George and Pete go to Parliament

Four years ago, during the House of Commons Science and Technology Sub-Committee’s Evidence Check on Homeopathy, Dr. Peter Fisher of the (then named) Royal London Homeopathic Hospital, in response to subtly sardonic questioning from then Committee member Evan Harris, unashamedly said (@ 1: 34 → ), “The shaking is important… If you just gently stir it, it doesn’t work.” The Committee didn’t buy this physician’s belief that succussion (shaking water containing no active ingredient) works to potentise intended homeopathic remedies; however, it’s concluding recommendation that NHS funds not be frittered on homeopathy was subsequently ignored by PR-prioritising government… apparently because patient choice trumps rational decision making on public health policy.

Although homeopaths’ ‘evidence’ was deemed inconsequential back then, it was nevertheless afforded another airing last week (29 Oct’ 2013) during the HoC Select Committee for Health‘s third oral evidence session on the Management of Long-Term Conditions. Back came Fisher, of the (now renamed) Royal London Hospital for Integrated Medicine, alongside George Lewith, Head of the Complementary and Integrated Medicine Research Group at the University of Southampton. The Uncorrected Transcript of Oral Evidence is now available, if you want to form your own assessment of some of the statements given in ‘evidence’ by these ‘witnesses’. (And you can read the tweets of various sceptics who were listening in on this as it happened.)

When introducing himself, Fisher deemed it pertinent to inform the Committee that he is “physician to Her Majesty the Queen” (I’m not sure of the relevance here: because the Queen is an elderly person with long-term conditions? Wouldn’t most doctors have such patients/clients? Note he didn’t say he is homeopath to her). Upon being asked to clarify the phrase ‘integrated medicine’, he differentiated between vertical (primary and secondary) and horizontal (across secondary) care integration, deeming it necessary, as he talked, to clarify with respective up/down and side to side hand gestures, which had me wondering whether he was blessing the Committee. There then ensued much talk of ‘evidence’, with Fisher quickly endorsing acupuncture in pain control before happily (for a while) giving way to Lewith, who espoused at length on a “complex” issue. Lewith proceeded to (mis)inform the Committee that:

“The evidence in terms of specific therapies is very powerful for acupuncture, pretty powerful for some of the mindfulness meditation approaches and reasonably powerful for some of the herbal medicines. The evidence is probably non-existent in areas such as reflexology and aromatherapy and patchy in others, such as healing. So there are various levels of information that we have from rigorous randomised placebo-controlled trials.”

So, has Lewith commenced here by leading the Committee to believe that rigorous randomised placebo-controlled trials have provided very powerful evidence for acupuncture? This surely must have furrowed some Committee brows. Yet acupuncture has seemingly been around for so long, it seems to evade due challenge as to its effectiveness… for anything. No one on the Committee saw fit to query meridians, and Ch’i… and whether a belief in the effectiveness of acupuncture is predicated on belief in such ‘energy medicine’ nonsense.

Lewith then went on in confusing fashion, seemingly justifying an appeal to popularity as “a different kind of evidence.” Chronic, long-term conditions bring very high use of CAM. But what evidence is this? That CAM is effective; or that it provides something (else) that medicine does not? He apparently concedes repeatedly the involvement of placebo (a concession not so welcomed, I think, by Fisher), and the difficulties in investigating and evaluating this and other effects:

“Very often, the double-blind randomised controlled trial with a placebo is impossible to construct from a patient’s perspective in terms of a CAM intervention…”

seemingly contradicting his earlier statement on the “… information that we have from rigorous randomised placebo-controlled trials”, whilst denying that the assessment of evidence of CAM is different. Yet, let’s not look solely for opportunity to take swipe; Lewith does make valid statements:

“The most powerful treatment that most GPs have at their disposal in many chronic long-term conditions is the contextual effects of seeing the doctor. One of the ways we might develop evidence is to learn from the complementary therapies about what they do so effectively and reproduce it in conventional medicine.”

“If you ask the patients why they are using CAM, they talk about different kinds of consultations, consultation environments and empowerment processes and that is something that we really need to take notice of…”

and goes on to extol the importance of “contextual effects”, invoking a study from his own group, interpretable (among others) as questioning the very existence of homeopathy. Nothing to do with remedies, but all to do with “powerful and long-lasting” contextual effects. (Does this conclusion from ‘… a multi-centred placebo-controlled randomized double-blind exploratory clinical trial assessing homeopathy (remedy ± consultation) as an adjunctive treatment for RA (rheumatoid arthritis)’ contradict Lewith’s earlier assertion that the double blind randomised control trial is “impossible to construct from the patient perspective.”?)

But we know this already, do we not? Good care makes (unwell) people feel better – whether or not it actually improves their chronic, long-term condition, which, by definition, is irresolvable. But herein lies the ‘power’ of CAM – the attentive care. Why can we not concur on rejecting the associated nonsense and concentrate on improving care? It doesn’t require research funds for wasting on all the associated ‘energy’ nonsense: the sugar pilules, the shaken water, the needles, the shamanistic hands, the bullshit.

So, the sceptic might be encouraged by Lewith’s lengthy assertion on the importance of good care. Until he is asked:

“Is it about managing the pain and discomfort or is it about dealing with the underlying pathology?”

To which he replies “Both”, and reiterates the “good evidence for good acupuncture.”

Fisher, with the understatement of the day, concedes “there are problems with interpretation of studies”, before resorting to one of CAM’s misleading mantras:

“Treating people, not disease.”

I’ve never understood what this frequently encountered chestnut is supposed to mean. Fisher is both a consultant physician and a practicing homeopath. Is he therefore saying that, when performing as a physician, he ‘treats’ diseases (an odd scenario); but when he shape-shifts into the guise of homeopath, he then treats ‘the whole person’? And who decides which persona he adopts? Himself, or his patient by request? Thus, as he is “physician to HM the Queen”, what exactly is he doing when he administers to her?

Committee member Andrew Percy injects some common sense:

“Physiologically, delivering a homeopathic remedy does nothing to them, does it?”

And as you might guess, Fisher is by now becoming uncomfortable and goes on the defensive:

“I do homeopathy on patients with rheumatoid arthritis all the time and I would not do it for two minutes if I thought it was purely placebo. I have absolutely no qualms about maximising the non-specific effects of my consultation, but I do not think it is true that homeopathic medicines have no genuine real physiological effect.”

Which is apparently the opposite of the conclusion of Lewith’s study mentioned previously. Fisher is, of course, a prescriber of such remedies.

Committee member Sarah Wollaston questions reasonably:

“Why should not homeopathic remedies be subject to the same standards of proof through a randomised double-blind placebo-controlled trial?”

And then follows a somewhat tetchy exchange between Wollaston and Lewith, in which Lewith effectively admits that complementary approaches are, by and large, merely placebo. And finally resorts to argumentum ad ignorantiam: “We do not know.” In other words: “How do you know it doesn’t work?” Lewith appears to be positioning himself as neutral here (in which case, why is he present as a ‘witness’ for complementary approaches to the management of long-term health conditions?); but he surely knows full well that this tactic is a favourite fall-back of CAM apologists: those who believe, or want to believe, in the effectiveness of whatever modal version are more likely to resort to the “How do you know it doesn’t work?” fallacy. No answer is sufficient here; it’s a faith position: belief overrides rational logic.

Wollaston then attempts to refer Lewith back to his earlier statement on the lack of trial quality. And this is just too much for Fisher, who cuts across Wollaston in a defence of the quality of trials on homeopathy. This is actually uncomfortable viewing/listening, in which Fisher denies the effect of the context of consultation (in the studies he cites).

The Chair’s attempt to then move things on are immediately thwarted by the entry into proceedings of the Committee’s David Tredinnick. If you are familiar with the leanings of this member, you will not be at all surprised by how he positions himself: rather than as Committee juror whose job it is to question the witnesses, he spoon-feeds them ‘evidence’ (as he sees it) that he wants presented to the Committee, in effect serving as a third witness. There is blatant conflict here:

“… while we are on homeopathy, just to put this in another context, in the last Parliament the Science and Technology Committee ran an evidence check on homeopathy and decided that there was not much evidence out there, and since then, it is my understanding—and I would like your comment on this—that a lot of research has been done.”

As we might predict, Fisher readily picks up this baton, which Tredinnick takes as justification for his position:

“I think, from what I have heard, there has been a sea change since that report was done in 2009-10 by the Science and Technology Committee and I imagine that is something that that Committee might want to revisit to update itself.”

That Committee, on which now sits Tredinnick himself. This is quite disgraceful.

Following an exchange after interjection by Wollaston, Lewith, who had just stated:

“We are pretty rational people. We are just trying to present you with the evidence”

proceeds with resort to appeals to popularity (numbers of CAM practitioners in Europe) and authority (as handily provided by authenticating registration bodies). And Tredinnick then invites Fisher to comment on the popularity (satisfaction rating) of his hospital… again impressing his own outcome preference on the committee. Fisher proclaims proudly that it was his hospital that introduced acupuncture into the NHS in the 1970s. There we have it… Fisher’s hospital initiated the wasting of NHS funding on a placebo.

Tredinnick finishes his slot with:

“There is a vast amount of money spent on research every year. Do you think there is enough spent on establishing the effectiveness of these integrated therapies?”

Though he knows the answer – not just because Lewith had just provided it – he is more than happy to allow Lewith to continue this line.

There’s more if you want to follow the session, or read the transcript. And see if you sense a tension at work. It strikes me that Lewith acknowledges that placebo and context are real effects, whereas Fisher is not so comfortable conceding such.  As ‘witnesses’, they often appear to be singing from different hymn sheets. Either way, if their aim is more funding for research into CAM’s effectiveness in the management of long-term conditions – and hence (further) NHS integration – I’m not at all clear on what there is to research. We know the answer, don’t we?

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