering a ‘pure placebo’ such as homeopathy, they should consider recommending an ‘impure placebo’. This is a treatment that is not, like homeopathy, utterly useless, but which may be effective in treating symptoms similar to those presented by the patient. The authors give the example of treating a patient complaining of depression with magnesium (which may be beneficial for patients with rare conditions presenting with similar symptoms). They consider that this is much more acceptable than a pure placebo, ‘because we are avoiding complete lies’, though they admit that ‘we are still dealing in half-truths, as opposed to complete truths’.
The hopeless tangle into which the authors have got themselves in their attempts to reconcile problems of deception and paternalism reflects a wider problem of truth-telling in medical matters. The ‘good lie’ – the subordination of science to propaganda – has become an established feature of public health campaigns: it is central to the AIDS panic, the crusade against passive smoking and the links between diet and heart disease and cancer (3). These are some of the issues with much greater impact on the health and welfare of society than Prince Charles’ promotion of homeopathy that are ignored in the radical crusade against alternative medicine.
Singh and Ernst criticise GPs for ‘encouraging patients’ to seek out alternative therapists. In a bizarre parallel with the world of drug addiction, they argue that ‘introducing patients to alternative therapists in relation to a minor condition could act as a gateway to a longer-term reliance’. One taste of a (tasteless) homeopathic pill or twist of an acupuncture needle could lead to a serious habit, and they may end up refusing vaccinations and stopping prescription drugs.
This is getting silly. In my experience, patients pursue a pragmatic approach, pursuing alternative therapies as an adjunct to mainstream treatments, in the prevailing consumerist spirit which has transformed health into a sphere of recreation – this rather than the alternative fads is the real problem of contemporary health care. It is true that patients with serious conditions occasionally reject effective medical treatments in favour of quackery, but I do not believe that this is more common now than it was in the past – scare stories of such cases are not likely to discourage the wider resort to alternative therapies. A much bigger problem, to return to the ‘impure placebo’, is the expansion of ill health reflected in the wider diagnosis of conditions such as depression. The real issue is not whether to treat patients with Prozac or CBT or magnesium, but whether it is appropriate to diagnose ‘one in four’ of the population with a condition that 20 years ago was regarded as affecting 0.5 per cent.
The authors regret that ‘patients have virtually no protection when they enter the world of alternative medicine’. This leads them to recommend further measures of state regulation of alternative therapies and therapists, such as the imposition of warning labels ‘this product is a placebo’ on the model of anti-smoking campaigns. But this approach simply replaces medical paternalism with government paternalism. It diminishes the autonomy of the citizen that is central to both democratic politics and informed choice in matters of health.
Here, Singh and Ernst would be better advised to pursue the logic of their excellent critique of the failure of scientists and doctors to take up the challenge of pseudoscience and quackery in public debate. As they rightly argue, ‘too many medical researchers have stood by and silently watched the rise of alternative medicine and the crackpot theories behind them’. The way to reduce the influence of alternative medicine is not by state bans and proscriptions but by drawing a clear distinction between medical science and alternative medicine (rather than by fudging it with concepts such as ‘complementary’ medicine) and by the sort of public discussion towards which this book is an important contribution.
Michael Fitzpatrick is the author of MMR and Autism: What Parents Need to Know. (Buy this book from Amazon (UK).)
Trick or Treatment?: Alternative Medicine on Trial, by Simon Singh & Edzard Ernst is published by Bantam Press. (Buy this book from Amazon(UK).)
(1) Managing Scarcity, Rudolph Klein, 1996
(2) See The Tyranny of Health: Doctors and the Regulation of Lifestyle, by Dr Michael Fitzpatrick, 2000, Routledge
(3) See Nasty to be nice, by Dr Michael Fitzpatrick, Guardian, 24 May 2008