Science Based Nutrition

February 18, 2010

December 17, 2009

Comedy gold in parliament and tragedy from Prince of Wales: editorial in British Medical Journal

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The Yuletide edition of the BMJ carries a lovely article by Jeffrey Aronson, Patent medicines and secret remedies. (BMJ 2009;339:b5415).

I was delighted to be asked to write an editorial about it, In fact it proved quite hard work, because the BMJ thought it improper to be too rude about the royal family, or about the possibility of Knight Starvation among senior medics. The compromise version that appeared in the BMJ is on line (full text link).

The changes were sufficient that it seems worth posting the original version (with links embedded for convenience).

The cuts are a bit ironic, since the whole point of the article is to point out the stifling political correctness that has gripped the BMA, the royal colleges, and the Department of Health when it comes to dealing with evidence-free medicine. It has become commonplace for people to worry about the future of the print media, The fact of the matter is you can often find a quicker. smarter amd blunter response to the news on blogs than you can find in the dead tree media. I doubt that the BMJ is in any danger of course. It has a good reputation for its attitude to improper drug company influence (a perpetual problem for clinical journals) as well as for clinical and science articles.  It’s great to see its editor, Fiona Godlee, supporting the national campaign for reform of the libel laws (please sign it yourself). 

The fact remains that when it comes to the particular problem of magic medicine, the action has not come from the BMA, the royal colleges, and certainly not from the Department of Health, It has come from what Goldacre called the “intrepid, ragged band of bloggers”. They are the ones who’ve done the investigative journalism, sent complaints and called baloney wherever they saw it. This article was meant to celebrate their collective efforts and to celebrate the fact that those efforts are beginning to percolate upwards to influence the powers that be.

It seems invidious to pick on one example, but if you want an example of beautiful and trenchant writing on one of the topics dealt with here, you’d be better off reading Andrew Lewis’s piece "Meddling Princes, Medical Regulation and Licenses to Kill” than anything in a print journal.

I was a bit disappointed by removal of the comment about the Prince of Wales.  In fact I’m not particularly republican compared with many of my friends.  The royal family is clearly good for the tourist industry and that’s important.  Since Mrs Thatcher (and her successors) destroyed large swathes of manufacturing and put trust in the vapourware produced by dishonest and/or incompetent bankers, it isn’t obvious how the UK can stay afloat.  If tourists will pay to see people driving in golden coaches, that’s fine.  We need the money.  What is absolutely NOT acceptable is for royals to interfere in the democratic political process.  That is what the Prince of Wales does incessantly.  No doubt he is well-meaning, but that is not sufficient.  If I wanted to know the winner of the 2.30 at Newmarket, it might make sense to ask a royal.  In medicine it makes no sense at all.  But the quality of the advice is irrelevant anyway.  The royal web site itself says “As a constitutional monarch, the Sovereign must remain politically neutral.”. Why does she not apply that rule to her son? Time to put him over your knee Ma’am?

Two of the major bits that were cut out are shown in bold, The many other changes are small.

BMJ editorial December 2009

Secret remedies: 100 years on

Time to look again at the efficacy of remedies

Jeffrey Aronson in his article [1] gives a fascinating insight into how the BMA, BMJ and politicians tried, a century ago, to put an end to the marketing of secret remedies.  They didn’t have much success. 

The problems had not improved 40 years later when A.J. Clark published his book on patent medicines [2]. It is astounding to see how little has changed since then.  He wrote, for example, “On the other hand the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”>  Clark himself was sued for libel after he’d written in a pamphlet “ ‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous”. Although he initially tried to fight the case, impending destitution eventually forced him to apologise [3].  If that happened today, the accusation would have been repeated on hundreds of web sites round the world within 24 hours, and the quack would, with luck, lose [4].

As early as 1927, Clark had written “Today some travesty of physical science appears to be the most popular form of incantation” [5].  That is even more true today.  Homeopaths regularly talk utter nonsense about quantum theory [6] and ‘nutritional therapists’ claim to cure AIDS with vitamin pills or even with downloaded music files.  Some of their writing is plain delusional, but much of it is a parody of scientific writing. The style, which Goldacre [7] calls ‘sciencey’, often looks quite plausible until you start to check the references.

A 100 years on from the BMA’s efforts, we need once again to look at the efficacy of remedies.  Indeed the effort is already well under way, but this time it takes a rather different form.  The initiative has come largely from an “intrepid, ragged band of bloggers” and some good journalists, helped by many scientific societies, but substantially hindered by the BMA, the Royal Colleges, the Department of Health and a few vice-chancellors.  Even NICE and the MHRA have not helped much.  The response of the royal colleges to the resurgence in magic medicine that started in the 1970s seems to have been a sort of embarrassment.  They pushed the questions under the carpet by setting up committees (often populated with known sympathizers) so as to avoid having to say ‘baloney’.  The Department of Health, equally embarrassed, tends to refer the questions to that well-known medical authority, the Prince of Wales (it is his Foundation for Integrated Health that was charged with drafting National Occupational Standards in make-believe subjects like naturopathy [8].

Two recent examples suffice to illustrate the problems.

The first example is the argument about the desirability of statutory regulation of acupuncture, herbal and traditional Chinese medicine (the Pittilo recommendations) [9].

Let’s start with a definition, taken from ‘A patients’ guide to magic medicine’ [10]. “Herbal medicine: giving patients an unknown dose of an ill-defined drug, of unknown effectiveness and unknown safety”.

It seems to me to be self-evident that you cannot start to think about a sensible form of regulation unless you first decide whether what you are trying to regulate is nonsense, though this idea does not seem to have penetrated the thinking of the Department of Health or the authors of the Pittilo report.  The consultation on statutory regulation has had many submissions [11] that point out the danger to patients of appearing to give official endorsement of treatments that don’t work.  The good news is that there seems to have been a major change of heart at the Royal College of Physicians.  Their submission points out with admirable clarity that the statutory regulation of things that don’t work is a danger to patients (though they still have a blank spot about the evidence for acupuncture, partly as a result of the recent uncharacteristically bad assessment of the evidence by NICE [12]).  Things are looking up.  Nevertheless, after the public consultation on the report ended on November 16th, the Prince of Wales abused his position to make a well-publicised intervention on behalf of herbalists [13]Sometimes I think his mother should give him a firm lesson in the meaning of the term ‘constitutional monarchy’, before he destroys it.

The other example concerns the recent ‘evidence check: homeopathy’ conducted by the House of Commons Science and Technology Select Committee (SCITECH). First the definition [10]: “Homeopathy: giving patients medicines that contain no medicine whatsoever”.  When homeopathy was dreamt up, at the end of the 18th century, regular physicians were lethal blood-letters, and it’s quite likely that giving nothing saved people from them.  By the mid-19th century, discoveries about the real causes of disease had started, but homeopaths remain to this day stuck in their 18th century time warp. 

In 1842 Oliver Wendell Holmes said all that needed to be said about medicine-free medicine [14].  It is nothing short of surreal that the UK parliament is still discussing it in 2009.  Nevertheless it is worth watching the SCITECH proceedings [15].  The first two sessions are fun, if only for the statement by the Professional Standards Director of Boots that they sell homeopathic pills while being quite aware that they don’t work.  I thought that was rather admirable honesty.  Peter Fisher, clinical director of the Royal Homeopathic Hospital, went through his familiar cherry-picking of evidence, but at least repeated his condemnation of the sale of sugar pills for the prevention of malaria. 

But for pure comedy gold, there is nothing to beat the final session.  The health minister, Michael O’Brien, was eventually cajoled into admitting that there was no good evidence that homeopathy worked but defended the idea that the taxpayer should pay for it anyway.  It was much harder to understand the position of the chief scientific advisor in the Department of Health, David Harper.  He was evasive and ill-informed.  Eventually the chairman, Phil Willis, said “No, that is not what I am asking you. You are the Department’s Chief Scientist. Can you give me one specific reference which supports the use of homeopathy in terms of Government policy on health?”.  But answer came there none (well, there were words, but they made no sense). 

Then at the end of the session Harper said “homeopathic practitioners would argue that the way randomised clinical trials are set up they do not lend themselves necessarily to the evaluation and demonstration of efficacy of homeopathic remedies, so to go down the track of having more randomised clinical trials, for the time being at least, does not seem to be a sensible way forward.”  Earlier, Kent Woods (CEO of the MHRA) had said “the underlying theory does not really give rise to many testable hypotheses”.  These two eminent people seemed to have been fooled by the limp excuses offered by homeopaths.  The hypotheses are testable and homeopathy, because it involves pills, is particularly well suited to being tested by proper RCTs (they have been, and when done properly, they fail).  If you want to know how to do it, all you have to do is read Goldacre in the Guardian [16].

It really isn’t vert complicated.   “Imagine going to an NHS hospital for treatment and being sent away with nothing but a bottle of water and some vague promises.”  “And no, it’s not a fruitcake fantasy. This is homeopathy and the NHS currently spends around £10million on it.”

That was written by health journalist Jane Symons, in The Sun [17].  A Murdoch tabloid has produced a better account of homeopathy than anything that could be managed by the chief scientific advisor to the Department of Health.  And it isn’t often that one can say that.

These examples serve to show that the medical establishment is slowly being dragged, from the bottom up, into realising that matters of truth and falsehood are more important than their knighthoods.  It is all very heartening, both for medicine and for democracy itself.

David Colquhoun.

Declaration of interests. I was A.J. Clark chair of pharmacology at UCL, 1985 – 2004.

1.  Aronson, JK BMJ 2009;339:b5415

2.  Clark, A,J, (1938) Patent Medicines FACT series 14, London.  See also Patent medicines in 1938 and now  http://www.dcscience.net/?p=257
(A.J. Clark FRS was professor of Pharmacology at UCL from 1919 to 1926, and subsequently in Edinburgh).

3.  David Clark “Alfred Joseph Clark, A Memoir” (C. & J. Clark Ltd 1985 ISBN 0-9510401-0-3)

4.  Lewis, A. (2007) The Gentle Art of Homeopathic Killing

5.  A.J. Clark (1927) The historical aspect of quackery, BMJ October 1st 1927

6.  Chrastina, D  (2007) Quantum theory isn’t that weak,  (response to Lionel Milgrom).

7  Goldacre, B. (2008) Bad Science. HarperCollins

8. Skills for Health web site
   The ‘competences’ have been revised since the account at http://www.dcscience.net/?p=215#sfh, but are still preposterous make believe.

9. A very bad report: gamma minus for the vice-chancellor

10. A Patients’ Guide to Magic Medicine,  and also in the Financial Times.

11.  An excellent submission to the consultation on statutory regulation of alternative medicine (Pittilo report)

12.  NICE fiasco, part 2. Rawlins should withdraw guidance and start again

13. BBC news 1 December 2009 Prince Charles: ‘Herbal medicine must be regulated’.

14.  Oliver Wendell Holmes (1842) Homeopathy and Its Kindred Delusions.

15.  House of Commons Science and technology committee. Evidence check: homeopathy. Videos and transcripts available at  http://www.viewista.com/s/fywlp2/ez/1

16.  Goldacre, B.  A Kind of Magic  Guardian  16 November 2007.

17.   Homeopathy is resources drain says
Jane Symons.  The Sun 2 December 2009. 

Follow-up

There is a good account of the third SCITECH session by clinical science consultant, Majikthyse, at The Three Amigos.

16 December 2009.. Recorded an interview for BBC Radio 5 Live. It was supposed to go out early on 17th.

17 December 2009.  The editorial is mentioned in Editor’s Choice, by deputy editor Tony Delamothe. I love his way of putting the problem "too many at the top of British medicine seem frozen in the headlights of the complementary medicine bandwagon".  He sounds remarkably kind given that I was awarded (by the editor, Fiona Godlee, no less) a sort of booby prize at the BMJ party for having generated a record number of emails during the editing of a single editorial (was it really 24?). Hey ho.

17 December 2009.  More information on very direct political meddling by the Prince of Wales in today’s Guardian, and in Press Association report.

17 December 2009Daily Telegraph reports on the editorial, under the heading “ ‘Nonsense’ alternative medicines should not be regulated“. Not a bad account for a non-health journalist.

17 December 2009. Good coverage in the excellent US blog, Neurologica, by the superb Steven Novella.’ “Intrepid, Ragged Band of Bloggers” take on CAM‘ provides a chance to compare and contrast the problems in the UK and the USA.’

18 December 2009.  Article in The Times by former special advisor, Paul Richards. “The influence of Prince Charles the lobbyist is out of hand. Our deference stops us asking questions.”

“A good starting point might be publication of all correspondence over the past 30 years. Then we will know the extent, and influence, of Prince Charles the lobbyist.”

Comments in the BMJ Quite a lot of comments had appeared by January 8th, though sadly they were mostly from the usual suspects who appear every time one suggests evidence matters. A reply was called for, so I sent this (the version below has links).

After a long delay, this response eventually appeared in the BMJ on January 15 2010.

It’s good to see so many responses, though somewhat alarming to see that several of them seem to expect an editorial to provide a complete review of the literature.  I ‘ll be happy to provide references for any assertion that I made.

I also find it a bit odd that some people think that an editorial is not the place to express an opinion robustly.  That view seems to me to be a manifestation of the very sort of political correctness that I was deploring.  It’s a bit like the case when the then health minister, Lord Hunt, referred to psychic surgery as a “profession” when he should have called it a fraudulent conjuring trick.  Anything I write is very mild compared with what Thomas Wakley wrote in the Lancet, a journal which he founded around the time UCL came into existence. For example (I quote)

“[We deplore the] “state of society which allows various sets of mercenary, goose-brained monopolists and charlatans to usurp the highest privileges…. This is the canker-worm which eats into the heart of the medical body.” Wakley, T. The Lancet 1838-9, 1 

I don’t think it is worth replying to people who cite Jacques Benveniste or Andrew Wakefield as authorities.  Neither is it worth replying to people who raise the straw man argument about wicked pharmaceutical companies (about which I am on record as being as angry as anyone).  But I would like to reply directly to some of the more coherent comments.

Sam Lewis and Robert Watson. [comment] Thank you for putting so succinctly what I was trying to say.

Peter Fisher [comment].  I have a lot of sympathy for Peter Fisher.  He has attempted to do some good trials of homeopathy (they mostly had negative outcomes).  He said he was "very angry" when the non-medical homeopaths  were caught out recommending their sugar pills for malaria prevention (not that this as stopped such dangerous claims which are still commonplace).  He agreed with me that there was not sufficient scientific basis for BSc degrees in homeopathy.  I suppose that it isn’t really surprising that he continues to cherry pick the evidence.  As clinical director of the Royal London Homeopathic Hospital and Homeopathic physician to the Queen,  just imagine the cognitive dissonance that would result if he were to admit publicly that is all placebo after all.  He has come close though. His (negative) trial for homeopathic treatment of rheumatoid arthritis included the words "It seems more important to define if homeopathists can genuinely control patients’ symptoms and less relevant to have concerns about whether this is due to a ‘genuine’ effect or to influencing the placebo response” [2]. [download
the paper
].  When it comes to malaria, it matters a lot.

Adrian White [comment] seems to be cross because I cited my own blog.   I did that simply because if he follows the links there he will find the evidence.  In the case of acupuncture it has been shown time after time that "real" acupuncture does not differ perceptibly from sham.  That is true whether the sham consists of retractable needles or real needles in the "wrong" places.  A non-blind comparison between acupuncture and no acupuncture usually shows some advantage for the former but it is, on average, too small to be of much clinical significance [3]. I agree that there is no way to be sure that this advantage is purely placebo effect but since it is small and transient it really doesn’t matter much.  Nobody has put it more clearly than Barker Bausell in his book, Snake Oil Science [4]

White also seems to have great faith in peer review.  I agree that in real science it is probably the best system we have.  But in alternative medicine journals the "peers" are usually other true believers in whatever hocus pocus is being promoted and peer reveiw breaks down altogether.

R. M. Pittilo [comment] I’m glad that Professor Pittlo has replied in person because I did single out his report for particular criticism.  I agree that his report said that NHS funding should be available to CAM only where there is evidence of efficacy.  That was not my criticism.  My point was that in his report, the evidence for efficacy was assessed by representatives of Herbal Medicine, Chinese Medicine and Acupuncture (four from each).  Every one of them would have been out of work if they had found their subjects were nonsense and that, no doubt, explains why the assessment was so bad.  To be fair, they did admit that the evidence was not all that it might be and recommended (as always) more research   I’d like to ask Professor Pittilo how much money should be spent on more research in the light of the fact that over a billion dollars has been spent in the USA on CAM research without producing a single useful treatment.  Pittilo says "My own view is that both statutory regulation and the quest for evidence should proceed together" but he seems to neglect the possibility that the quest for evidence might fail. Experience in the USA suggests that is exactly what has, to a large extent, already happened.

I also find it quite absurd that the Pittilo report should recommend, despite a half-hearted admission that the evidence is poor, that entry to these subjects should be via BSc Honours degrees.  In any case he is already thwarted in that ambition because universities are closing down degrees in these subjects  having realised that the time to run a degree is after, not before, you have some evidence that the subject is not nonsense.  I hope that in due course Professor Pittilo may take the same action about the courses in things like homeopathy that are run by the university of which he is vice-chancellor.  That could only enhance the academic reputation of Robert Gordon’s University.

George Lewith [comment]  You must be aware that the proposed regulatory body, the Health Professions Council, has already broken its own rules about "evidence-based practice" by agreeing to take on, if asked, practitioners of Herbal Medicine, Chinese Medicine and Acupuncture.  They have (shamefully) excluded the idea that claims of efficay would be regulated.  In other word they propose to provide exactly the sort of pseudo-regulation which would endanger patients   They are accustomed to the idea that regulation is to do only with censoring practitioners who are caught in bed with patients.  However meritiorious that may be, it is not the main problem with pseudo-medicine, an area in which they have no experience.  I’m equally surprised that Lewith should recommend that Chinese evaluation of Traditonal Chinese medicine should be included in meta-analyses, in view of the well-known fact that 99% of evaluations from China are positive: “No trial published in China or Russia/USSR found a test treatment to be ineffective” [5]. He must surely realise that medicine in China is a branch of politics.  In fact the whole resurgence in Chinese medicine and acupuncture in post-war times has less to do with ancient traditions than with Chinese nationalsim, in particular the wish of Mao Tse-Tung to provide the appearance of health care for the masses (though it is reported that he himself preferred Western Medicine).

1. Lord Hunt thinks “psychic surgery” is a “profession”. http://www.dcscience.net/?p=258

2. Fisher, P. Scott, DL. 2001 Rheumatology 40, 1052 – 1055.   [pdf file]

3. Madsen et al, BMJ 2009;338:a3115  [pdf file]

4. R, Barker Bausell, Snake Oil Science, Oxford University Press, 2007

5. Vickers, Niraj, Goyal, Harland and Rees (1998, Controlled Clinical Trials, 19, 159-166) “Do Certain Countries Produce Only Positive Results? A Systematic Review of Controlled Trials”. [pdf file]

15 January 2010. During the SciTech hearings, Kent Woods (CEO of the MHRA) made a very feeble attempt to defend the MHRA’s decision to allow misleading labelling of homeopathic products. Now they have published their justification for this claim. It is truly pathetic, as explained by Martin at LayScience: New Evidence Reveals the MHRA’s Farcical Approach to Homeopathy. This mis-labelling cause a great outcry in 2006, as documented in The MHRA breaks its founding principle: it is an intellectual disgrace, and Learned Societies speak out against CAM, and the MHRA.

22 January 2010 Very glad to see that the minister himself has chosen to respond in the BMJ to the editorial

Rt Hon. Mike O’Brien QC MP, Minister of State for Health Services

I am glad that David Colquhoun was entertained by my appearance before the Health Select Committee on Homeopathy. But he is mistaken when he says, “you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense.”

Regulation is about patient safety. Acupuncture, herbal and traditional Chinese medicine involve piercing the skin and/or the ingestion of potentially harmful substances and present a possible risk to patients.

The Pittilo Report recommends statutory regulation and we have recently held a public consultation on whether this is a sensible way forward.

Further research into the efficacy of therapies such as Homeopathy is unlikely to settle the debate, such is the controversy surrounding the subject. That is why the Department of Health’s policy towards complementary and alternative medicines is neutral.

Whether I personally think Homeopathy is nonsense or not is besides the point. As a Minister, I do not decide the correct treatment for patients. Doctors do that. I do not propose on this occasion to interfere in the doctor-patient relationship.

Here is my response to the minister

I am very glad that the minister himself has replied. I think he is wrong in two ways, one relatively trivial but one very important.

First, he is wrong to refer to homeopathy as controversial. It is not. It is quite the daftest for the common forms of magic medicine and essentially no informed person believes a word of it. Of course, as minister, he is free to ignore scientific advice, just as the Home Secretary did recently. But he should admit that that is what he is doing, and not hide behind the (imagined) controversy.

Second, and far more importantly, he is wrong, dangerously wrong, to say it I was mistaken to claim that “you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense". According to that view it would make sense to grant statutory regulation to voodoo and astrology. The Pittilo proposals would involve giving honours degrees in nonsense if one took the minister’s view that it doesn’t matter whether the subjects are nonsense or not. Surely he isn’t advocating that?

The minister is also wrong to suppose that regulation, in the form proposed by Pittilo, would do anything to help patient safety. Indeed there is a good case to be made that it would endanger patients (not to mention endangering tigers and bears). The reason for that is that the main danger to patients arises from patients being given “remedies” that don’t work. The proposed regulatory body, the Health Professions Council, has already declared that it is not interested in whether the treatments work or not. That in itself endangers patients. In the case of Traditional Chinese Medicine, there is also a danger to patients from contaminated medicines. The HPC is not competent to deal with that either. It is the job of the MHRA and/or Trading Standards. There are much better methods of ensuring patient safety that those proposed by Pittilo.

In order to see the harm that can result from statutory regulation, it is necessary only to look at the General Chiropractic Council. Attention was focussed on chiropractic when the British Chiropractic Association decided, foolishly, to sue Simon Singh for defamation. That led to close inspection of the strength of the evidence for their claims to benefit conditions like infant colic and asthma. The evidence turned out to be pathetic, and the result was that something like 600 complaints were made to the GCC about the making of false health claims (including two against practices run by the chair of the GCC himself). The processing of these complaints is still in progress, but what is absolutely clear is that the statutory regulatory body, the GCC, had done nothing to discourage these false claims. On the contrary it had perpetrated them itself. No doubt the HPC would be similarly engulfed in complaints if the Pittilo proposals went ahead.

It is one thing to say that the government chooses to pay for things like homeopathy, despite it being known that they are only placebos, because some patients like them. It is quite another thing to endanger patient safety by advocating government endorsement in the form of statutory regulation, of treatments that don’t work.

I would be very happy to meet the minister to discuss the problems involved in ensuring patient safety. He has seen herbalists and other with vested interests. He has been lobbied by the Prince of Wales. Perhaps it is time he listened to the views of scientists too.

Both the minister’s response, and my reply, were reformatted to appear as letters in the print edition of the BMJ, as well as comments on the web..

July 16, 2009

University of Central Lancashire stops its alternative medicine degrees (or does it?). Yes, it does!

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.The University of Central Lancashire (UCLAN) is the first place I asked to see teaching materials that were used on its homeopathy “BSc” course. The request was refused, and subsequent internal appeals were refused too, Clearly UCLAN had something to hide.

UClan-logo

An appeal to the information commissioner took almost two years to be judged, but the case was won. The eventual decision by the Information
Commissioner rejected all the grounds that UClan had used to evade the Freedom of Information Act.

UClan appealed against the judgement and I still haven’t got the stuff but that hardly matters now, because the course in question shut its doors. In any case, plenty of stuff from similar courses has leaked out already.

Meanwhile, in September 2008, UCLAN announced an internal review of all its courses in magic medicine, The review seemed to be genuine. For a start they asked me to give evidence to the review (something that no other university has done). They also asked Michael Eslea to give evidence. He is the UCLAN psychologist, whose magnificent open letter probably tipped the authorities into holding the review.

Just in case it is useful to anyone, here is a copy of the written evidence that I sent [download pdf],

Report of the Working Party on the Review of issues associated with Homeopathy, Acupuncture and Chinese Herbal Medicine

1. Introduction

As a consequence of concerns expressed by some colleagues within the University of Central Lancashire (UCLan) Dr Malcolm McVicar, Vice Chancellor appointed a working party to review the issues associated with the University offering courses in Homeopathy, Acupuncture and Chinese Herbal Medicine.

MEMBERSHIP:

Eileen Martin (Chair)                Pro-Vice Chancellor and Dean of Faculty of Health and Social Care 
Professor Gordon Bromage      Head of Centre for Astrophysics
Professor Malcolm Edmunds    Emeritus; Built and Natural Environment
Professor Doris Schroeder        Director of Centre for Professional Ethics
Elaine Austin                               Project Manager, Faculty of Health and Social Care


The report was the subject of a special meeting of UCLAN’s Academic Board on 9th July 2009. The following resolutions were passed.

Resolutions

R1    That further minor revisions be made to the report prior to publication on the University’s website;

R2   That the University refrain from offering any practitioner-qualifying courses in Homeopathy, Acupuncture and Chinese Herbal Medicine until such disciplines have achieved statutory regulation status;

R3    That the University consider offering a limited number of postgraduate research studentships (leading to Masters by Research of PhD) to suitably qualified UCLan students and staff in these disciplines. They should have interdisciplinary supervisory teams to facilitate development of a broad range of research skills and to contribute to the generation of knowledge in CAM;

R4   That the University consider how more interdisciplinary teaching can be achieved, where appropriate, within both undergraduate and postgraduate teaching to facilitate greater exposure to subject expertise and different paradigms.

Resolutions 1, 3 and 4 say very little. Resolution 4 sounds thoroughly relativist. We are talking about medicine, about treating sick patients. There is only one “paradigm”. That is to find treatments that are as effective and safe as possible. There aren’t two sorts of medicine, regular and alternative. There is just medicine that works and medicine that doesn’t work. It’s a good illustration of DC’s rule number 2, “never trust anyone who uses the word paradigm”.

Resolution 2 is the really interesting one, because none if the topics, Homeopathy, Acupuncture and Chinese Herbal Medicine, is subject to statutory regulation.

If taken literally, resolution 2 means that all the UCLan courses in alternative medicine will close their doors. Bafflingly, this inevitable conclusion is not stated explicitly.

At least resolution 2 means that homeopathy, already closed, will stay closed. It is never likely to get statutory regulation.

For practical purposes, we can ignore for the moment the obvious fact that statutory regulation of nonsense subjects results only in nonsense. The only forms of alternative medicine that have got “statutory regulation” at the moment are chiropractic and osteopathy. The public has not been safeguarded by the General Chiropractic Council (GCC). The GCC, on the contrary, has endangered the public by allowing false health claims to be made with impunity. Perhaps the members of the review committee had not noticed that the Simon SIngh affair has resulted in almost 600 complaints being made to the GCC? The faith of the review in statutory regulation is clearly misplaced.

The Pittilo report is critical for what happens next

Acupuncture and Chinese Herbal Medicine are not subject to statutory regulation at present, so one would suppose that these degrees will close their doors too. However the infamous Pittilo report has proposed that they should become regulated by the Health Professions Council (HPC). The many problems of the Pittilo report have been documented here, in “A very bad report: gamma minus for the vice-chancellor“. There was also a high-profile critique of the report in The Times (and on this blog).

The HPC has, as one of its criteria for regulation, “evidence-based practice”. Disgracefully, the HPC has already shown its willingness to ignore its own rules and to act as statutory regulator for Acupuncture and Chinese Herbal medicine. This rather disgraceful behaviour is documented in “Health Professions Council ignores its own rules: the result is nonsense“.

The UCLAN report seems to assume that the recommendations of the Pittilo report will be accepted. But the long-awaited consultation has still not opened. We can be sure that when it does, the opposition to it will be very strong indeed.

The report in full

Here are a few comments on the report itself.    Download the full report (as of July 15th).

i have to say that when I visited Preston to give evidence, my views seem to be treated seriously, even sympathetically, so it was a great disappointment to see the outcome. So what’s wrong? The major disaster is declared early in the report.

Section 2, Context

The debate is centred on a number of key themes which relate to:-

1. The quality of and/or absence of an evidence base to support claims of the efficacy and benefits of such treatments, linked to issues of public safety/protection and professional regulation.

Sounds good. What matters about any sort of medicine is whether or not it works and whether it is safe. It therefore verges on the incredible that we read in section 4.1

“conclusions from research into the efficacy of the various CAM’s are outside the remit of this report.”

The whole point about CAM is that there is very little evidence that any of it works. So the review committee decided to ignore the most important problem of the lot.  I can’t see how any rational decision can be made without first deciding whether the treatment is better than placebo.  That, surely, is the main question, and it was dodged.

UCLAN has failed to grasp the nettle, just as the Department of Health has also consistently failed to do so.

Section 4,1  Efficacy   This section repeats the assertion, absurd to my mind, that it is possible to judge CAM courses while declining to assess whether they work or not.

Section 4.2 Role of Universities in Society.

There is universal agreement that critical thinking is crucial to the idea of a university, but the judgement of whether CAM teaches critical thinking is simply fudged. Again the report fails to grasp the nettle.

“Disagreements about critical thinking within CAMs arises because some will argue that such substantiation and assessment can occur within the discipline, whilst others will argue that the methodology for substantiation, that is evidence provision, is universal. As a result, the latter will demand that evidence is provided using methods from one field (e.g. randomised controlled trials) for use in another.”

Sadly, the report dodged the crucial judgement once again. The most obvious characteristic of every form of alternative medicine is their total lack of critical self-appraisal. It is very sad that the review committee could not bring itself to say so.

Section 4.4   Nomenclature of degrees

Recommendation
The nomenclature of courses, leading to a professional as well as an academic award, should reflect the professional route; for example Bachelor with Honours in Complementary Medicine, B Comp. Med.(Hons) or B Acupuncture (Hons).

This sounds to me like another truly pathetic fudge. What on earth is solved by changing the name of the degree? You’d still be teaching students the same load of gobbledygook and then letting them loose on sick people, whether you call it a Bachelor of Science, a Bachelor of Arts, or, as is recommended here, a Bachelor of nothing whatsoever.

Well, I suppose there is a (doubtless unintended) irony in calling CAM degrees “Bachelor of nothing whatsoever”.

Section 4.4   Ethical, non-harm and economic considerations

This section list a lot of reasons why teaching alternative medicine should be unethical. but nevertheless manages to conclude that

” . . . it is not unethical to offer courses in Homeopathy, Acupuncture and Chinese Herbal Medicine at a university.”

I find the logic by which this bizarre conclusion was reached quite impossible to follow. Like much of the rest of the report this conclusion seems to stem from a reluctance to grapple with the really important questions, like ‘does it work or not?’.

Despite this the recommendation is perhaps the most interesting of all.

Recommendation
• The University refrains from offering any CAM courses until such disciplines have achieved statutory regulation status.”

This recommendation was accepted, and passed as a resolution at Academic Board. If it is implemented now, than there will be no more alternative medicine degrees next year at the University of Central Lancashire. If and when this happens, the University must be congratulated on its return to rational medicine.

Follow-up

Michael Eslea, UCLAN’s hero in resisting nonsense from the inside, has posted on this topic.

17 July 2009. It seemed odd that that no announcement was made about the future if the remaining CAM courses at UCLAN. So I asked deputy Vice-Chancellor Patrick McGhee for clarification. After a couple of days, I got this response.

From: CTheobald@uclan.ac.uk

To: d.colquhoun@ucl.ac.uk
Subject: uclan clarification

Hi David,

I have been asked to respond to your question below on the running of acupuncture and Chinese herbal medicine at UCLan. It is correct to assume that UCLan will not be taking any new entrants onto these programmes until further notice.

Best Wishes

Chris

Chris Theobald
Corporate Communications
University of Central Lancashire

So the report may have been disappointing, but it has done the job. As several people have pointed out in comments, it would be asking too much to expect a university to say “sorry we just noticed that we have been running junk-science courses for years”. But they have done the right thing anyway.

July 15, 2009

BMJ defends freedom of speech (but censors my comment)

Jump to follow-up

It’s good to see the BMJ joining the campaign for free speech (only a month or two behind the blogs). The suing of Simon Singh for defamation by the British Chiropractic Association has stirred up a hornet’s nest that could (one hopes) change the law of the land, and destroy chiropractic altogether. The BMJ’s editor, Fiona Godlee, has a fine editorial, Keep the libel laws out of science. She starts “I hope all readers of the BMJ are signed up to organised scepticism” and says

“Weak science sheltered from criticism by officious laws means bad medicine. Singh is determined to fight the lawsuit rather than apologise for an article he believes to be sound. He and his supporters have in their sights not only the defence of this case but the reform of England’s libel laws.”

Godlee refers to equally fine articles by the BMJ’s Deputy Editor, Tony Delamothe, Thinking about Charles II“, and by Editor in Chief, Harvey Marcovitch, “Libel law in the UK“.

free debate

The comments on Godlee’s editorial, show strong support, (apart from one from the infamous quantum fantasist, Lionel Milgrom). But there was one that slighlty surprised me, from Tricia Greenhalgh, author of the superb book, “How to read a paper”. She comments

“the use of the term ‘bogus’ seems both unprofessional and unscholarly. The argument would be stronger if expressed in more reserved terms”

That set me thinking, not for the first time, about the difference between journalism and scholarship. I can’t imagine ever using a word like ‘bogus’ in a paper about single ion channels. But Singh was writing in a newspaper, not in a scientific paper. Even more to the point, his comments were aimed at people who are not scholars and who, quite explicitly reject the normal standards of science and evidence. The scholarly approach has been tried for centuries, and it just doesn’t work with such people. I’d defend Singh’s language. It is the only way to have any effect. That is why I sent the following comment.

The ultimate irony is that the comment was held up by the BMJ’s lawyers, and has still to appear.

Thanks for an excellent editorial.

I doubt that it’s worth replying to Lionel Milgrom whose fantasy physics has been totally demolished by real physicists. Trisha Greenhalgh is, though, someone whose views I’d take very seriously. She raises an interesting question when she says “bogus” is an unprofessional word to use. Two things seem relevant.

First, there is little point in writing rational scholarly articles for a group of people who do not accept the ordinary rules of evidence or scholarship. We are dealing with fantasists. Worse still, we are dealing with fantasists whose income depends on defending their fantasies. You can point out to your heart’s content that “subluxations” are figment of the chiropractors’ imagination, but they don’t give a damn. They aren’t interested in what’s true and what isn’t.

Throughout my lifetime, pharmacologists and others have been writing scholarly articles about how homeopathy and other sorts of alternative medicine are bogus. All this effort had little effect.   What made the difference was blogs and investigative journalism.  When it became possible to reveal leaked teaching materials that taught students that “amethysts emit high yin energy“, and name and shame the vice-chancellors who allow that sort of thing to happen (in this case Prof Geoffrey Petts of Westminster University), things started to happen. In the last few years all five “BSc” degrees in homeopathy have closed and that is undoubtedly a consequence of the activities of bloggers and can assess evidence but who work more like investigative journalists. When the BCA released, 15 months after the event, its “plethora of evidence” a semi-organised effort by a group of bloggers produced, in less than 24 hours, thoroughly scholarly analyses of all of them (there is a summary here). As the editorial says, they didn’t amount to a hill of beans, They also pointed out the evidence that was omitted by the BCA. The conventional press just followed the bloggers. I find it really rather beautiful that a group of people who have other jobs to do, spent a lot of time doing these analyses, unpaid, in their own time, simply to support Singh, because they believed it is the right thing to do.

Simon Singh has analysed the data coolly in his book. But In the case that gave rise to the lawsuit he was writing in a newspaper. It was perfectly clear from the context what ‘bogus’ meant. but Mr Justice Eady (aided by a disastrous law) chose to ignore entirely the context and the question of truth. The description ‘bogus’. as used by Singh, seems to be entirely appropriate for a newspaper article. To criticise him for using “unprofessional” language is inappropriate because we are not dealing with professionals. At the heart of the problem is the sort of stifling political correctness that has resulted in quacks being referred to as “professions” rather than fantasists and fraudsters [of course I use the word fraudster with no implication that it necessarily implies conscious lying].

At least there are some laughs to be had from the whole sorry affair. Prompted by that prince among lawyers known as Jack of Kent there was a new addition to my ‘Patients’ Guide to Magic Medicine‘, as featured in the Financial Times.

Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant.

It is, perhaps, misplaced political correctness that lies at the heart of the problem. Who can forget the letter from Lord Hunt, while he was at the Department of Health, in which he described “psychic surgery” (one of the best known fraudulent conjuring tricks) as a “profession”.

Follow-up

Two days later, the comment has appeared in the BMJ at last. But it has been altered a bit.

Unprofessional language is appropriate when dealing with unprofessional people

Thanks for an excellent editorial.

I doubt that it’s worth replying to Lionel Milgrom whose fantasy physics has been totally demolished by real physicists. Trisha Greenhalgh is, though, someone whose views I’d take very seriously. She raises an interesting question when she says “bogus” is an unprofessional word to use. Two things seem relevant.

First, there is little point in writing rational scholarly articles for a group of people who do not seem to accept the ordinary rules of evidence or scholarship. You can point out to your heart’s content that “subluxations” are figment of the chiropractors’ imagination, but they don’t give a damn.

Throughout my lifetime, pharmacologists and others have been writing scholarly articles about how homeopathy and other sorts of alternative medicine are bogus. All this effort had little effect. What made the difference was blogs and investigative journalism. When it became possible to reveal leaked teaching materials that taught students that “amethysts emit high yin energy”, and name and shame the vice-chancellors who allow that sort of thing to happen (in this case Prof Geoffrey Petts of Westminster University), things started to happen. In the last few years all five “BSc” degrees in homeopathy have closed and that is undoubtedly a consequence of the activities of bloggers and can assess evidence but who work more like investigative journalists. When the BCA released, 15 months after the event, its “plethora of evidence” a semi-organised effort by a group of bloggers produced, in less than 24 hours, thoroughly scholarly analyses of all of them (there is a summary here). As the editorial says, they didn’t amount to a hill of beans, They also pointed out the evidence that was omitted by the BCA. The conventional press just followed the bloggers. I find it really rather beautiful that a group of people who have other jobs to do, spent a lot of time doing these analyses, unpaid, in their own time, simply to support Singh, because they believed it is the right thing to do.

Simon Singh has analysed the data coolly in his book. But In the case that gave rise to the lawsuit he was writing in a newspaper. It was perfectly clear from the context what ‘bogus’ meant. but Mr Justice Eady (aided by a disastrous law) chose to ignore entirely the context. The description ‘bogus’. as used by Singh, seems to be entirely appropriate for a newspaper article. To criticise him for using “unprofessional” language is inappropriate because we are not dealing with professionals.

At least there are some laughs to be had from the whole sorry affair. Prompted by that prince among lawyers known as Jack of Kent there was a new addition to my ‘Patients’ Guide to Magic Medicine’, as featured in the Financial Times.

Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant.

Here are the changes that were made. Hmm.very interesting.

changes made by lawyers

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