Edzard Ernst Exposed

H:MC21 (Homeopathy: Medicine for the 21st Century) report that Professor Edzard Ernst the leading ‘authority’ on homeopathy, and perhaps its most referenced critic, has no qualifications in homeopathy.

William Alderson of HMC21 also claims that Ernst’s book Trick or Treatment? shows Ernst to be unreliable as a researcher into homeopathy. He outlines 11 mistakes made by Ernst which can arise from ignorance of the principles of homeopathy, and which can seriously affect the reliability of randomised controlled trials and meta-analyses of homeopathy.

He says ‘We believe that it is time to recognise that opposition to homeopathy is largely based on the opinions of individuals who are unqualified or unwilling to judge the evidence fairly.’

‘The trouble with skeptics’, ‘illiberal liberals’ and skeptic projection

I appreciate jdc325’s piece on inappropriate skeptic attitudes and behaviours, having been subject to them on this blog.  I’m pleased to say however that generally the skeptic tone is much better than two years ago: Skeptic insults to homeopaths daily count: December 4th 2007.  I’d like to add a skeptic fail of my own: making up facts based on logic, or ‘flact’ for short.

Also of interest this week is Brendan O’Neill’s piece in Spiked online on the illiberal, anti-free speech treatment of Johnny Ball’s scepticism of man-made climate change at a ‘religious style get together of rationalists’ including freedom-of-speech-for-scientists and anti-homeopathy campaigners. Further evidence that science or scientism is the new orthodox fundamentalist religion.  Update: even Randi is being subject to the same treatment

And finally I agreed with homeopathyblogs that Goldacre et al are projecting onto homeopaths their own unscientific and biased approach as detailed by William Alderson’s review of Ernst and Singh’s Trick or Treatment.  The printed version of  Goldacre’s notorious anti-homeopathy piece in the Guardian contained cartoons projecting pharma’s love of its pills and forcefeeding them to innocent patients.  Given that Goldacre is involved in psychiatric work you would think that he would recognise this, unless of course he was wilfully using it to influence.

Singh and Ernst’s book ‘Trick or Treatment?’ “has no validity as a scientific examination of alternative medicine.”

From H:MC21: ‘Halloween Science’

A critique of Trick or Treatment? by Simon Singh and Edzard Ernst written by William Alderson on behalf of H:MC21 (Homeopathy: Medicine for the 21st Century); March 2009.

Trick or Treatment? by Simon Singh and Edzard Ernst claims to “examine the various alternative therapies in a scrupulous manner” (p.3). This critique assesses the validity of this claim, both in general and specifically in respect of homeopathy, by analysing the authors’ own arguments and evidence for accuracy, consistency and reliability. Where information is lacking in Trick or Treatment?, the critique incorporates evidence from other primary sources (where possible) or reputable secondary sources. Some conclusions reached on the basis of Ernst and Singh’s own statements are also supported by reference to other sources. All sources are referenced.
RESULTS: We have identified nineteen major faults in the case presented by this book

Evidence: (1) The authors frequently rely on figures, trials, events, quotations, statements, opinions and explanations which are unsupported by reference to sources. (2) This evidence is frequently misleading as a result of being presented out of context. (3) The authors use different criteria when assessing the validity of evidence, depending on whether the evidence supports their views or not.

Science: (4) The authors commit the common fallacy of confusing absence of proof with proof of absence. (5) The importance of theory is minimized or even ignored, when discussing both science in general and individual alternative therapies. (6) The authors assume that orthodox medicine is scientific, but offer no justification for this position. (7) There is evidence that the authors do not understand the principles and practice of orthodox medicine.

Definitions: (8) Alternative medicine is defined in four different ways in the course of the book. (9) Other significant terms, such as ‘science’, ‘disease’, ‘cure’, ‘effectiveness’ and ‘orthodox medicine’ are undefined. (10) This allows arguments to be built on vague preconceptions rather than on clearly defined principles. (11) The differences between orthodox medical and alternative medical definitions is not taken into account, despite their impact on the design of trials. (12) The authors fail to present the ideas of evidence-based medicine accurately. (13) The authors fail to present the nature and development of homeopathy accurately, raising doubts about their presentation of the other therapies. (14) They also call into question the principles of orthodox drug therapy, despite the fact that the tests used by this therapy underpin much of their argument.

Analytical tools: (15) The authors fail to prove that their main tool, the randomised controlled trial (RCT), is valid for testing curative interventions, while presenting evidence that there are serious problems with using it for this purpose. (16) They show that a tool derived from these trials, the meta-analysis, is prone to lack of objectivity, yet they rely on this for some of their conclusions. (17) Their conclusions are also dependent on the concept of the placebo effect, but they make it clear that this effect has no scientific basis and is so unpredictable as to have questionable scientific validity in this context. (18) They acknowledge the importance of individuality in the curative process, but deny its significance for the design of analytical tools. (19) They fail to take into account the need for analysis of evidence from clinical practice.

CONCLUSIONS: Ernst and Singh have failed to provide a secure theoretical or evidential base for their argument, and have used analytical tools inadequate (in this context) for achieving objective and reliable conclusions. The result of these weaknesses is that their argument relies heavily on preconceptions, variable definitions and opinion, a problem exacerbated by a tendency to confirmation bias on the authors’ part. As a result, Trick or Treatment? has no validity as a scientific examination of alternative medicine.

Full report here

Edzard Ernst’s uncritical endorsement of EBM is ’empirical quackery’

Dr Michael Fitzpatrick’s review of the book ‘Trick or Treatment’ by Simon Singh and Edzard Ernst at  spiked-online (they say: “an independent online phenomenon dedicated to raising the horizons of humanity by waging a culture war of words against misanthropy, priggishness, prejudice, luddism, illiberalism and irrationalism in all their ancient and modern forms”) makes the following observations and criticisms of interest:

“Despairing of their capacity to engage with serious adversaries or big issues, former left-wingers are inclined to re-fight the battles of the past and to seek out soft targets for their invective: current favourites include neo-fascists, creationists and conservative religionists. Though any small success of these forces is trumpeted as a menace to civilisation, in reality they are as marginal as they have ever been. Exaggerating these threats enables liberals to imagine a return to their glory days, and allows them to evade the real problems of the present.”

“Alternative medicine, the focus of a new critique titled Trick or Treatment? by the science writer Simon Singh and Edzard Ernst, ‘the world’s first professor of complementary medicine’, has become another target of the radical backlash. Following the spectacular success of a series of works promoting militant secularism, a spate of books and blogs now signals a new crusade against alternative medicine.”

“it is light on references”

“My reservations about Trick or Treatment? concern its uncritical endorsement of what the health policy expert Rudolph Klein has characterised as the ‘new scientism’ of ‘evidence-based medicine’ (1), its incoherent advice to doctors on telling the truth and its curiously paternalistic approach towards patients.

According to Singh and Ernst, ‘evidence-based medicine’, a term coined by the epidemiologist David Sackett in 1992, has ‘revolutionised medical practice’. They acknowledge that ‘prior to the development of evidence-based medicine, doctors were spectacularly ineffective’. However, ‘once the medical establishment had adopted such simple ideas as the clinical trial, then progress became swift’. As a result, ‘today’, less than two decades later, according to this remarkable telescoping of the familiar narrative of progress from darkness to enlightenment, ‘the clinical trial is routine in the development of new treatments and medical experts agree that evidence-based medicine is the key to effective health care’.

While it is true that evidence-based medicine (EBM) has made some useful contributions to contemporary medical practice, notably in the systematic use of randomised controlled trials in the study of therapeutic interventions, it is nonsense to claim that it has played a major role in the successes of modern medicine (such as vaccines, antibiotics, steroids, anaesthetics, surgical techniques) which arose from developments in the basic medical sciences.”

“To some of its critics, in its disparagement of theory and its crude number-crunching, EBM marks a return to ‘empiricist quackery’ in medical practice.”

“Why are so many GPs tolerating, promoting or even using bogus treatments?’ is the provocative question posed by Singh and Ernst to my colleagues in primary health care. They consider various possibilities (though they do not seem to apply their commitment to an evidence-based approach to their speculations in this area). Could it be that GPs are simply ignorant of the facts that alternative medicine is useless? They raise the possibility that some GPs may be true believers in alternative therapies, but – understandably – find this too terrifying a subject to investigate further. They believe that many GPs are so inconsiderate towards their patients that this drives them into the sympathetic, empathetic arms of alternative therapists. But for them the most likely explanation is that GPs are simply lazy and respond to their patients’ relentless minor complaints by ‘fobbing them off with placebos’, in the form of ‘bogus remedies’ and referrals to alternative therapists.”

“Singh and Ernst criticise GPs for ‘encouraging patients’ to seek out alternative therapists. In a bizarre parallel with the world of drug addiction, they argue that ‘introducing patients to alternative therapists in relation to a minor condition could act as a gateway to a longer-term reliance’. One taste of a (tasteless) homeopathic pill or twist of an acupuncture needle could lead to a serious habit, and they may end up refusing vaccinations and stopping prescription drugs.

This is getting silly.”

I have received the following further comments from Ralf Jeutter PhD RSHom:

“The quotes from the book presented by Fitzpatrick show how superficial Singh and Ernst’s critique is. It is primarily based on the assumption that EBM is a reliable tool with which to judge treatments, totally ignoring that EBM is far from accepted as that.  Fitzpatrick calls it ‘incoherent advice to doctors’; the ‘founder’ of EBM, Sackett, wrote: ‘EBM … never replaces clinical skills, clinical judgment and clinical experience’, thus refuting in one single sentence everything Ernst claims: that EBM is the most reliable and generally accepted standard for assessing clinical effectiveness.

Ernst is a dramatiser who has lost perspective of real academic/scientific issues when he writes that ‘prior to the development of evidence-based medicine, doctors were spectacularly ineffective.’ If he really means this it is clear that he has an utterly uncritical enthusiasm for what is only the latest fashion in medicine, one that is neither established nor universally accepted. The one appeal it has is its mind numbing simplicity, which totally ignores clinical realities.

The review also highlights how desperate Ernst is to find ANYTHING to discredit CAM: apparently it is habit forming on a par with, well, seriously habit forming things. Rightly Fitzpatrick says: ‘This is silly’.

Ernst loses academic credibility by refusing to acknowledge the real complexity of research into CAM. Moreover he refuses to acknowledge that most conventional treatments and interventions are not evidence based. He has found a way of making headlines by propagating very crude science indeed. His academic status is further undermined by acting much more like a quackbuster of recent years than as somebody who should be encouraging more research (including research methodologies into CAM) to benefit the profession and patients.

It really does not become a Professor of CAM to dismiss such a longstanding and successful practice like homeopathy as ‘bogus’ and ‘nonsense’. As an academic he has had to make a determined effort to ignore the plethora of research which has grown around homeopathy over the last 200 years: pre-clinical fundamental research; fundamental research into physics and chemistry as far as it has a bearing on homeopathy; experiments on plants with ultra-high dilutions; experiments on animals and animal tissue with ultra-high dilutions; in-vitro studies; clinical studies, be they observational or comparative studies; controlled studies of nosological clinical homeopathy to randomised clinical isopathic and epidemiological studies. He has also ignored the dedicated hard work of many researchers into CAM and associated fields: dismissing all of this as useless activity which has yielded nothing and will never yield anything. I think it would suit Prof. Ernst to show more respect to his colleagues and a modicum of modesty.

Ernst has come to the conclusion that homeopathy doesn’t work by cherry-picking what he considers to be state-of-the-art research methodologies, which conflict in many instances with clinical realities.

It appears that it is Ernst’s desire to call a premature end to homeopathy which informs his understanding of ‘science’. Homeopathy has survived many fads, fashions and detractors, and will no doubt survive this latest attempt at discrediting it. In my own modest predicition, Ernst, in all likelihood, will become a footnote in the history of homeopathy, like so many before him.  He is an academic who mistakes scientific models with reality.”

Wholesale scorn on complementary medicine is unscientific.

Madeleine Bunting (at my least favourite newspaper ‘The Guardian’ since ‘I’m a cuddly junior doctor/you’re-making-it-up-psychiatrist’ Ben Goldacre’s devoid of any twisted homeopathic facts propaganda piece) makes some pertinent points about the state of Sceptic-Woo wars in complementary medicine.  I disagree that homeopathy is ‘just placebo’ as the benefits of homeopathic treatment can be much more profound than just ‘feeling better’ or ‘removal of symptoms’ but otherwise I agree with her thinking:

“Suckers: How Alternative Medicine Makes Fools of Us All; Snake Oil Science; and next month sees another, Trick or Treatment: what these new books have in common is varying degrees of frustration at the seemingly inexorable rise of complementary medicine. It seems the aim of some of these authors is to finish off a burgeoning health industry that they believe is based on charlatans and quacks preying on the gullible and desperate.

The books reflect the growing exasperation in some quarters that public opinion is not as amenable to persuasion and scientific evidence as they would hope. The language gets lurid; the mood music to pronouncements on complementary medicine is increasingly alarmist – we are living in dangerous times, an unEnlightenment looms as tides of irrationality threaten to overwhelm the palisades erected by science. “Reason is a precious but fragile thing,” declared Richard Dawkins in his series, The Enemies of Reason, last autumn. “Reason has liberated us from superstition and given us centuries of progress. We abandon it at our peril.”

What so troubles these science warriors is that it is estimated a third of people in the UK now use complementary medicine, at a cost of £1.5bn a year. In the US, the figures are substantially higher; it has been calculated that more visits are made to healing therapists than to doctors. There is an extraordinary paradox here: a half-century of astonishing conventional medical advances has not succeeded in eliminating complementary medicine. Quite the reverse: the breakthroughs in conventional medicine have been accompanied by the proliferation of other forms of healing – many of which have little or no evidence base to prove their efficacy. Indeed, it only takes a short surf on the web to discover that the wilder shores of this burgeoning industry are, well, pretty wild.

To the science warriors, this bizarre state of affairs can only be explained by irrationality. They bemoan the state of science education and lament how, contrary to expectation, literacy and access to information have failed to eradicate superstition. Meanwhile, in this increasingly sharply polarised debate, complementary medicine practitioners are equally exasperated by what they see as blinkered scientific reductionism.

So it takes a brave scientist to launch into this territory and risk getting attacked from both camps by daring to ask a simple question: is there anything science can learn from complementary medicine? That is precisely what Kathy Sykes is doing in her current television series, Alternative Therapies (the second programme is on BBC2 tonight). As Bristol University’s professor of public engagement in science and the director of the Cheltenham Festival of Science, no one can challenge her credentials as a scientist, yet her scrutiny of particular therapies throws up serious challenges to conventional medicine.

Sykes is too good a scientist to give complementary medicine an easy run. Tonight she examines reflexology, and gives it pretty short shrift. There are 30,000 reflexologists working on a million British feet a year. They base their work on a theory that parts of the sole of the foot correlate to organs in the body. The only problem is that Sykes could find no one, reflexologist or scientist, who could explain how these correlations might work. Furthermore, it turned out that this “ancient” healing system seems to have originated with an imaginative American woman in the 1930s. But patients swear by it. One reflexologist points Sykes to her annual garden party full of babies and children as evidence of the success she has had with infertility problems. This is the point where most scientists snort with derision at the use of personal anecdote as evidence, but Sykes presses on and it takes her into two areas of scientific research. First, she digs up new research on the importance of touch, which can have a profound impact on the brain. Even the hand of a stranger reduces anxiety and that of someone with whom one has a close relationship is even more significant. In fact, Sykes finds some scientific underpinning which goes beyond placebo in many of the therapies she looks at. But it is placebo which emerges as a recurrent and crucially important thread in her quest, and it leads her to the work of several American scientists who are trying to identify what placebo is, who it works for, and why it works.

This is one of the most common charges made against complementary medicine – that most of it is no better than placebo. But there is a way of turning that accusation around: perhaps complementary medicine is an effective way to harness placebo as one of the most powerful – and cheapest – of healing processes. Rather than being derogatory about the phenomenon as “just” placebo, perhaps we should see it as one of the most remarkable and little understood aspects of the human body.

That line of inquiry has taken Sykes to the US several times over the course of the two series she has made. There placebo has become a new frontier in medicine. In a range of studies with startling results – even sham knee surgery can be as effective as the real thing – many factors contribute to placebo: the confidence of the doctor; the social, cultural expectations around the procedure; the empathy and warmth of the patient-doctor relationship; the patient’s degree of faith. Get all these right, and the outcome can be remarkable. Harvard professor Ted Kaptchuk is publishing a study this week which shows that placebo is as good as any conventional treatment available for irritable bowel syndrome. Given that the eight most industrialised nations spend $40bn a year on medication for this condition, that’s revolutionary stuff.

This kind of research into placebo gives some insight into why complementary medicine has boomed and why there are so many people who cite their own experience to passionately defend it. The average consultation with a GP is 4.6 minutes, while the complementary therapist can devote an hour to taking detailed personal histories. That time and relationship provide a context and an opportunity for the ritual and recasting of personal experience which Kaptchuk believes are the crucial elements of placebo.

Complementary medicine is most popular where conventional medicine fails, such as with musculoskeletal conditions and mental health – stress, depression, anxiety (the recent revelations about the inefficacy of Prozac were another reminder of how shaky the science is in a large area of conventional medicine). Several complementary therapies are particularly effective at pain relief – you had to see Sykes’s footage of hypnotism helping a woman to have teeth extracted without anaesthetic to believe it. Kaptchuk argues that pain is not a static given but can be experienced dramatically differently.

Conventional medicine prolongs life but is less successful in prolonging good health – we can expect to spend more years of our life in poor health, as a government report showed last week – and in producing wellbeing. So people are voting with their feet, trying to find other ways to fill the gaps left by conventional medicine. We need scientists to help to identify what they are looking for and why, rather than pouring scorn indiscriminately on the whole field and on the relations between belief, mind and body, of which science still has such a fragmentary understanding.”