Jane McCredie: A gentle reproach

YOU don’t see the word “gentle” in the title of a scientific paper all that often.

But there it is atop a paper coauthored by two homeopaths and two prominent Australian medical ethicists, Associate Professor Ian Kerridge and Professor Paul Komesaroff: “A gentle ethical defence of homeopathy”.

Homeopathy doesn’t usually keep that kind of company. Medical leaders are generally more likely to lambast the alternative health practice than to defend it.

These authors, however, suggest those who criticise homeopathy as unethical have “an impoverished idea of ethics — one that fails to account for either the moral worth of care and of relationships or for the perspectives, values, and preferences of patients”.

“The choice to seek care from a homeopath can be just as valid and as ethically sound as any other health care choice that a patient or consumer makes, and the notion that consent or agency is untenable in respect to homeopathy is deeply paternalistic and challenges the very idea of moral autonomy”, they write.

I can’t help gently suggesting that perhaps the authors are setting up a bit of a straw man here.

I’m not sure that even the most virulent critics of homeopathy would argue an adult seeking homeopathic care was acting unethically, though they might criticise that choice on other grounds.

But what of the homeopaths? Is it unethical to provide a treatment that comprehensively fails to meet the normal standards of evidence-based medicine (EBM) (see this MJA review)?

The authors of the current paper argue the EBM approach alone is not enough, but that we need “a more sophisticated approach to evidence in medicine” in this and every other field of health care.

“This approach would recognise that what constitutes evidence can be defined and measured in different ways by different people or groups and that judgements about competing epistemes are ultimately statements about the ‘value’ of particular data or outcomes”, they write.

“When looked at in this way, it then seems completely appropriate that congruence with patients’ values, goals and preferences as well as their reported experiences and outcomes from homeopathic interventions should be included in any comprehensive evaluation of the efficacy of homeopathy.”

That’s all getting a bit postmodern for me.

I have no doubt many patients experience benefit from seeing a homeopath, and I support their right to keep doing it. I also don’t doubt the vast majority of homeopaths hold a sincere belief in the value of what they do.

But I don’t believe their medicines “work”, other than by triggering a sometimes powerful placebo effect, and I am disturbed when claims are made for them that go beyond that.

I wrote last year, for example, about homeopathic remedies being sold in pharmacies with claims they were effective against fever and other symptoms in children, claims that were withdrawn after a successful complaint to the Therapeutic Products Advertising Complaints Resolution Panel.

Randomised controlled trials (RCTs) are far from perfect but, as Winston Churchill famously said about democracy, they’re the worst system we have, except for all the others.

I’d certainly rather base my decisions about health care on RCTs than on a bunch of patient anecdotes.

Others have different values and different decision-making processes and that’s fine. I have friends who attest to the mental health benefits of past-life regression and tarot readings and I respect that.

My own ethical concerns about homeopathy arise when attempts are made to place it in contexts where it doesn’t belong, when the public purse subsidises it through private health insurance rebates, for example (something that may come to an end next year).

And I think it’s fundamentally misleading for a practice without a conventional evidence base to be promoted in a scientific context — as happens when pharmacists endorse homeopathic products or universities teach homeopathy as part of a science degree.

The ethics of that, I’d gently suggest, are troubling.

Jane McCredie is a Sydney-based science and medicine writer.