Homeopathy: the clinical picture is no clearer

Dear Sir,

Relton and colleagues[ ¹ ] attempt to bring clarity to the debate on homeopathy, yet fail to do so for reasons which are themselves clear. They quite rightly show that terminology may be variably used, and seem to imply that this is particularly a problem with homeopathy. The fact is that the same occurs throughout medicine. The very word ‘medicine’ can mean a course of education, a practice, or a treatment. ‘Pharmacy’ similarly can mean a place where drugs are dispensed, a university course, or a functional area within a research project. The reality is that terms are in part defined by their context, and few of us have difficulty with this. However in the present debate it is what homeopaths themselves say that matters. Whatever terms are being used, what are homeopaths claiming? Are they claiming that ultra-dilute preparations of certain substances have specific therapeutic effects? If they are, then this is readily testable and indeed has been tested repeatedly. If they are not, then what are they claiming?

The authors approach the truth in their consideration of ‘efficacy’ versus ‘effectiveness’, but they miss the point. Surely there is huge danger in accepting the latter while ignoring the need for the former? Effectiveness is a measure of the generalisability of a finding of efficacy. This is an important distinction when considering the role of the National Institute for Clinical Excellence (NICE). The paper alludes to the steadfast refusal of the government to refer any complementary or alternative medicine (CAM) to NICE, a fact which has previously been documented.[ ² ] But to be fair to NICE, cost-effectiveness can only be calculated when a measure of effectiveness is available, and the prerequisite for that is a positive finding of efficacy. For orthodox medicines, NICE will not carry out any appraisals unless Randomised Controlled Trials (RCTs) show efficacy. Why should CAM be different?

I am particularly concerned at the authors' treatment of the term ‘evidence’. I agree that the contextual effects of a homeopathic consultation might be beneficial, but I have to return to the question of what homeopaths are claiming. If they are claiming that the consultation alone does the job, then fine, but they are claiming more than that. What they are doing to my mind is to make it impossible to identify what really is happening, by refusing to allow the separation of treatment from consultation. This only happens in CAM, and in no other area of medicine or indeed of science. I do not dismiss the value of observational evidence. However it ranks poorly in the hierarchy of evidence,[ ³ ] and it is hardly reasonable to accept it in the absence of RCT evidence. Relton et al. follow the time-honoured tradition of homeopaths by citing a colourful anecdote as if this were evidence for anything.

It is the mission of science, and of scientists, to bring clarity to that which was unclear. Refusing to allow the analysis of homeopathy as a practice, however one wants to define it, serves only to raise the turbidity of already muddy waters (even though the water in question really contains nothing). Yet Relton et al. do an about face at the end, with a remarkably reductionist set of recommendations. Will homeopaths take any notice? I suspect that herding cats will be easier to achieve. It is hard to see how this paper has added to our knowledge, and whether its recommendations have any value in the context of the barren evidential landscape that is homeopathy. It is noteworthy that funding by the Department of Health is acknowledged. This presumably is the sort of work that the government refers to when it claims to be supporting research into CAM.

• References

• 1 Relton C., O'Cathain A., Thomas K.J. ‘Homeopathy’: untangling the debate. Homeopathy 2008; 97: 152-155.
• 2 Rose L., Ernst E. Cam and politics. Ernst E. Healing, Hype or Harm?. 2008. Societas Imprint Academic Exeter, UK; 115.
• 3 Guyatt G.H., Sackett D.L., Sinclair J.C., Hayward R., Cook D.J., Cook R.J. Users' guides to the medical literature. IX. A method for grading health care recommendations. J Am Med Assoc 1995; 274: 1800-1804.