Should Complementary Medicine be made available on the NHS? A Reply to the Sceptics
Professor George Lewith
I have published substantially in the area of CAM with outcomes that
have been equally divided between positive and negative trials. This
includes studies in homeopathy (as a practising homeopath) that both
support and challenge the clinical effects of the ultramolecular dose.
Clearly that makes me a supporter of evidence based medicine (EBM) and,
like a number of my CAM colleagues, a practitioner who is open to good
science. ‘CAM
within the NHS’ seems to be more about belief than objective science,
a stance that is alien to all reasonable CAM practitioners. The
current debate about CAM relates to the distribution of NHS resource:
why should we pay for CAM and not Herceptin? We should use evidence
as the basis for purchasing care and I have always thought that we should
be using acupuncture to help chemotherapeutically induced nausea, the
evidence is there (1), but not the financial resource. Some of
the ‘weird ideas’ first aired in traditional Chinese texts
such as the double circulation of blood predate William Harvey’s
observations’ by some 2000 years; are we to really believe all
CAM philosophies are complete rubbish or some devious Orwellian plot?
Within
an EBM culture we often ignore evidence; placebo arthroscopy works as
well as the real thing for OA knee, yet we continue to expose patients
to the risk of operation (2). General practitioners are inevitably confronted
with a plethora of chronic benign illness such as irritable bowel, asthma,
migraine, depression and musculoskeletal pain. The evidence for the efficacy
of many of the ‘conventional’ primary
care based interventions for these conditions is flimsy. SSRIs may only
have a 10% advantage over placebo whilst the non-specific effects of
any intervention may form the most substantial part of treatment effectiveness
(3). There is often no evidence base upon which to recommend a specific
intervention so consensus and ‘best practice guidelines’ are
often the basis for EBM in general practice . This is a world
apart from the specialist areas like breast cancer.
The evidence for CAM,
(including homeopathy) is not a barren wasteland. Linde and colleagues
reported that the effects of homeopathy could not be dismissed as placebo
(4). The different methodology employed recently by Shang (5) concluded
that homeopathic medicines had no specific therapeutic effect. Both systematic
reviews were based on much the same data and published by the Lancet,
both had their critics and neither was conclusive. This suggests that
we have too little research upon which to draw any real conclusions about
the effectiveness of homeopathy, an argument for greater research investment.
Why do so many sensible people think that homeopathy works for them;
are they all being ‘conned’? Homeopaths
and conventional doctors have assumed it’s the medicine but it
may be the very specific nature quality, content and context of the homeopathic
consultation that’s the key to success through its ability empower
patients with chronic illness. Perhaps conventional medicine might learn
from this? It seems that homeopathy can’t work because it
isn’t feasible. I wonder what the Catholic Church said to
Galileo or Newton. Where would we be without Plank and quantum
mechanics overturning Newton’s ‘truth’ with one of
the most counter intuitive scientific theories ever proposed. On
the basis of quantum and chaos theory we can suggest that a butterfly’s
wings in London will influence a cyclone in Florida. What could
be less feasible, yet modern electronics are firmly founded on these
assumptions. Perhaps it is the essential conservatism of medicine that
makes addressing new ideas difficult.
CAM and homeopathy may be driven out of the NHS but what does that
mean ? If over 50% of the UK population has tried CAM and the vast
majority (80-90% of them) report that they found benefit, then telling
them that “CAM doesn’t work” is inappropriate. If
an individual has personally experienced benefit, yet is being told by
a physician that it “doesn’t count”, it’s not
a “real treatment” and by implication they must have “imagined
it all” that could create discord between patients and their doctors. Removing
CAM from the NHS means that patients will seek CAM elsewhere and may
be wary of telling their doctor what they are consuming as they might
assume their GP is “anti-CAM”. This could recreate
the bad old days of irresponsible and unregulated practice with the patient’s
care and wellbeing at risk. This ‘old fashioned’ approach
is something that GP’s have been trying to “manage out” of
their practices for the last 20 years. Risking division between
patient and doctor in primary care will make it increasingly difficult
for a general practitioner to have a thoughtful input into an individual’s
disease management. The evidence for CAM is often no better or
worse than in many other areas of primary care. The consequence
of this attack on CAM may simply lead to conflict, discord and lack of
trust between patient and physician, surely this is no one’s real
interest, certainly not the patient’s.
References
- Vickers AJ. Journal of the Royal Society of Medicine 1996;89:303-11 .
- Moseley JB. The new England Journal of medicine. 2005;347(2):81-88.
- Kirsch I. Complementary Therapies in Medicine 2003;11:193-5.
- Linde K. The Lancet. 1997;350:834-843.
- Shang A. The Lancet. 2005;366: 762-732.
