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Complementary medicine
Practitioner-augmented placebo effect
From Dr R. J. Schmidt, MRPharmS
Although there are, I know, many opponents of complementary therapies
in the Western medical establishment, I am not sure that Edzard Ernst
is appropriately categorised as such. And he surely does not need me
to wade in to defend him on this issue. However, I would point out to
Robert Woodward and
David Needleman (PJ, 17 June, p717) that a researcher
who is applying the so-called scientific method formulates a hypothesis
and then designs an experiment to disprove it. That is how scientific
understanding moves forward. It is only when you fail to disprove a hypothesis
that the hypothesis becomes recognised as a fact. A hypothesis can remain
unproven, or can be disproven by an experiment. Normally, the results
from a single experiment in the biomedical sciences cannot ever provide
unequivocal proof of a hypothesis, but can lend support to it. So a true
scientist will inevitably appear to be an opponent of complementary medicine.
These are principles that all pharmacy graduates are exposed to in their
undergraduate courses and which must surely be applied in order to gain
a doctorate.
The problem in the field of complementary medicine is that the scientific
establishment does not seem to have a robust way of disentangling the
pharmacological effects of a medicine from the psychological impact of
the practitioner. So in all interventions that involve the administration
of a substance purported to have medicinal potential, those who design
clinical trials eliminate as far as practicable the practitioner-mediated
effects and look only for evidence of a measurable pharmacological effect.
Yet the medical profession has known since at least the ninth century
that “a physician … must always make the patient believe that
he will recover, for the state of the body is linked to the state of
the mind”.1 The healer does not have to be a contemporary physician
for this to hold true.
I have seen a claim by a crystal therapist in our local free newspaper
that she can heal all sorts of ailments and can even fix ailing computers.
I have no doubt that she does have an impact on the state of health of
some of her clients; I am rather more sceptical about her claimed powers
over inanimate objects. Almost every properly designed, randomised, double-blind,
placebo-controlled drug trial yields evidence that perhaps 40 per cent
of subjects see an improvement in their condition even though they have
been administered a placebo. Add in a psychological or spiritual dimension,
and especially one involving physical contact between the physician or
healer and the patient, and this figure might well reach dizzier heights.
The practitioner-augmented placebo effect is a phenomenon the existence
of which I am sure Professor Ernst will acknowledge. The problem, I fear,
is that the medico-scientific establishment will not provide the grants
that researchers need to investigate this phenomenon properly.
Richard Schmidt
Barnoldswick,Lancashire
Reference
1. Tibi S. Al-Razi and Islamic medicine. Journal of the Royal Society
of Medicine 2006:99:206–07.
Lively response requires addressing
From Professor E. Ernst, FRCP
I am delighted that my
short letter (PJ, 10 June, p677) created such
a lively response from Robert
Woodward and David Needleman (PJ, 17 June,
p717). Here are a few points that require addressing.
Dr Woodward is right: proponents of complementary and alternative medicine
are unlikely to agree with scientists as to what constitutes evidence.
This, of course, begs the question: whose view is correct? I have always
believed that there can only be one standard in medicine which, to me,
suggests that CAM should adhere to the standards of the rest of medicine
rather than vice versa.
Dr Woodward seems to think that I am an opponent of CAM. I do not think
this is true and I believe I can prove it. The update of our ‘Desktop
guide to complementary and alternative medicine’ details 52 situations
where CAM is demonstrably effective and many more where effectiveness
is likely.1 To call unbiased scientists who inevitably generate “positive” and “negative” results
opponents of CAM simply discloses the biases of the commentator.
David Needleman states that only 15 per cent of what GPs do is evidence-based.
The actual data demonstrate this figure to be around 80 per cent.2 He
also seems to think that aspirin has “never been clinically trialled”.
A simple glance at Medline reviews shows that there are hundreds of such
studies.
Mr Needleman and probably many other people want to know who financed
the letter we wrote to the NHS trusts. I can easily clarify this burning
issue: the signatory themselves did — no drug industry conspiracy
there.
Finally Mr Needleman claims that I am “employed to promote” CAM.
Wrong again. The mission statement of my unit has always been as follows:
· To conduct rigorous, inter-disciplinary and international collaborative
research into the efficacy, safety and costs of CAM
· To further analytical thinking in this area
· To be neither promotional nor derogatory but to struggle for objectivity
The only way science can work is first to generate a hypothesis and
then to try disproving it. If this attempt fails, the hypothesis was
probably correct. I regret that so many CAM enthusiasts are unfamiliar
with these basic principles of science and view this essential process
as “undermining” CAM.
Edzard Ernst
Director of Complementary Medicine
Peninsula Medical School
Universities of Exeter & Plymouth
References
1. Ernst E, Pittler MH, Wider B, Boddy K. The desktop guide to complementary
and alternative medicine (2nd ed). Edinburgh: Mosby/Elsevier; 2006.
2. Ernst E. How much of general practice is based on evidence? British
Journal of General Practice 2004;54:316–7. |
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