Finally, the report on the funding of homeopathy in the UK is to recommend the withdrawal of support from the National Health Services. Patients seeking this form of “treatment” will need to pay for it themselves. Hurrah I hear you all calling but before we start cracking open the celebratory bottles, I think that hopeopathy (which after all is how it works) is not likely to disappear. At the risk of attracting the anger and ridicule of the anti-homeopath lobby, let’s remember a couple of things. First, it works… not because of any supernatural mechanism of sympathies and infinite dilutions. People who believe in it get better. Second, some of the established medicines, most notably SSRI anti-depressants also work not much better than the placebo effect according to recent meta-analyses which throws a spanner in the works somewhat. Third, paying for something makes it more effective than free treatments. (I am reminded about the fact that a £16,000 bomb-detector is considered more effective than one that is made from a coat-hanger). Finally, the way the NHS is going, soon we will all be directly paying for our treatments, one way or another through various health plans etc. So while this may be a victory for evidence-based medicine, I do not think it will disappear. What do you think?
I am adding this video from Ben Goldacre for clarity and to address some of the questions raised in the comments.
brucemhood.wordpress.com 
As an ex-homeopath, I am glad your government is not supporting it. But I doubt it will go away, sugar pills are cheap “medicine”.
I think people should be paying for their own health care however you do it so that they learn to make wise decisions. Now, if we supplement the medical bank accounts for disasters or very bad luck, that is another thing. But if the government supports something and offers it “free”, people will continue to make very bad decisions.
Excellent, but I agree. It won’t change people’s belief but it might help delineate between real medicine and homeopathy. I am sure that many think that if its on the NHS it MUST have something to it. Well other than what you have pointed out 🙂
Richard Wiseman commented on this on Twitter saying isn’t the placebo effect economically beneficial to the NHS? My answer would be no, because they’re still not getting the correct treatment because they’re relying on the placebo effect, which still would cost money and waste money that could go somewhere else. Treatment by being fooled? Ethical?
I’m a pharmacist and am very happy this step has been taken. You’ve no idea how rediculous I feel when people come in and ask for arnica tablets and I have to sell them. And they aren’t even cheap! A container of 30c Nelsons Arnica tabs is £5.95 where I work! I almost cringe when I explain how to use them…”try not to touch the tablet, don’t have anything too strong smelling to eat or drink after as it might inactivate the tablets…” riiiiiiight! A good move but people will still wanna buy things OTC fo sho!
I think I agree with Richard Wiseman on this. In the past, GPs used to prescribe sugar pills which triggered the placebo effect and no-one really complained because it worked and did not harm anyone. Along comes homeopathy, a treatment that also relies on the placebo effect but because of its obvious basis in woo, people object. The actual cost to the NHS is I understand around £4m but that might be comparatively less than removing homeopathy which patients seek. After all, lets not forget that it does work. And as I said above, conventional medicine with active ingredients also triggers the placebo.
Now, where I do object to homeopathy is when it replaces treatments that are known to work. The malaria prophylaxis scandal in London for example. So here is the slippery slope – if the state sanctions a faith-based cure then does that open the flood-gates for all quackery?
In my opinion, if people want to pay for this, and their health is not put at risk and they do not draw on expensive investigative routines by the NHS or take up valuable consultation time – then fine – I’m all for it.
But then I question the morality of letting people pay for something which they think might work because the state has sanctioned it – especially if they cannot afford it.
Hmmm, if people think they drive better when drunk, should the government make special allowance for these people? 🙂
If we say the government should fund placebo treatment, can anyone advise me of a product or service that should NOT be funded? Surely all of CAM exists because someone believes. I know people who swear by ear candles!
I agree with AndyD. It’s cheaper to say it’s okay to go to a backstreet abortion clinic, but would you tell a patient that?
By all means people should have the right to choose to buy a treatment they personally believe in, but state sanctioning something like homeopathy does, as you say, Bruce, give it some ‘easy access’ credability. If that carries on we will be funding witch doctors next!
Can I just say it again… homeopathy does work
Believing that you drive better when drunk doesn’t and you are unlikely to suffer from homeopathy in comparison to a back-street abortion (unless caveat about neglecting effective treatment is violated).
So I hear you guys… this is quackery… supernatural thinking… should not be found in a modern society… but (as I have been at pains to point out in SuperSense) not too surprising given the foibles of the human mind.
The question is which is the lesser of the two evils. You might say that £4m would be better spent on real medicine. How many MRI scans would you get for that? Now all those additional investigations for chronic patients will mount up and that will be at a cost to all the other treatments in the NHS… so money and ethics go hand in hand.
As to funding witch doctors… well if it works and no one is harmed (muti killings aside) then yup I have to say that my logic would have to allow this as well.
Placebos work because people believe them to be effective. Once you undermine the credibility, then you lose the effect. The problem with licensing homeopathy is that it undermines the credibility of all medicine (much of which, not just antidepressants, gets a boost from the placebo effect).
Incidentally, placebos that cause side effects (i.e. not homeopathy) are more effective than placebos that don’t. And antidepressants are effective – just not in mild depression.
With regard to the cost, you also need to factor in the time wasted by physicians and pharmacists dealing with people with trivial problems who want to get some ‘medicine’. If we stopped doling it out, then they would stop coming.
Hi Tom,
Did you take a look a the meta-analysis study I posted? It reaches a pretty damning conclusion that the effectiveness of antidepressants …”reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category.”
Not so sure about the time wasted either. Patients expect to receive something when they go to the GPs. That’s one of the reason’s we have drug-resistant infections. The over-prescription of antibiotics reflected this “give me something” and then people stopped taking the course and developed resistance.
So now that we have removed the sugar-pills, what does the GP have to replace it? Counseling would be great except it is even more expensive.
My new best friend Dr Phil Hammond, told me that GPs need to give them something.
Could you clarify why you think homeopathy works? Is it because of the ‘belief’ side or are you saying it is actually a pharmaceutical type medicine?
Also, from what you are saying, I get the impression you think it’s okay for a doctor to effectively lie to a patient about a prescription’s effectiveness as long as it makes that patient believe they feel better. Please do let me know if I’ve got this all wrong.
Homeopathy works on the basis of the placebo effect. How the placebo effect works is a really fascinating topic with some interesting theories. I particularly like Nick Humphrey’s ideas on this. Put simply, we have the capacity to self-heal to some extent if we believe we can. We also have the capacity to become ill through psychological processes as well. Amazing when you think about it.
Yes, I think lying is morally acceptable if the patient ultimately benefits.
Bruce, I’m not aware that placebo effects do anything other than affect perception. While in the case of pain, and sometimes certain mental ailments such as depression, this is in and of itself beneficial, obviously affecting one’s perception of cancer or an aneurysm will cause it to get better.
Please see Ben Goldacre’s excellent video summary I have just added to the initial post.
I think the issue with the debate has for too long been focusing on establishing that homeopathy works no better than a placebo. I think that yes, you cannot dissuade the true believers, but that it has been well established that homeopathy is a placebo-based treatment. The debate therefore ought to be about the ethics of provision of placebo-based treatments, and how great an impact the placebo effect has on health, which I suspect is over-stated. Research into placebos show that the level of effect hinges on a wide variety of factors, such as the level of consideration prior to prescription, how new and excting the tested treatment is, the colour of the pills, and the dress and confidence of the prescriber. How much impact, therefore, does participation in a trial itself have on placebo response?
I would also say that the placebo / investigation trade-off doesn’t ring entirely true. Placebos are most effective in self-limiting conditions, where treatment or investigation would not lead to very much except in extremely rare case. Added to that is the “bigger picture” issue. How does one apply an ethical code, within the framework of the NHS and GMC, to prescribing placebo treatment? How does one maintain the fiction? How does one rubber stamp CAM in one place (run-down of Dorset) without endorsing by association CAM in another place (malaria sufferer of Tanzania)?
I think I was clear that the caveat should be that it is not acceptable in situations where there are established, effective treatments…. (malaria a point in case see earlier comment)
I had already watched Goldacre’s video, and still I agree with neuralgourmet’s skepticism about the ability of the placebo effect to have a strong influence on truly objective outcomes. It is obviously quite powerful for subjective symptoms. It might have some impact beyond that, but it is far from clear.
Many medical professionals now consider it unethical to prescribe placebos. It is a result of the move from a paternalistic model of medical care to one that is more consent-driven. After all, “informed consent” is by definition not possible when you knowingly prescribe a placebo, is it? And “informed consent” is a cornerstone of modern medical ethics.
Is the placebo effect on health over-stated? I don’t know….there is a wealth of anecdotal evidence that shows that if a person “believes” they will benefit from a treatment or that they will get better that the mere belief affects the outcome. This anecdotally is the experience of transplant surgeons or oncologists where the outcome can be strongly influenced by the demeanor of the patient. In otherwords those with a positive outlook and belief that they will get better do much better than those who have a negative outlook. In addition those who scoff at the sugar pills are assuming that all of the medical interventions used today have a proven scientific basis for their use. This is not true. There are a significant number of procedures in medicine where there is no robust scientific basis for their continued practice however it continues. For example the “bare below the elbows” campaign is widespread and well recognised as a method to reduce the spread of infection from healthcare worker to patient however there is no good scientific study to prove it. It is however common sense as it makes it easier to wash your hands and not have dripping damp cuffs contaminating the hands. A significant number of medical interventions do not have a good scientific study to back up their use however common sense dictates they should work and in some cases traditional methods fine tuned over many years are effective although again there is no scientific study.
This does not mean that I think that homeopathy should be considered a scientifically proven or even in many situations reasonable treatment choice however in some situations where it does no harm, it may psychologically do some good. Remember Medicine by many as an art not a science.
James and Blue Moon
I don’t think the evidence is either anecdotal or subjective. As I understand it, the data from gastric ulcers is pretty well substantiated as Ben Goldacre points out.
Bruce – yes, I know the study. If you look at Fig 3 you can see what’s going on. Medication effect remains constant across all baseline severities, while placebo effect declines. Basing a clinically meaningful difference on the HRSD scale as ‘1’, only patients with severe depression reach this *on average*. But there is a detectable difference at lower baseline depression – it’s just that patients here get an average change of <1 on the scale. So it all depends on what you mean by 'difference' 🙂
Incidentally, part of the efficacy of 'genuine' antidepressant medicine seems to be because it has side effects. Patients in placebo-controlled trials pick up on this. If they get side effects, they assume they are getting the 'real' stuff and – hey presto – it's more effective.
WRT placebos, I suspect that if patients believe that doctors are purposefully giving them sugar pills, the placebo effect would vanish. In other words, once the homeopathy cat is out of the bag, then keeping it in the armementarium is not viable.
Which is a shame, of course. Because as you say, it's cheap and mostly harmless.
James has a point, by the way. Studies of the placebo effect tend to focus on diseases with subjective outcomes – depression, pain, irritable bowel syndrome. Gastric ulcers respond but then they can be stress-related.
It’s an important point – cancer sufferers can’t will themselves better. It’s easy to go to far and switch into a mentality of blaming the patient for not curing themselves!
I think that there is too much assumption going on here -& I am guilty here as well…
This is not my area of expertise so I will leave it for others with expert knowledge to comment.
As far as I am aware remission is subject to psychological factors.
I have to agree with Bruce, with a slight caveat. Homeopathy and other forms of alt-med placebo are not going to go away. People want to believe in these things, so they will continue via private funding or whatever.
I don’t agree that letting doctors prescribe or people to dose themselves with placebos is entirely without harm, however. Anyone who has seen my website What’s The Harm (http://whatstheharm.net) knows my opinion of that.
There’s something that I tell skeptics all the time that bears repeating in this context: we don’t ever get to WIN. There is no point where skeptics can say, “well that’s it then” and quit what we are doing. We are not going to defeat homeopaths or psychics or UFO believers or anyone else. They will continue to be out there. Bruce’s book is all about why this is.
Skeptics have to understand that, while victories like this are useful fun to celebrate, we are fundamentally in the business of educating the public. Because it is only through education that someone can become an informed consumer and reject these ridiculous forms of magic being sold to them.
The need for this skeptical education, just like with any form of education, never stops. There’s always someone who hasn’t had placebo explained to them. Soldier on.
Caveat appreciated. My concern is that when the placebo has pseudo-science attached to it, as is the case in homeopathy, then there is no logical reason not to use it to treat more serious (and preventable or manageable) conditions. I suppose you could “black box” the placebo, inasmuch as a drug is a drug is a drug, but to go on prescribing something that hangs on an irrational theory, and resides in a culture that is actively anti-evidence-based medicine, can only cause problems, whatever the immediate benefit.
Tim… I, of course, agree
So, if we accept homeopathy as a placebo treatment but oppose its use in areas where there is a real alternative, does this suggest homeopathy should be very heavily regulated and available only through real doctors as a last resort?
If not, how do we stop the ani-vax, anti-“allopathy” homeopaths attracting customers who need real medicine?
Should chemists be allowed to sell the placebos too?
And what will the cost be if govt funding is extended to every type of woo/CAM out there?
AndyD,
Good points. I would have to say yes. Shut down the homeopaths who lack medical knowledge and place patients at risk if they offer treatments for conditions where there are proven effective medical alternatives.
I suspect that homeopathy will simply become “private” and remain as popular as usual. However, I am concerned that we start looking at other conventional practices where there the placebo is also at work. So I disagree with comments that it only works only subjective symptoms.
I also think that GPs need to be able to retain the option of prescribing sugar pills when necessary. This recent spotlight on homeopathy raises this as problematic too.
The placebo effect is not a constant – it’s culturally determined (there’s a nice article in Wired magazine: http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect). It’s effective in the West because people have a lot of confidence in doctors and the treatments they give. In the NHS, there’s a strong move towards evidence-based medicine – i.e. only medicines that are proven to be effective beyond the placebo effect (and cost-effective) can be placed on the formulary. Ironically, this sort of approach probable strengthens the placebo effect, because it increases people’s confidence in the medicine they’re given.
If doctors start overtly handing out sugar pills, you’ll erode the placebo effect. I agree that we should harness the placebo effect, but we have to be smart about how we do it. The challenge is to leverage the placebo effect within conventional, evidence-based medicine.
Here’s a timely piece in Sci Am on the ethical problems of using the placebo effect:
http://www.scientificamerican.com/blog/post.cfm?id=beyond-the-sugar-pill-are-doctors-m-2010-02-18
Even more worrisome, they reported, with all of the data about the power of the placebo effect now widely recognized, some doctors might be blurring ethical lines by employing it to treat patients without full disclosure. “Routine conscious attempts to identify and exploit features of the clinical encounter to augment placebo effects represent ethical means of applying the understanding of placebo mechanisms to improve clinical outcomes,” Finniss and his colleagues noted. But at what point can this treatment tool become deceptive?
Though they might not be sending their patients home with sugar pills, “clinicians often prescribe various active treatments with the main intent of promoting a placebo response,” they wrote. Better disclosure might be the solution, they note, but if patients are given a placebo with full disclosure of its inertness—as well as its possible benefits—will it still work as well? The researchers prescribe more clinical research.
Even the BMJ admit that 46% of conventional treatments are of unknown effectiveness.
http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp
In other words, there is a helluva lot less evidence-based medicine than the general public assumes. Now where are the ethics here of giving treatment and not knowing if it works?
Yes, there’s still an awful lot of non-evidence based medicine in use today. That’s why NICE was created. The cutting off of homeopathy is part of the general trend towards reducing the prescription of medicine with doubtful efficacy.
The NHS report summed up very nicely why letting patients “choose” a placebo is not a choice at all:
On a separate topic, Bruce said:
Three points in response:
First, there is a big difference between offering a treatment of “unknown efficacy” vs. offering a treatment that is known to be complete bullocks. In many cases I agree that the former, if done knowingly, is not particularly ethical either, but it pales in comparison to the latter.
Second, as frustratingly non-evidence-based as mainstream medicine can be at times, there is at least a mechanism for progress. It is a slow and messy progress, but over time conventional but wrong-headed notions are overturned one by one. A recent example is vertebroplasty, which was recently shown to be ineffective — though has not yet been phased out of mainstream medicine. But at least there is progress. What progress is there in CAM? We’ve had two hundred years of homeopathy, and it’s still rubbish. When do you throw in the towel? In CAM, you don’t. That’s an important difference: Mainstream medicine is wrong a shocking amount of time, but it at least tries to be right. CAM doesn’t even try to be right; it only tries to be profitable.
And lastly, two wrongs don’t make a right anyway. Pointing out, for example, that vertebroplasty is still paid for by most insurance companies (and I presume the NHS), despite the fact that it is looking to be nothing more than an invasive placebo, does not mean the NHS should pay for homeopathy. Ideally, they shouldn’t pay for either one.
I guess I am more of a pragmatist who wants to get the best out of the system… a system that is over-stretched. I think two wrongs can make a right when it is the most cost-effective way of getting rid of chronic patients who gum up the NHS requesting more and more investigations. They want a treatment and you can’t send them home with nothing. .. actually you can.. it’s called homeopathy!
Why not send them on their way with a magical cure that is not going to harm them, makes them feel better, might have some beneficial effect and is so much cheaper?
Guess I am not that moral after all.
Equally, you could tell them to pray for salvation…
Talking of which, belief in a caring god increases the placebo effect in depression (i.e. the add-on effect from taking real medication): http://www.sciencedaily.com/releases/2010/02/100223132021.htm
The answer to the “why not” is because the patient does not have informed consent, i.e. they have been denied an ability to participate in the decision-making process. You have made it clear you do not have a problem with this, which is fine… but where do you draw the line?
When does it eventually become unacceptable for someone in a position of authority to use their power to deceive, even if it is “for the deceived’s own good”?
Would it be acceptable for the leader of a country to lie about the underlying reasons behind a war, if she felt that the true reasons were justifiable but unpopular? Perhaps this person felt that was the most cost-effective way to get a despotic tyrant out of power. Would that make it okay?
Of course there is a big difference between that and a sugar pill, but I’m just saying, it is not just idealism (or a lack of pragmatism) that causes some of us to frown on the deception inherent in purposeful prescription of a placebo. There is a real danger here.
James, I am not about to enter into an extended debate on ethics but suffice to say, extrapolating from the health of the individual which poses minimal risk, to whether to wage war with the extensive loss of life seems to me a line of argument taken too far.
Also if nearly half of GPs are already knowingly giving out placebos that are not inert (e.g. antibiotics for viral infections) then this is surely the greater evil (this is one reason we have drug resistant MRSA).
Informed consent…. an ideal to strive for but rarely achieved