h2g2 The Hitchhiker's Guide to the Galaxy: Earth Edition

Maybe you would be interested in the following point of view on homeopathy and placebo effect:

http://www.martinwinckler.com/article.php3?id_article=667

kea, you've claimed that because each homeopathic (ideally) should treat the individual, it doesn't lend itself to bulk, double-blind studies.

Imagine then this study: A group of people with symptons/illness which seem similar (by western standards) are divided into 2 groups. One group is treated by the homeopathic method. The homeopathic healer can do whatever they want to any individual. The can do not need to be restricted in any way.

The second group is not treated in the real homeopathic method, but instead by a fake - something similar on the surface.

Can you explain why this study would fail to allow the individual treatment required by homeopathy?

>>"Potholer, I think it's pretty well recognised now that doctors have been misprescribing antibiotics for some of the reasons you say. But I think that aspect of 'if I give them this actually wrong drug it will help them get better' fits the general meaning of placebo."

If someone is thought to possibly have (or be at significant risk of) a secondary bacterial infection, antibiotics may be a perfectly valid treatment even for someone with an [assumed] viral infection. Taking a more 'holistic' view, having them stay at home and not come back to cough in the waiting room even if they don't feel better for a couple of days can have potential public health benefits even if it doesn't do the patient any good.

>>"But what if there was a treatment that could cure a believer but not a sceptic? Would you think it shouldn't be allowed?

No - I'd just think it probably meant there wasn't anything happening beyond a placebo effect, which could mean various other therapies might do about as well. Things shouldn't be allowed to be sold as treatments for anything but the most minor conditions without some information about how well they work.

Though there can certainly be a placebo effect happening with regular drugs, one of the points of conventional drug trials is to determine the potential *extra* value of the drug over and above the placebo effect obtained in the trial.
It's certainly true that the placebo effect obtained in such a trial may be less than might be obtained elsewhere (possibly partly due to people knowing they were taking part in a trial).

What I'm concerned about is therapists claiming that a particular action might or should help someone without obvious evidence, and/or extrapolation from conditions where placebo effects may be strong to conditions where they may not be.

If it helps the placebo effect for a therapist to be convinced a treatment (conventional or otherwise) works, one has to be wary of someone being so convinced their treatments work that they aren't really looking to see whether they do or not. Faith healing could be an extreme example of that. I'd imagine that the most confident (and possibly therefore 'best'?) healers may make good salespeople but relatively poor observers.
The best people to look at efficacy are probably people with the most open minds - that's one reason for 'reductionist' double-blind trials.

>>"You seem to want everything to be strictly physiologically medical, but it's not. Even medical people know that."

For a dirty *reductionist*, even the mental is physiological.

>> >>"(like the idea that anything 'natural' can only do good, despite the fact that many of the most toxic substances on the planet are entirely natural)."

>>"Well, I'd like to see the CAM training school that teaches that anything natural can only do good"

I've heard more than the odd vocal fan of herbal medicine use precisely that reasoning.
Do people have to be certified before being allowed to pontificate?

>>"CAM specialises in treatments that support the body in its own inherent healing capacities."

That's one of the claims. I just wonder where the evidence is.

>>"If you think that belief for instance should have nothing to do with it, then I doubt that you will ever understand how CAMs work."

Just *where* did I say I thought belief had nothing to do with it?
For some alternative treatments, belief is pretty evidently the only possible active constituent.

>>>
kea, you've claimed that because each homeopathic (ideally) should treat the individual, it doesn't lend itself to bulk, double-blind studies.
>>> Arnie

Actually, what I was saying was that the homeopath (the practitioner not the remedy) treats the individual not the illness. A homeopath could be presented with 5 different people all with the same illness and could prescribe 5 different remedies.


>>>
Imagine then this study: A group of people with symptons/illness which seem similar (by western standards) are divided into 2 groups. One group is treated by the homeopathic method. The homeopathic healer can do whatever they want to any individual. The can do not need to be restricted in any way.

The second group is not treated in the real homeopathic method, but instead by a fake - something similar on the surface.

Can you explain why this study would fail to allow the individual treatment required by homeopathy?
<<< Arnie

This is an interesting idea, and is one of the directions I would go in myself if thinking this through.

I don't think you could do a double-blind trial - from what I know of classical homeopathic prescribing I think that the practitioner needs to be the person doing the interview and the prescription. It's just more effective that way.

But you could do a single blind trial in the way you suggest (where the patient doesn't know if they are getting a remedy or a placebo).

What essentially you are suggesting is not just a trial to determine the efficacy, or lack of, of homeopathy in general (which presumably would be your purpost) but also the efficacy of the prescribing homeopath. I think you'd have to do a number of trials with a range of practitioners in order to rule out other variables (eg an exceptionally compassionate practitioner for instance might get a higher placebo rate. And bear in mind that most medical trials have a significant placebo rates so what we are looking for is action above the placebo rate. Or you might get a really crap practitioner who's success rate is really low).

I think doing a 3 way trial would be useful too (remedy group, placebo group, control group) because you'd want to see what the placebo rate was compared to no treatment.

Also, if you did a series of single-blind trials and if they showed something above placebo then I guess you could try some double-blind ones to see how important the pracitioner/client relationship is.

I need to have a think on this some more because there may be reasons why this would or wouldn't work that aren't immediately obvious. I'd be interested to know if there is any precedent for doing a study on the practitioner rather than the remedy. I've not heard of such a thing in clinical trials (at least nothing springs to mind).

There may be other issues as well. Ideally in designing a trial you'd want researchers that were both experienced classical homeopaths and well trained in Western scientific methodology.

>>Right, I could make this a major length posting but no one would read it so I won't.

Basically this boils down to two differing ways of approaching the world.

1) that we can understand the world through rational thought and application of rational logical processes to it.

2) that there's irrational inexplicable stuff out there that just happens because. Some people have secret special knowledge of this irrational stuff and can make it work predictably (????) and we shouldn;t question them or stop them in what they do cos they've got special knowledge.

and never the twain shall meet.
<<

Icotan, I'm not sure how you got to that from this conversation, but I just want to clarify that what you write there is *your* view. I don't believe that in any way at all.


>>
But one last before I go, couldn;t resist it:
"And the reality is that most CAM is relatively benign compared to most western medicine."

Um, but no one knows anything about the active ingredients or side effects or how it even works so we don;t know that for sure. CAM may well be relatively benign compared cos it doesn't do anything. In which case such a measure is meaningless.
<<

Actually we do know quite a bit about some CAM treatments now. eg in NZ acupuncture by medical practitioners is mainstreamed (paid for by the govt). Many herbal medicines have had at least some research done on them. So it's not accurate to suggest that we don't know *anything.

You might also want to read up about the reality of drug trials and what gets onto the market with what degree of safety. The relevant word in my sentence that you quoted was "relative".


In terms of safety and what we know for sure, you may be right ideologically and theoretically, but in reality it works like this:

We have massive amounts of pharmaceuticals consumed in the world daily. And we have massive amounts of CAM medicines consumed daily. We KNOW that many people die from taking pharmaceuticals and from being treated by doctors (and we're talking about thousands of people annually. There appear to be few people dying from CAM treatments. Even allowing for better reporting of medical deaths, where are the reports or studies of people dying from CAM? Or even quality anecdote (eg from GPs)? Yes, there are a few deaths, handfuls, but no where near the numbers you would expect to see if overall CAM was as dangerous as pharmaceuticals.

I'm not saying this to suggest that drugs are evil and CAM is angelic. I think that many medical treatments warrant the associated risks. Although most people are unaware of the risks it must be said.

I also don't believe that CAMs are inherently benign, and most practitioners I know or have read of are aware of this. And there are idiotic and quack pracitioners out there (but you get those in the medical field as well).

But just because alot of CAM doesn't fit into the mainstream notion of science YET, doesn't mean it's either ineffective or unsafe. It's illogical to think that it does.

>>
>>"You seem to want everything to be strictly physiologically medical, but it's not. Even medical people know that."

For a dirty *reductionist*, even the mental is physiological.
<<

Potholer, you need to get over yourself there , or at least get over whatever notion you have about my argument...

Where reductionist science is a tool I'm in favour of its appropriate use, and do in fact have quite an appreciation for it.

Where its a fundamental belief system that stops one from seeing other realities, that's another kettle of fish.


>>
Faith healing could be an extreme example of that. I'd imagine that the most confident (and possibly therefore 'best'?) healers may make good salespeople but relatively poor observers.
The best people to look at efficacy are probably people with the most open minds - that's one reason for 'reductionist' double-blind trials.
<<

Wouldn't quality thinking suggest that instead of 'imagining' something about the subject one actually gets informed (this doesn't mean agrees with)?

And yes, open minded people would make good researchers. But I'm not really seeing that here, nor in much of the discussion amongst medical people about CAM.

It would be open minded, IMO, to understand a thing on its own terms and then design research to best suit that. Assuming you've never been to a big body of water and are having trouble believing such a thing exists, if you wanted to test whether a boat really could transport people on water you wouldn't try driving it in the desert.

It seems to me that much of the anti-CAM argument is based in the belief that it doesn't work. Which strikes me as fundamentally unscientific.


>>
>>"Well, I'd like to see the CAM training school that teaches that anything natural can only do good"

I've heard more than the odd vocal fan of herbal medicine use precisely that reasoning.
Do people have to be certified before being allowed to pontificate?
<<

And that would be another example of the general illogic around CAM critique. How can you take a handful of people who go on about herbal medicine being natural and benign and then extrapolate that to most herbal medicine practitioners?

Do you realise that medical herbal practitioners have years of formal training, including in western disciplines such as anatomy and physiology? Do you really believe that they think that herbs are totally and inherently benign? How then do you explain the training in herb/drug interactions, or when to not use certain herbs because it might harm the patient?

Yes there are people who think that "herbs are natural" = inherent safety. But I know more people who think "drugs have been tested"= inherent safety. I know which is the bigger bollix and the most dangerous belief.

kea, I agree that you would need multiple homeopathic healers. I think the double blind wouldn't be about the homeopath healers knowing or not knowing, it would be about the experiment evaluators - medical personnel who are going to evaluate the efficacy of the treatment. These people wouldn't know whether the person they were evaluating was a member of the real or the control group. Then you have the fact that the patients don't know if they're getting real treatment or not, neither do the evaluators.

>>"Where its a fundamental belief system that stops one from seeing other realities, that's another kettle of fish."

When people talk about 'other realities', I do start to wonder what they actually mean. Just because someone thinks something is real doesn't mean it actually is.
'Real-to-me' or 'real-in-my head' or even 'real in-my-culture' aren't necessarily *really* real.

Now, if, for example, someone with arthritis claims to *feel* better or happier after some treatment or other, I'm entirely happy to accept that they probably really do feel better or happier.
If they claim they are more mobile, but actually they don't seem to be, I can accept that they think they are more mobile while doubting that they actually are in reality.

>>"It seems to me that much of the anti-CAM argument is based in the belief that it doesn't work. Which strikes me as fundamentally unscientific."

I think much anti-CAM argument is founded in the suspicion that much of it may well not work, the feeling that *some* promoters of it may end up dissuading people from conventional medicine when that's tyhe best course of action, and the opinion that even if a technique might work, some underlying theories appear to make little sense.
*Does* 'like cure like'?.
In contrast to most of chemistry, why *should* dilution make things stronger, and how does a near infinitely dilute solution magically distinguish between the almost non-existent trace of the intended chemical in it, and the almost non-existent traces of god knows how many other chemicals in the water it's diluted with?
How could some delicate miniscule trace survive the aggressive environments of mouth and stomach?

If someone proposes a theory of how something works without evidence that it actually works, *or how they came up with it* they're likely at best to be ignored by scientists.

>>"And that would be another example of the general illogic around CAM critique. How can you take a handful of people who go on about herbal medicine being natural and benign and then extrapolate that to most herbal medicine practitioners?"

I didn't. My narrow Western logic wouldn't allow me to make the leap from 'some people' to 'all herbalists' You invented that extrapolation all by yourself.
*I* just put the original point forward as an example of an idea worthy of derision. An idea that, while maybe not on any 'official' CAM syllabus, I've heard more than once by people pushing 'natural' wellbeing regimes, in the context of popular programmes.

In any case, we're not just talking about approved practitioners of CAM
Until you started going off on one about how unfair reductionist Western medicine is to alternatives in general, we were talking specifically about faith healing, and the possible relevance of the placebo effect therein.
I'm not sure how many schools there are churning out approved and licensed faith healers. I always assumed it was a rather self-appointed career.