A homeopathic "debate" in BMJ?

Homeopathy is quackery.

There, I've said it for the hundredth or even thousandth time, but I don't care if it's repetitive because it can't be emphasized enough times that homeopathy is The One Quackery To Rule Them All, with the possible exception of reiki and other "energy therapies." I also find it useful to make it clear right where I'm coming from right off the bat. If you're a homeopath and are offended, quite frankly, I don't care. Any "medicine" whose very precepts break multiple laws of physics and chemistry, laws that wouuld have to be proven not just wrong but spectacularly wrong for homeopathy to work deserves only ridicule.

Think of it this way. There are two "laws" of homeopathy, neither of which has any basis in reality. First, there is the law that states "like cures like" and asserts that, to relieve a symptom, you need to use a substance that causes that same symptom in healthy adults. There is, of course, no evidence that this is a general principle of medicine. For instance, we don't generally treat fever by administering something that causes fever or treat vomiting with something that causes vomiting. The second law, however, is the one that's completely ridiculous. Basically, it's the law of infinitesimals. This law states that a homeopathic remedy is made stronger with dilution, specifically serial dilutions with vigorous shaking between each dilution step to "potentize" the remedy. That's ridiculous enough, but homeopaths, never satisfied with the merely ridiculous have to turn the ridiculous up to 11 and beyond by using this principle to assert that dilutions far beyond the point where there is likely even to be a single molecule of the original remedy left are effective and become more so with more dilution. For instance, a 30C dilution is 30 one hundred-fold dilutions (C=100, get it?), or a 10-60 dilution. Avogadro's number is only on the order of 6 x 1023, or more than 1036-fold less than the dilution. The simple mathematics of homeopathy just doesn't work, although this doesn't stop homeopaths from coming up with some truly spectacular flights of pseudoscience (like the "memory of water") to try to "explain" how it can work.

For this reason and many others, there is no good reason for a reputable scientific journal to publish anything about homeopathy, and certainly there is no reason to publish a "debate" about homeopathy, any more than there is a reason to publish a debate over whether creationism, intelligent design or young earth, has validity compared to evolution. Unfortunately, that's exactly what a prestigious medical journal, The BMJ, has done, asking Should doctors recommend homeopathy? On the "yes" side there is Peter Fisher, director of research, Royal London Hospital for Integrated Medicine. Note that "integrated medicine" seems to be a British variant of "integrative medicine," the oft-criticized (on this blog at least) of integrating quackery with real medicine. Note also that the Royal London Hospital for Integrated Medicine used to be called the Royal London Homeopathic Hospital. Indeed, the last time I was in London (alas, eight years ago!), I made it a point to have my picture taken in front of its sign. In any case, Fisher is a homeopath, and a rather famous one at that. On the "no" side, we have Edzard Ernst. Now, I have no idea why Ernst agreed to this, but I wish he hadn't. His debating a homeopath would be not unlike an evolutionary biologist debating a young earth creationist. There's no point, and all it does is to elevate the stature of the crank by association. In fact, it's even more like a creationist debate than you might think in that Fisher proves himself adept at doing the old Gish Gallop.

Hilariously, this is how Fisher chooses to begin:

Of all the major forms of complementary medicine, homeopathy is the most misunderstood. Based on the concept of “treating like with like,” homeopathy originated with the German physician Samuel Hahnemann (1755-1843). But similar ideas are found in the Hippocratic Corpus, in the work of Paracelsus, and in the medical traditions of several Asian countries.

Homeopathy is part of a family of toxicological and pharmacological phenomena that are attracting growing interest, characterised by secondary, reverse, or paradoxical reactions to drugs or toxins as a function of dose or time or both. These include hormesis (the paradoxical, stimulatory, or beneficial effect of low doses of toxins), paradoxical pharmacology, and rebound effects.

The controversial element of homeopathy is that some medicines are highly dilute, including “ultra-molecular” dilutions, in which it is highly unlikely that any of the original material is present. This is a major scientific concern and the source of the view that homeopathy “doesn’t work because it can’t work.”

First off, the problem with homeopathy is not that it is misunderstood. The problem with homeopathy, for homeopaths at least, is that it is understood all too well by scientists who have looked into it and become its critics, and that understanding is that it is quackery. Even though Fisher correctly points out the central problem with homeopathy, notice how he rebrands it in terms favored by homeopaths. Whenever you see "ultra-molecular dilutions" used as a term, it's an almost certain bet that you are dealing with a homeopath. The term sounds all science-y and important, but it is utterly meaningless. Notice how he also attacks a straw man. Yes, we skeptics do say that homeopathy can't work, because for homeopathy to work, our understanding of some long-established bedrock principles of chemistry and physics would have to be not just wrong but spectacularly wrong. But that's not the only reason why we say homeopathy doesn't work. We also look at the clinical evidence, which, when aggregated, is most consistent with the effects of homeopathy being nothing more than placebo effects. That's not surprising, given that homeopathy can't work, but in this case the science and the clinical observations we have both agree: Homeopathy doesn't work.

Fisher's also trotted out a veritable Gish gallop's worth of homeopathy tropes, many of which I've written about here before, as well as on my not-so-secret other blog. Similar ideas are found in Hippocratic writings? So what? Hippocrates's followers also believed in the four humors and that illness was caused by imbalances in the four humors. Yes, Hippocrates and those who followed made some significant contributions to medicine, not the least of which was the idea that diseases were natural and not caused by gods and evil spirits, but much of what they taught was based on prescientific beliefs about biology and physiology. Paracelsus, too, made great contributions to medicine, but he was also an alchemist, astrologer, and occultist. In fact, it is true that the ideas of homeopathy do resemble those of various ancients. Unfortunately for homeopaths the ancient ideas that homeopathy most resembles come from sympathetic magic, namely Frazier’s Law of Similarity ("like cures like") and the Law of Contagion or "contagious magic" (the memory of water).

Last up, there's the usual nonsense about hormesis and paradoxical drug effects. Repeat after me: Hormesis does not justify homeopathy. It’s an analogy that homeopaths love because it’s a hypothesis that states that some substances that are toxic at high doses might be benign or even beneficial at lower doses. That hormesis has anything to do with homeopathy is, of course, wishful thinking on the part of homeopaths, representing extreme over-extrapolation. Hormesis might apply to low doses, but much of homeopathy involves no dose; i.e., dilution far, far beyond the point where it is highly unlikely that even a single molecule of the original remedy remains. Not that this stops Fisher:

However, recent in vitro research shows repeatable effects (for instance, inhibition of basophil degranulation by highly dilute histamine1) while basic physical research shows that the homeopathic manufacturing process changes the structure of the diluent, including the formation of nanoparticles of silica and gas.2 The physical research is of little clinical relevance but provides a possible mechanism of action for the controversial high dilutions.

He's referring to Jacques Benveniste's study, which he claimed to have found evidence for the "memory of water." Basically, Benveniste diluted allergens down to homeopathic dilutions and showed that they could trigger basophils to activate. The then editor of Nature, Sir John Maddox, agreed to publish Benveniste's paper—but only on one condition. Benveniste was required to open his laboratory to a team of independent referees, who would observe and evaluate his techniques. Among that team was James Randi. Indeed, the Benveniste affair was, from my perspective, one of Randi's greatest achievements in skepticism. Basically, Randi and the team of referees asked Benveniste to repeat the experiment, but went to extraordinary lengths to make sure that the people carrying out the experiments didn't know what groups were the control groups and which groups were the ultradilute samples. Under these conditions, Benveniste's results were not replicable. Basically, Randi showed how critical proper blinding was to experiments involving homeopathy. Indeed, this is a lesson that anyone doing lab work could take to heart, because blinding is actually uncommon in basic lab research for most experiments.

As for the bit on "nanoparticles," that's just the latest pseudoscientific "explanation" for homeopathy. It's one particularly favored by a rather vocal proponent of homeopathy whom we've met before, Dana Ullman. it's nonsense, of course, just like every "explanation" of homeopathy other than that it "works" solely through placebo effects.

It also turns out that Fisher is—surprise, surprise!— very unhappy with some systemic reviews and meta-analyses of homeopathy that show it to have no specific effects above and beyond placebo effects, as one would expect given what homeopathy is. As is usual for homeopaths, he attacks the 2005 Lancet meta-analysis by Shang et al, but worse, he misrepresents its findings. Contrary to Fisher's characterization of the meta-analysis, Shang et al did not find that there was "weak evidence for a specific effect of homeopathic remedies." That's a cherry-picked quote. Actually, Shang et al concluded quite the opposite:

We acknowledge that to prove a negative is impossible, but we have shown that the effects seen in placebocontrolled trials of homoeopathy are compatible with the placebo hypothesis. By contrast, with identical methods, we found that the benefits of conventional medicine are unlikely to be explained by unspecific effects.

Then, as homeopaths are wont to do, Fisher picks crappy or old meta-analyses. Incredibly, this leads to a discussion of comparative effectiveness research involving homeopathy! Here's a hint: Doing comparative effectiveness research is only appropriate to compare the effectiveness of treatments already shown in clinical trials to be efficacious. Such is not the case for homeopathy. One study he cites is an old study looking at comparing homeopathy to conventional therapy for a self-limited condition. It's not randomized (of course), and the two groups (conventional treatment and homeopathy) are ridiculously poorly matched in terms of age and location. Sure, they had, as an aggregate, well-matched health scores, but demographically the groups are so different as to be uncomparable, making the study basically uninterpretable. Other studies referenced are all basically unrandomized and relied heavily on interviews, with the possibility of recall bias. Indeed, what the two studies suggest is not so much that homeopathy works rather than that general practitioners tend to overprescribe antibiotics for upper respiratory infections and nonsteroidal anti-inflammatory drugs for musculoskeletal pain.

All of this leads Fisher to conclude:

Doctors should put aside bias based on the alleged implausibility of homeopathy. When integrated with standard care homeopathy is safe, popular with patients, improves clinical outcomes without increasing costs, and reduces the use of potentially hazardous drugs, including antimicrobials. Health professionals trained in homeopathy do not oppose the use of conventional treatments, including immunisation (www.facultyofhomeopathy.org/media/position-statements/immunisation). Doctors should recommend the use of homeopathy in an integrated manner.

I'm so relieved that a bunch of homeopaths grudgingly recommend vaccination. No, I'm not, given that if you go to the link, you'll note that in the case of patients for whom there is a medical contraindication to being vaccinated it "may be appropriate to consider the use of the relevant homeoprophylactic preparation applicable to that disease." It is most definitely not appropriate.

Finally, contrary to Fisher's plea to ignore the inconvenient science that shows how ridiculously implausible homeopathy is, doctors should most definitely not put aside "bias" regarding its implausibility because homeopathy has plausibility that is as close to zero as it is possible to get. In other words, Fisher doesn't think that "plausibility bias"—or, as I like to call it sometimes, "reality bias"—is a good thing. Indeed, the only reason I don't give homeopathy zero plausibility is more philosophical than anything else. I always leave open the possibility, however small, that maybe several laws of physics are not just wrong, but spectacularly wrong. Whether that is being too "open minded" or not, I leave to the reader. In practice, the difference is negligible, undetectable even. Using Bayesian methods, which take into account the plausibility (or lack thereof) of the remedy being tested, equivocal tiny "results" plus extreme implausibility of the method equal negative results. Basically, in clinical trials of homeopathy what is being observed is statistical noise and publication bias.

I don't feel a need to go over Edzard Ernst's response. It's just Ernst doing what Ernst does best and, of course, mentioning some of the dangerous things homeopaths recommend, such as homeopathy for Ebola. I encourage you to read it. What I do feel obligated to do is to ask once again what the hell the editors of BMJ were thinking when they decided to publish this "point-counterpoint" in their journal. If they were looking for page views, no doubt they'll get it. After all, I linked to the article, and so will, I predict, a lot of skeptical bloggers, to mock and criticize. All I can ask the editors is this: Were the page views worth the ridicule?

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"...what the hell the editors of BMJ were thinking when they decided to publish this “point-counterpoint” in their journal."

I'd put money on your estimation that this is for traffic. My guess is they are not just fishing for scholars but using click-bait headlines in order to remain relevant in the new media. It is a really good click-bait headline btw.

Medicine will flirt with homepathy as it does with big data as it does with mobile apps (just beginning - buy stocks in mobile apps now!) because all that really matters is the appearance of being on the cutting edge of the next big epic event (even if ancient). They'll figure out the details later.

Please don't take this the wrong way; it is merely an observation. But it looks like people in the medical field are really getting gob-smacked by business marketing teams.

/cynicism

By Not a Troll (not verified) on 14 Jul 2015 #permalink

But similar ideas are found in the Hippocratic Corpus, in the work of Paracelsus, and in the medical traditions of several Asian countries.

Yes, it's called sympathetic magic. And it comes in various forms, arguably distinct ones. With homeopathy, it's about the supposed effects of a substance (determined while dreaming, no less).
With other medical traditions, it's more about eating a kidney-shaped veggie to treat, you guess it, the kidneys.
Note that, with the latter forms, you are more likely to get some useful bioactive substances, albeit for the wrong reasons. Or you can get some harmful substances, too.

And no, homeopathy is not just that. Fisher forgot the part where the nostrum has to be diluted beyond recognition.

Pity there isn't a brain-shaped carrot, Fisher would well to do a cure of it.

By Helianthus (not verified) on 14 Jul 2015 #permalink

I wish I could say I was disappointed in BMJ, but I am not. The usual caveats apply: I am not a doctor I am a scientist, I have not made an exhaustive study of their articles, I have hopes for the success of opening publishing, but the BMJ articles that come to my attention are not generally impressive. So I have to pile this article with the rest of them, and grumble that they have lent their prestige to such a dodgy cause.

By Robert L Bell (not verified) on 14 Jul 2015 #permalink

Respectfully, this article gets it all wrong. Totally wrong. I haven't read Ernst's reply, but your closing comments suggest he gets it wrong too.

Why? Not because any of it is factually incorrect, but because you fulfil your own prophecy of promoting "homeopathy by association" by paying lip service to the idea that homeopathy might work.

For a debate in the BMJ, that is not where the debate lies. The starting point of such a debate is "homeopathy doesn't work". From there the only discussion is whether it (or any placebo) should be prescribed by doctors and whether shops like Boots should sell it. I'd go so far as to ask whether doctors should be allowed to give out sugar pills and SAY they're homeopathic. Does compounding a lie about placebo do any harm in that respect?

That is what the debate needs to be about, and you and the BMJ do readers a disservice by failing to move it on from the extremities.

By VaccineTruthUK (not verified) on 14 Jul 2015 #permalink

@Helianthus #2 My (Korean) wife eats brain shaped nuts under the impression that they will make her smarter, which may (accidently, as you observe) be the case because of all the omega-3 fatty acids. She also believes that plunging her arm into a bag of ketchup while a quack tries to rip the o-ring from her grip is a reliable way of diagnosing food allergies. Truly, it takes all kinds to make the world go 'round.

By Robert L Bell (not verified) on 14 Jul 2015 #permalink

Doctors should put aside bias based on the alleged implausibility of homeopathy.

And engineers should put aside bias based on the alleged implausibility of flying carpets.

I am always curious how strong is the belief in homeopathy in people like FIsher (or Ullman). I'd love to see them in some sort of Saw inspired game, where they need to choose between homepathic remedy or conventional pharmaceutical for a condition that'd kill them in hours/day. I have strong suspicion that few of them would go for homeopathy.

By The Smith of Lie (not verified) on 14 Jul 2015 #permalink

Unfortunately, that’s exactly what The BMJ has done

Just by the by, I reject their preposterous attempt at enforced logoization with extreme prejudice.

@ Robert L Bell #3

At a couple of physician blogs I read, the BMJ is generally held in high regard especially for their data sharing/open publishing efforts and their COI stance vs NEJM. But there are complaints of some of the political decisions they've made.

When you write that "the BMJ articles that come to my attention are not generally impressive", do you mean in scholarship or in political stance?

Understand that I only have a superficial grasp of all this but it comes up often enough at the other blogs that I would value a little more insight into your opinion about them. Thanks.

By Not a Troll (not verified) on 14 Jul 2015 #permalink

Oh, and...

Similar ideas are found in Hippocratic writings? So what?

They're not. IIRC, the paradoxical effects of mandrake are the only thing going.

Here's something I never understood about homeopathy. Aside from the fact that it is magic I mean. For the sake of argument lets assume that both laws it is based on "like cures like" and "law of infinitesimals" are true and work as advertised.

So if we have a cyanide poisoning, the cure would be more cyanide, right? Since it causes the symptoms in the first place, then it should cure them, cause "like cures like".

Furthermore, potentization is supposed to make diluted substance even stronger. So why are poisons - since some of remedies use such toxins as snake venom or similar - made stronger through potentization suddenly a cure instead of becoming even more deadly?

The latter especially confounds me. Assuming I go through all the steps properly, with shaking and hitting the bible between each dilution, that homeopathic cyanide I just made, according to what homeopaths say about the process, be enough to kill anyone who gets a drop dead. Just think about all the uses for tasteless, odorless and undetectable poison!

And yet an extensive research (single google search, first hit) shows me that Kali Cyantum (or homeopathic potassium cyanide) is remedy for:

Sudden sinking sensation. Cancer of tongue and agonizing neuralgia have been benefited by this drug. Sick headache; sciatica; epilepsy.

How the heck is that supposed to work? I mean, within what the laws of homeopathy themselve suggest.

By The Smith of Lie (not verified) on 15 Jul 2015 #permalink

VaccineTruthUK@4:

Respectfully, this article gets it all wrong. Totally wrong. I haven’t read Ernst’s reply, but your closing comments suggest he gets it wrong too.

Bollocks. When an anti-vaxxer demands you engage them in reasoned debate as to whether or not vaccines cause autism, what's your response then? You clearly know how it actually works (despite your obviously ill-chosen 'nym), so enough of this PoMo apologist bullshit already.

Homeopaths are the ones making loud, confident claims of efficacy. In religion, that is all that's required; science, however, is mandated to tell them to GTFO and not come back without hard evidence to back their claims up. And no amount of special pleading, unethical fudging, or cowardly opportunism gets to change that. There is no debate, only evidence. And there is already a vast mountain of embarrassingly allopathic evidence proving homeopaths to be so full of 1C shit that their eyeballs are positively floating in it.

Homeopathy crossed the line at which it ceased to be a hypothesis and established itself as religion 150 years ago, and has shown zero intent or desire to stop itself since. So honestly, at this point the only productive thing left to say to such willful self-deceivers is "You are liars and fools. Fuck off already"; and shame on the BMA mouthpiece for implying anything else.

Until someone tells me which homeopathic preparations have interesting near-lethal overdose potential when sufficiently diluted, I'm not interested.

By herr doktor bimler (not verified) on 15 Jul 2015 #permalink

One of the most common misconceptions about homeopathy is that it is similar to vaccination which of course it isn't. Can someone please explain to me, in terms understandable by a layman, why it isn't. I found myself in a recent situation where I was confronted by this conundrum while discussing it with another layperson and I couldn't find the right words.

@VaccineTruthUK,

I believe your beef is not with Orac but with Peter Fisher. If you read the original BMJ article, you'll see that he argues that yes, doctors should recommend homeopathy because it works. Orac's post refutes Fisher's points.

Ernst, on the other hand, starts out with saying that it doesn't work. He then goes on to say that recommending it - even knowing it doesn't work - doesn't help, may be actively harmful, and is a waste of money. This, I suspect, is the argument that you were looking for.

By Mephistopheles… (not verified) on 15 Jul 2015 #permalink

I don't understand why anyone would need a repeat homeopathic treatment. If the effect got strong as it became more dilute, then wouldn't it get stronger? If you did this with alcohol then wouldn't you get more drunk over time as the alcohol in your blood became more and more dilute?

I mean I do understand why this doesn't happen because I'm not an idiot that believes in this junk, but how do homeopaths respond to this?

Actually forget that, I'm now thinking of opening a line of homeopathic beer...

Dan - homeopathic beer has been done. It's called "light lager".

By Mephistopheles… (not verified) on 15 Jul 2015 #permalink

@ The Smith of Lie #10 - Those all confound me, as well. Also--if there are X number of molecules in a teaspoon and you've shaken and diluted things to the point where all the molecules present are now magical, how can that be made even stronger by further dilution? At a certain tipping point, isn't the solution as "strong" as it can possibly get? In the real world, if I want a larger dose of, say, a statin, I take a larger dose--20mg instead of 10mg, for example. In homeopathy it seems, you take the same amount but somehow, magically, the molecules become "more-so".

Excuse me while I take an aspirin for the headache this is giving me.

By Canonical (not verified) on 15 Jul 2015 #permalink

Fisher is correct in a sense that homeopathy is misunderstood. Many people who use it think it s a form of herbal medicine. If they understood what it really was, they would chuck it. Fisher does his best in this piece to make sure it remains misunderstood by wrapping it up in senseless jargon co-opted from physics.

I mean I do understand why this doesn’t happen because I’m not an idiot that believes in this junk, but how do homeopaths respond to this?

Ah, this one is simple. The reason is the same for which the water in your tap does not contain memory of all the unsavory substances it may have come in contact before. It is not enough to dilute substance, you need to apply secret process of potentization to the mix. Namely, shake it energetically 10 times between each dilution step. Hitting the container with a leatherbound bible may or may not be involved.

It is also very convenient how details about potentization are vague, since whenever you prove that certain nostrum does nothing, homeopaths need just say you did something wrong with your potentization. Maybe you shook it too energetically. Or not energetically enough. Did you use Gutenberg's bible? Have you spun three times widdershins why potentizing? Were you skyclad under full moon?

If answet to any of the above was "no" there's your problem. You just made your homeopathic remedy wrong way.

Actually, even if you answered all of the above with "yes" you still made it wrong way, because then it would turn out that you were supposed to do none of the above.

Isn't homeopathy beautifu?

By The Smith of Lie (not verified) on 15 Jul 2015 #permalink

One thing Peter Fisher is correct about is that homeopathy is usually misunderstood. Though the two main ideas of homeopathy usually are fairly well-known, their underlying concepts are seldom acknowledged. The concept for "similia similibus curantur" not only lack scientific substantiation, it also lack every bit of intuitive understanding. The "like" effects has nothing to do with actual effects of compounds in a remedy - they are rather subjectively decided by the process of "proving". Thus homeopathic cyanide has little to do with suffocation, and Dan's proposed anti-sobering effects after a hard night out isn't applicable. You supposedly need special training to be part of a "proving" to actually recognize which effects of the tested compound-heading-for-remedy-status are actually true "ssc"-activity, and yet a lot of "provings" seem to be done by students attending courses in homeopathy...
I think it is important that publications like this debate are done - there is a downward trend in science interest and education and sadly a heaving wave of health and wellness interest based on population data. The combination is devastating especially when medical students now seem to set out on their career path with emphasis on social pathos and individual rights to utopian health instead of knowledge about the scientific (and ethical) limitations of evidence-based care and practices.

By Pharmacist-in-Exile (not verified) on 15 Jul 2015 #permalink

There's a simple proof. Rabies virus is 100% lethal. So ultra-dilute rabies virus should raise the dead. We should ask Mr. Fisher to volunteer for the experiment.

Can someone please explain to me, in terms understandable by a layman, why it isn’t.

Vaccines contain nonzero amounts of the pathogen(s) against which they are intended to confer protection. That's how your immune system works: it learns to recognize this particular virus or bacterial protein as foreign, and mobilizes to kill the invader. In some cases the pathogen has been killed, and in some cases it has been weakened (I don't know the details of this process), but in either case the weakened or dead pathogen is still part of the vaccine.

Contrast with homeopathy: for any dilution beyond about 12C, the probability of having even one molecule of the substance present (other than via contamination or imperfect distillation of the water with which you dilute it) is vanishingly small.

Some numbers for comparison: A 30C dilution is about enough to homeopathically dilute the entire Earth. A 40C dilution is about enough to homeopathically dilute the entire Universe. Some homeopathic preparations go beyond that: I have heard of 100C dilutions.

By Eric Lund (not verified) on 15 Jul 2015 #permalink

@ Eric Lund

Vaccines contain nonzero amounts of the pathogen(s) against which they are intended to confer protection.

I would even say that the amount of (dead) pathogens is very different from zero: there has to be enough of them to trigger a lasting immune reaction.
A dilute solution of the same pathogens, alive or dead, won't result in a good protection.

That's one of the reasons vaccine manufacturers add adjuvants to vaccine, like aluminium oxide: these are meant to entice the immune system into a stronger response to the small amount of injected pathogens.

I believe that gathering the biological material is the most expensive/difficult part in vaccine manufacturing. Viruses don't grow on trees (well, not the ones which are interested in harming us). If the manufacturers could simply dilute by a factor of 12C the suspension of pathogens and still get an effective vaccine out of it, they would do it.

By Helianthus (not verified) on 15 Jul 2015 #permalink

To add to #22 and arguments that speak well to a layperson (such as yours truly for example) I personally very like comparison, that if memory serves was made by Amazing James Randi in one of his lectures.

To visualize 30C dilution of substance take the whole Solar System. From Sun to aphelion of Neptune, whole thing, with all the planets and everything. Now imagine the ball of water that is the size of Solar System. Take that sphere that is roughly 9.1 bilion km in diameter. Now take a single grain of rice and put it inside the aforementioned sphere.

This is THE MOST active substance that homeopathic remedy will contain, usually much less than that.

By The Smith of Lie (not verified) on 15 Jul 2015 #permalink

to add onto #22

The vaccine contains a small amount of the exact thing that causes the disease. Or at least some small part of the exact thing that causes the disease.

Homeopathy, even at dilutions that may still have something, contain a small (or diluted to zero) amount of something that kind of does the same thing in some people at full dose.

So instead of a small amount of the rabies virus that has been rendered incapable of causing rabies directly, you would start with something on this list http://en.diagnosispro.com/differential_diagnosis-for/foaming-frothing-… then dilute that.

And might add other things that might cause other symptoms kinda sort of like the symptoms of rabies and then add a few things that have to do with the personal characteristics of the person rather than the disease.

Orac:

First off, the problem with homeopathy is not that it is misunderstood.

I vehemently disgree. This is *precisely* the problem with homeopathy, and one which its purveyors willfully exploit. Most people who use homeopathy have no clue how insanely ridiculous it actually is, and over time the practice of homeopathy has progressively raised more and more barriers to patients understanding just what it really is. I will be generous and say that not all homeopaths are *intentionally* obfuscating homeopathy to stay in business, but certainly some of them really are, and the language typically used to explain it to laypeople dances around the core principles enough that a typical patient could well be excused for walking away with the notion that there is some sort of active ingredient in the medicine. They will think that "arnica" is an herb that is put into the homeopathic remedy, when in fact arnica is pretty much definitely not remotely in the remedy at all. And then there's oscillionococcium, a remedy named for a bacterium that doesn't exist, made from the organs of a Muscovy duck which are then completely removed from the remedy, and used to treat a virus that homeopaths don't believe in.

The degree of absurdity in homeopathy is so profound that I think very few consumers believe it could be anything remotely so ridiculous. So naturally they assume that they must be misunderstanding something, and that it's just some sort of herbal remedy. The botanicesque names for the remedies obviously enhance this misapprehension. And I think *intentionally* so, even for Hahnemann, who came from a time when many doctors (including homeopathic ones) actually wanted a barrier of understanding between them and their patients. Times have changed since then, at least for mainstream physicians. Less so for the homeopaths.

(Side-note: for the funniest depiction of the common cultural view of the doctor-patient relationship centuries ago, check out Moliere's "La malade imaginaire", or "The Imaginary Invalid". P. G. Wodehouse's translation is sublimely hilarious, with the dog-latin "medical exam" at the end.)

By Calli Arcale (not verified) on 15 Jul 2015 #permalink

I meant understood by scientists who know something about homeopathy and that's a problem for homeopaths. Of course, the lack of understanding of just how batshit crazily nonsensical homeopathy is among the general public and even most doctors is a problem for skeptics.

@Not a Troll #8 My prune juice wasn't working last night so I was pretty cranky. BMJ's clinical articles may be good, but I wouldn't know because I am not fit to judge. In the statistical articles, the ones that come to my attention as a demonstration of some or other point that is in contention, the editors allow authors to make claims that I do not see as supported by the evidence adduced - the point may be true, but you can't show that from the evidence given and the unwary reader is left with an unwarranted impression of confidence.

Basically, it's this sort of thing: https://xkcd.com/882/

By Robert L Bell (not verified) on 15 Jul 2015 #permalink

Crap. I've been using an homeopathic preparation (anhydrous) for my pathological polydipsia... thanks for breaking it, hero.

A homeopathic hospital?
Is that one in which hospital rooms are scattered within a vast complex of warehouses, factories, offices and residences?

By Denice Walter (not verified) on 15 Jul 2015 #permalink

Orac, fair point, but I think too often we focus on trying to convince scientists and medical professionals on the subject when honestly, apart from the shruggies (who suffer from the same problem the general problem does), these are in two groups:

1) Those who know homeopathy is bollocks and to whom therefore we are preaching to the choir:
2) Those who are profiting off of homeopathy, don't care that it's bunk, and would just as soon like to see the public remain misinformed on the subject so they can keep selling it to them.

Both of these understand homeopathy all too well, but #2 is a problem only because of the general misinformation on the subject of homeopathy -- a state of affairs which I suspect they encourage.

By Calli Arcale (not verified) on 15 Jul 2015 #permalink

Denice, if only it were so...

I lived for a few years in Bristol where we had one of those. Recently there has been much complaint as its contracts are not being renewed by the local NHS commissioners; Chucky (our queen's idiot son, as opposed to the other 2 idiot sons) hasn't been happy; the local berties have been very unhappy too.

None of them have collected their Nobel prizes for chemistry, physics and medicine for explaining exactly how homeopathy can work...

I feel obligated to ask once again what the hell the editors of BMJ were thinking when they decided to publish this “point-counterpoint” in their journal.

I'm not familiar with BMJ, so i don't know if it's considered a 'pure' science journal, but clicking the link to the Fisher-Ernst article, it's clearly bracketed as "NOT a scientific paper." Thus, it does not add legitimacy to homeopathy by taking Fisher's claims and conferring some 'objective' cred to them via a peer review judgement of their validity — as a science journal would do with a scientific paper.

Rather, what I see here is the method of publication in the Humanities: peer review does not confirm the claims are correct, but only that a contribution is made to what is essentially a philosophical discussion. That is, editors in the Humanities may publish a paper exactly because it is, or might be, WRONG. The method is to get the 'best' examplars of debates out into view, where readers can compare/contrast and figure it out for themselves. The relevance of debates is not based on scientific controversy, but social/cultural contention. Open pretty much any collection of essays on a given topic in the Humanities — in a 'theme' issue of a journal or an edited book — and you'll find essays taking (often more than two) opposing points of view, thus one, more, or all must be at least partly wrong. That's just how we roll...

So, I think Calli has it right, and I'm guessing BMJ isn't trolling for click-bait, but taking a broader view of the social responsibility of a medical journal to address controversies physicians must deal with in daily practice. And what this piece does is more-or-less go Don-Hewitt-Mike-Wallace on Peter Fisher's clueless arse. Like Dr. Jay agreeing to talk to CBS News correspondent Ben Tracy, Fisher's ego leads to conformation bias of "of course they want to spread my masterful wisdom" when actually the investigative journalist is setting the trap for an ambush interview that will make the con-man appear to be the shameless scammer he is.

In other words, I smell a set-up. BMJ wants to give Ezard Ernst a platform, and what better way to do that than feed him a fresh new batch of fish-in-a-barrel to blast out of the water? He gets the 'counter-point', the chance to debunk every bit of nonsense Fisher spews, and have the debunking be 'the last word' in the piece. Yet the ruse of 'debate' format lets BMJ claim neutrality/objectivity — and they don't have to 'own' Ernst's attack on Fisher in a way that would raise hackles of suspicion. It's more persuasive to any reader not-already-convinced homeopathy is bunk to allow Fisher to hoist himself by his own petard, and then let Ernst poke holes in him as he dangles.

Another way we might conceive the 'debate' frame of this piece is sham cover for something akin to a science journal demonstrating 'how not to do science' by publishing a particularly lame submission along with the devastating peer review critique that cut it's scientific pretensions to shreds...

In short, it seems to me BMJ has done a public service to PCPs who may get questions about homeopathy on a regular basis by relieving them of the burden of explaining why it's BS from scratch, by allowing them to say 'read this' or 'listen to this podcast'...

Actually, having invoked the intellectual vacuum that is our royal family, my mother-in-law (a reasonably bright woman with a couple of chronic conditions which just about respond to conventional medicine) in a recent fit of something or other reckoned she would give homeopathy a go. When challenged with my usual "There is no mechanism by which it can work" she fell back on a mix of conflating it with herbalism, then an appeal to (non-existent) authority by saying that Chucky thinks it is good therefore it must be.

I'm afraid I did point out that I out rank him in terms of qualifications in science and health related things. In fact just out rank him in terms of educational achievement, even though I fall behind in numbers of Aston Martins...

Is that one in which hospital rooms are scattered within a vast complex of warehouses, factories, offices and residences?

No, that's the one where the patients are crammed in three to a bed to be treated by one part-time physician and one part-time nurse--by mail. (Diluting out the healthcare provided potentizes its efficacy, don't you know.)

"Doctors should put aside their biases based upon the alledged implausibilty of homeopathy."
This argument is one that I see often I people who are unable to provide any evidence for their argument. The fundamental basis of a scientific argument is evidence for your assertion. It is not my, any scientist, or any other physicians duty to prove and accept homeopathy. It is the duty of those asserting homeopathy to prove that it works. If he wants me to consider homeopathy. He simply needs to produce all of the quality evidence and it should point towards benefit. It is essentially the same standard that used in US courts, and high school debates. "He who asserts, must prove." To make the argument that he makes, essentially says "I have no evidence for my case."

Tim@29: I feel your pain. I was very much enjoying my latest homeopathic bank statement telling me how I'm now the richest man in the universe, till Orac harshed my buzz.

None of them have collected their Nobel prizes for chemistry, physics and medicine for explaining exactly how homeopathy can work…

Exactly. This is one of the motivations of people working on experimental tests of general relativity: if somebody succeeds in finding an experimental disproof, and is able to make it stand up against every possible error in experimental design, he is overwhelmingly likely to win a Nobel Prize. Thus the heavy interest in the physics community a few years ago when a team was reporting particles that appeared to be traveling faster than light (it turned out to be an issue with a loose cable in the experiment). The same thing applies here: finding a consistent framework in which (1) homeopathy works and (2) all other experimental results are consistent with the predictions of the framework would be Nobel Prize worthy. Many attempts have been made (admittedly, mostly by cranks), but every framework that has been tried satisfies at most one of the two criteria, never both at the same time.

Rather, what I see here is the method of publication in the Humanities: peer review does not confirm the claims are correct, but only that a contribution is made to what is essentially a philosophical discussion.

This is a nitpick, but scientific peer review does not confirm that the claims are correct, either. The difference is that scientific peer review is intended to confirm that the conclusions presented are justified by the results presented, and that there are no obvious errors in the results of lab or computer experiments. Some erroneous results still get published, for various reasons, among them (1) the reviewers can't be expert on everything, and may miss some issues that fall outside their area of expertise; (2) the reviewers do not have time or resources to duplicate experiments, so they must trust that the described experiments were performed and the described results obtained; and (3) some reviewers are lazy and/or biased, and overlook obvious issues with the paper. Some posters upthread have taken issue with the quality of statistical results in some BMJ articles, a point I am not qualified to judge for myself, but it's plausible to me that some such papers do slip through review. More obviously, fraudulent papers are sometimes published; the peer review system is not designed to detect fraud.

By Eric Lund (not verified) on 15 Jul 2015 #permalink

@Robert L Bell #28

No problem. I didn't mean to put you on the spot. The doctors I read go back and forth on the clinical aspects and statistics within the journal articles there and I conclude that is just the search for truth in action. Not that they don't refer to seeing lower standards in scientific journal publishing sometimes but I don't spend much time on this as it is hard enough for me to understand the history and politics of the research.

I was a little hard on the choice BMJ made too. Their title of this debate really bothered me. Even though it looks like their standard format for debate titles, the wording is vague enough that when passed around the net by all kinds of news outlets it makes homeopathy appear as if it is a plausible thing that doctors should be considering and that this has enough merit to have a debate at the BMJ.

I wanted to clarify that when I speak of click-bait, I don't just mean raw numbers; I include making and keeping their platform relevant. I don't know why they think they need to be relevant in the populist sense in addition to their academic standing but I don't run an institution so it is probably just my ignorance.

Also, my view on Marketing winning over medicine hasn't been been driven by anything scientific thinkers here have posted; just past experience in business and watching things like the whole world (literary exaggeration) thinking that low serotonin causes depression. Big debate about that three months ago including in the BMJ, and although there is much anecdotal evidence that the mental health system colluded with pharmaceutical company marketers, there was never anything in the scientific literature to support this supposition.

sadmar, at the risk of being contrary yet again, I assure you I formulated most of my thoughts before I read your comment. You make a great point about having a forum allowing the undecided to be exposed to the debunking science. I just don't know why the BMJ would be the place for it, and I'll leave you with a quote I found while doing an unscientific review of how this was being advertised on the internet. [But I'm open to being wrong on this.]

Reality vrs Delusion at the BMJ

"Medicine is weird. Astrologers do not debate in astronomy journals and alchemists are not debating in chemistry journals. Yet in this BMJ this month there is a Head to Head, Should doctors recommend homeopathy?"

By Not a Troll (not verified) on 15 Jul 2015 #permalink

asking Should doctors recommend homeopathy?

I'd invoke Betteridge's law and call it a day.

Seems ironic that homeopaths generally oppose vaccination when vaccination is the one kind of actual, scientific medicine that most closely hues to homeopathic principles - a tiny amount of a substance that causes symptoms in healthy people (the formation of anti-bodies, at least, if not more noticeable symptoms) prevents the disease of those same symptoms. It's not an exact match to homeopathy, but it is as close as they are going to get. Perhaps that is the problem?

@Narad #41. Great advice for my troubled mind.

@Robert #28. Forgot to mention the cartoon. Funny and very apropos.

By Not a Troll (not verified) on 15 Jul 2015 #permalink

And let's not forget the physician or care-giver is the most potent placebo of all.

By Lighthorse (not verified) on 15 Jul 2015 #permalink

From fishers' words: post secondary health nuts with chronic conditions use homeopathy to treat self limiting conditions to better results than plebs who see an actual healthcare provider.
I noticed there was no comment on why they claim to treat chronic conditions when their best study didn't.
Hmmmm, could being active and eating a balanced diet help with favorable outcomes of self limiting conditions? Nope, it's the fairy tears and Venus water.
Fuck these dishonest shitheels.

By But I Play One… (not verified) on 15 Jul 2015 #permalink

Does Betteridge's law apply to our esteemed host's headline too?

By John Milligan (not verified) on 15 Jul 2015 #permalink

"Hormesis does not justify homeopathy. It’s an analogy that homeopaths love because it’s a hypothesis that states that some substances that are toxic at high doses might be benign or even beneficial at lower doses."

Actually, homeopathy pseudoscience says that at lower doses, the effect is greater. In real science, the fact that high doses a substance is toxic (effect is in overdrive) and that low doses of the same substance can be beneficial is quite the opposite: high doses has a higher, toxic effect while lower doses has a LESSER effect and is thus not toxic.

By Dr. Raymond G… (not verified) on 15 Jul 2015 #permalink

There is no real analogy between low dose homeopathy and the action of vaccines.

Homeopathy says that low doses of a substance that mimics the SYMPTOMS of a disease will CURE an EXISTING disease process.

Vaccines contain a whole or part of a specific INFECTIOUS AGENT that CAN cause a disease. When injected, the vaccine stimulates the immune system of a individual that has NEVER been infected by that specific agent which will PREVENT the disease from happening when the infectious agent tries to infect the immune individual.

By Dr. Raymond G… (not verified) on 15 Jul 2015 #permalink

And let’s not forget the physician or care-giver is the most potent placebo of all.

No, everyone knows that your mommie kissing your boo-boo is the most potent placebo.

I would agree that homeopathy has the same objective effect.

Does Betteridge’s law apply to our esteemed host’s headline too?

Grammatically, it doesn't qualify, but if one wants to interpolate modal verbs, it works for me.

@ Dr. Raymond G. Whitham

When injected, the vaccine stimulates the immune system of a individual that has NEVER been infected by that specific agent which will PREVENT the disease from happening when the infectious agent tries to infect the immune individual.

To nitpick, you can give a vaccine to someone who already had been infected in the past (booster vaccines could be in this category), or is being infected right now (in cases of rabies or tetanos).

It's still un-homeopathic. The quantities of pathogens alone are much higher than anything homeopathic.

My favorite analogy for vaccines is the training range.
Vaccines provide lookalike foes for the immune system to do some target practice and learn to recognize and deal with the enemy faster and more accurately.
A true homeopathic vaccine - a very diluted suspension of pathogens - would fail to provide anything to be excited about.

By Helianthus (not verified) on 15 Jul 2015 #permalink

@ Orac #34:

I wonder why the BMJ assigned a biased peer reviewer to Ernst’s article and the peer reviewers who reviewed Fisher’s article didn’t make him fix the egregious misstatements of fact in his article...

Ernst's blog post doesn't explain how peer review functioned for this 'debate' feature, compared to how it would function for a scientific research paper submission going through the normal editorial process. How did the editor treat the comments from the negative reviewooer? Did they demand changes from Ernst, just suggest changes, and if so, what? The editor could have been thinking 'your article will be stronger if you better articulate your argument in a way that addresses the kind of critiques the reviewer makes'. If Ernst feels his contribution as published was compromised in any way, he doesn't say so in his post.

Given that this was a by-invitation forum presentation, if would be sketchy indeed if BMJ sent the contributions to different sets of peer reviewers, expected the authors to conform to the reviewers' demands, and rigged the game with 'friendlies' for one side, and 'hostiles' for the other. I can only say how I would have handled handled something like this as a journal editor (which I was briefly, not in the sciences of course, and I never did an invited "point-counterpoint"): I would send each contribution to the same three reviewers – unblinded, because the the stature and record of the authors matters – one 'partisan' from 'each side' and one 'not commited' I'd imagine would be acceptable to both parties. I'd then send the collected reviews along to the authors, in both cases with notes on using the reviews to make the essays stronger from the POV of a neutral party and/or the POV of 'the author's own mocassins'. Then after any further discussions with the authors about tightening their arguments, I'd publish whatever they wound up with – since, after all, i invited them — unless one of them insisted on printing something outside the bounds of the frame I'd set that would cause some unanticipated major ruckus, in which case I'd scotch the whole project. Especially given Fisher's ties to the Prince, I'd play the whole thing very close to the vest, not letting anyone know the full reasons I thought the 'debate' was worth pursuing, or what I expected or hoped would come out of it. More specifically, if I was trying to rig the game for Ernst, I'd sure as hell cover my ass by sending out his piece to one reviewer I'd expect to take a dim view of it, thus preserving my claim to a cloak of neutrality and 'plausible deniability'.

If Ernst got to publish something he was content with despite receiving a "scathing" review "essentially claiming that it was entirely worthless", we can hardly deduce from the fact that Fisher's part as published "contained plenty of misleading information" that Fisher did not also receive a scathing review, or that he was not extended the same editorial courtesy of not having to hew to the critique he was given as was Ernst.

Anyway, Orac, I ask you: (not rhetorically)
1) If you were trying to stack a debate in Fisher's favor (even if that means just letting him come come off as less of a clown than he is), who would you invite as his interlocutor? What would be the rationale for choosing Ernst?
2) If you were trying to stack a debate AGAINST Fisher, would Ernst be high on your list of potential interlocutors, or would you consider him too weak? If so, why, and who would go with instead, and why?

Of course, I take it you wouldn't place any form of 'debate' having anything to do with homepathy in BMJ, so the questions are hypothetical, and for sake of discussion let's imagine this would appear in a serious respected publication where discussions of medical controversies have long been 'at home', not one primarily devoted to disseminating competitive primary research papers in medical science...

The main point here is whether we should accept any evaluation based on impact and citations. As a journal, BMJ can decide if its readers prefer to see papers on homeopathy, but we, should not accept impact factors as an indication of scientific value. Thanks to the BMJ, scientists can realize that evaluation based on the number of clicks or citations is meaningless. It's better to struggle against that rather than against quacks.

By Daniel Corcos (not verified) on 23 Jul 2015 #permalink