Placebos only work if you pretend they are effective, warns Professor Edzard Ernst
‘Even if it is just a placebo effect, homeopathy often gives great help to people for whom conventional medicine can do nothing – or can do no more.’ This is how Dr Michael Dixon, medical director of the Prince of Wales Foundation for Integrated Health, was quoted in the Sunday Telegraph last week.
At first glance, he seems to have a point – after all, as doctors, our foremost concern is not the evidence but the patient, and therefore we want to help by whatever means. On second glance, however, it is not difficult to discover how deeply misguided this attitude is.
Dixon seems to tacitly admit that homeopathic remedies are placebos but argues that, as such, they can nevertheless be helpful. Perhaps – but only if you do not tell the truth to your patient.
Imagine saying ‘take this remedy, there is nothing in it and the evidence shows it is a pure placebo, but it might still do you some good’. Chances that your patient will improve would be close to nil. If you want placebos to work, you need to pretend they are effective. In plain language, this is called deception. Ethicists have long ruled that this ancient paternalistic stance is no longer adequate and not in the best interest of the patient.
So it’s unethical, but to hell with ethics, if it helps my patient!? Not quite. Dixon and other defenders of homeopathy seem to forget something quite elementary: we don’t need a placebo in order to generate a placebo-effect. If we prescribe an effective treatment with the same dedication, time, empathy etc as homeopaths would prescribe the homeopathic placebo, patients will benefit from both the non-specific (placebo) effects and the specific effects of the treatment.
And what about the idea that homeopathy is benign? Sure, highly dilute remedies are unlikely to cause adverse effects. But what about the fact that people might use them as a replacement of effective therapies to treat serious conditions? Arguably, no ineffective treatment will ever be harmless when used in this way. There are plenty of dramatic examples of patients getting harmed or even losing their lives when this happens.
So, proclaiming that ‘homeopathy gives great help to people for whom conventional medicine can do nothing’ is apparently unethical, factually incorrect, potentially harmful – and certainly not in the interest of our patients.
Before critics reiterate what they have said so often before – ‘Ernst does not know what we have to deal with at the coal face of clinical practice’ – let me pre-empt this by stressing that I was a clinician for many years and have even treated patients in a homeopathic hospital.
Edzard Ernst Edzard Ernst