JOBNAME: No Job Name PAGE: 1 SESS: 8 OUTPUT: Tue Feb 21 11:59:45 2012 /v2501/blackwell/B_journals/bioe_v0_i0_newstyle/bioe_1948 Bioethics ISSN 0269-9702 (print); 1467-8519 (online) 1 2 3 doi:10.1111/j.1467-8519.2012.01948.x RESPONSES TO AGAINST HOMEOPATHY – A UTILITARIAN PERSPECTIVE BY KEVIN SMITH. RESPONSE 2: IS HOMEOPATHY REALLY ‘MORALLY AND ETHICALLY UNACCEPTABLE’? A CRITIQUE OF PURE SCIENTISM bioe_1948 1..4 4 5 LIONEL MILGROM AND KATE CHATFIELD 6 7 8 9 10 Keywords homeopathy, utilitarianism, scientism ABSTRACT In this short response we show that Kevin Smith’s moral and ethical rejections of homeopathy1 are fallacious and rest on questionable epistemology. Further, we suggest Smith’s presumption of a utilitarian stance is an example of scientism encroaching into medicine. 52 53 54 55 56 11 57 12 13 14 15 16 17 18 19 Smith’s starting premise that ‘homeopathic medicines have no direct biochemical or physiological effects’ (i.e. are ‘implausible’ placebos), is necessary in order to consider homeopathy’s presumed ethical ‘utilities and disutilities’. But it is a fallacy to ignore mounting and increasingly compelling scientific evidence2 which suggests not only that highly diluted substances produced in the homeopathic manner might have in vitro and in vivo 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 1 K. Smith. Against Homeopathy – a Utilitarian Perspective. Bioethics 2011; doi: 10.1111/j.1467-8519.2010.01876.x 2 M. Chaplin. Water Structure and Behaviour. Regularly updated online document at: www.lsbu.ac.uk/water. [Accessed 24 Nov 2009]; S. Samal & K.E. Geckler. Unexpected Solute Aggregation in Water on Dilution. Chem Commun 2001; 21: 2224–2225: V. Elia & M. Niccoli. Thermodynamics of Extremely Diluted Aqueous Solutions. Ann NY Acad Sci 1999; 879: 241–248; J-L. Demangeat. NMR Water Proton Relaxation in Unheated and Heated Ultrahigh Aqueous Dilutions of Histamine: Evidence for an Air-Dependent Supramolecular Organisation of Water. J Mol Liquids 2009; 144: 32–39: U. Wolf et al. Homeopathic Preparations of Quartz, Sulfur, and Copper Sulfate Assessed by UV-spectroscopy. Evid Based Complement Alternat Med 2009; May 27:e-pub ahead of print; L. Rey. Thermoluminescence of Ultra-high Dilutions of Lithium Chloride and Sodium Chloride. Physica (A) 2003; 323: 67–74; I.R. Bell et al. Gas Discharge Visualisation Evaluation of Ultramolecular Doses of Homeopathic Medicines under Blinded, Controlled Conditions. J Altern Complement Med 2003; 9: 25–38; R. Roy et al. The Structure of Liquid Water: Novel Insights from Materials Research. Potential Relevance to Homeopathy. Mat Res Innov 2005; 9: 557–608; I. Prigogine & I. Stengers. 1985. Order out of Chaos. London, UK: Fontana; A. Hankey. Are we Close to a Theory of Energy Medicine? J Altern Complement Med 2004; 10: 83–86; E. Del Guidice, G. Preparata & G. Vitiello. Water as a Free Electron Dipole Laser. Phys Rev Lett 1988; 61: 1085–1088: L. Montagnier et al. Electromagnetic Signals are Produced by Aqueous Nanostructures Derived from Bacterial DNA Sequences. Interdiscip Sci Comput Life Sci 2009; 1: 81–90. effects (i.e. are plausible),3 but also that they do not contravene known scientific laws and principles. Smith also fails to acknowledge conventional medical literature supporting a core homeopathic principle, namely hormesis – the biphasic dose response to a substance, characterized by a low-dose stimulating/beneficial effect, and a high-dose inhibitory/toxic effect.4 This, Calabrese notes, ‘. . . is far more common and fundamental (in medicine) than the (linear) dose-response models used in toxicology and risk assessment. . . . hormesis has the potential to profoundly affect the practice of toxicology and risk assessment. . . .’5 Modern toxicology therefore contradicts Smith’s assertion that homeopathy is fundamentally illogical. All this suggests that at the very least there is disagreement over the effects of homeopathic medicines, and that a more reasonable starting premise might be homeopathy is of uncertain efficacy. This would inevitably alter Smith’s conclusions as his whole argument rests on the assumption that homeopathy is nothing but placebo. 78 3 P. Belon et al. Histamine Dilutions Modulate Basophil Activation. Inflamm Res 2004; 53: 181–188; C.M. Witt et al. The In Vitro Evidence for an Effect of High Homeopathic Potencies – a Systematic Review of the Literature. Complement Ther Med 2007; 15: 128–138; L.R. Milgrom. ‘. . . Macavity’s Not There!’ J Altern Comp Med 2009; 15: 1051–1053, and references therein; S. Gariboldi et al. Low Dose Oral Administration of Cytokines for Treatment of Allergic Asthma. Pulmonary Pharmacology & Therapeutics 2009 doi:10.1016/ j.pupt.2009.05.002. [Accessed 2nd March 2011] 4 M.P. Mattson. Hormesis Defined. Ageing Res Rev 2008; 7(1): 1–7. 5 E.J. Calabrese. Toxicological Awakenings: the Rebirth of Hormesis as a Central Pillar of Toxicology. Toxicol Appl Pharmacol 2005; 204(1): 1–8, and references therein. 48 49 50 51 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 Address for correspondence: Dr. Lionel Milgrom, Programme for Advanced Homeopathic Studies, London. E-mail: lionel.milgrom@hotmail.com Conflict of interest statement: No conflicts declared © 2012 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 79 80 81 82 83 84 85 86 87 88 89 90 91 JOBNAME: No Job Name PAGE: 2 SESS: 8 OUTPUT: Tue Feb 21 11:59:45 2012 /v2501/blackwell/B_journals/bioe_v0_i0_newstyle/bioe_1948 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Lionel Milgrom and Kate Chatfield Smith studiously avoids utilitarian scrutiny of conventional medicine, yet according to an older ethical covenant (‘First, do no harm. . . .’), it has serious (and acknowledged) disutilities.6 Homeopathy in contrast has a good safety record with little risk of harm.7 Yet Smith claims potential for harm should patients seek homeopathy rather than conventional healthcare. This is simply untrue: patients rarely use homeopathy as primary care; most seeking homeopathic treatment have tried conventional approaches first.8 Also, many homeopaths refer patients back to their GPs after in-depth consultation reveals something missed. Hence, homeopathy can act as an extra safeguard rather than a potential risk. While claiming that scientific trials of homeopathy lack quality,9 Smith forgets that biomedical trials have significant problems of their own. For, of 2500 conventional medical procedures tested, over half (51%) were of unknown effectiveness.10 Worse, widespread academiacondoned fraud and abuse of science in biomedical research exists,11 with around 1000 incidents of suspected fabrication and plagiarism unreported in the US every year. Yet homeopathy’s positive effects are excluded from the mainstream literature: no bad thing perhaps when, as Marcia Angell points out: It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached. . . . over my two decades as the editor of The New England Journal of Medicine.12 But no one suggests conventional medicine ‘is ethically unacceptable. . . .’ or should be ‘actively rejected by healthcare professionals’. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 6 E. Leigh. A Safer Place for Patients: Learning to Improve Patient Safety. 51st report of session 2005–06 report, together with formal minutes, oral, and written evidence. House of Commons papers 831 2005–06, The Stationery Office. July 6, 2006. See http://www.healthcare-reform.net/causedeath.htm [Accessed 2nd March 2011]. 7 B.J. Kirby. Safety of Homeopathic Products. J Royal Soc Med 2002; 95: 221–222. 8 M. Markman, Safety Issues in Using Complementary and Alternative Medicine JCO 2002; 20: 39–41. 9 D.S. Spence, E.A. Thompson & S.J. Barron. Homeopathic Treatment for Chronic Disease: a 6-year, University-hospital Outpatient Observational Study. J Altern Comp Med 2005; 11: 793–798. 10 See, BMJ Clinical Evidence web-site. Online document at: http:// clinicalevidence.bmj.com/ceweb/about/knowledge.jsp [Accessed 19 Feb 2011]. 11 D. Fanelli. How Many Scientists Fabricate and Falsify Research? A Systematic Review and Meta- Analysis of Survey Data. PLoS ONE 2009; 4(5): e5738: doi:10.1371/journal.pone.0005738; S.L. Titus, A.J. Wells & L.J. Rhoades. Repairing Research Integrity. Nature 2008; 453: 980–982: doi:10.1038/453980a. 12 M. Angell. 2009. The New York Review of Books. LV1; 1: 15 Jan. More perplexing is Dr Smith’s claim that homeopathy could weaken support for science-based medicine. Such fear is rooted not in science but in scientism,13 i.e. the unscientific belief that compared to other forms of knowledge, science is the absolute and only justifiable access to truth. Taken to the extreme, scientism defaults to Internetfueled inquisitorial intolerance14 which, supported by certain academics, sections of the media, and (usually anonymous) blog sites, systematically vilifies anything considered ‘unscientific’, e.g. the campaign to undemocratically rid Britain’s NHS of its homeopathy/CAM facilities. Fortunately, not all share such fundamentalist views, especially at the frontline.15 It is also clear that under the guise of Evidence-Based Medicine (EBM), scientism infiltrates medical practice, much to its detriment.16 Begun as a rational attempt at clinical decision-making for patients’ benefit, EBM has become an evidence ‘monoculture’,17 downgrading practical experience in favour of only scientific evidence to inform clinical judgments.18 Over-enthusiastic enforcement could mean over 50% of all current medical procedures being postponed19 while awaiting proof of efficacy: meanwhile, patients would suffer. Is that ethical? Ultimately, Smith’s analysis rests on a questionable premise, so his ‘ethical’rejection of homeopathy is 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 13 M. Ryder. Scientism. Entry in the Encyclopaedia of Science, Technology, and Ethics. Copyright 2001–2006 by Macmillan Reference USA, an imprint of the Gale Group; A.F. Chalmers. 1994. What is this thing called science? An assessment of the nature and status of science and its method. 2nd edn. St. Lucia Qld, Australia: University of Queensland Press: 13–14. 14 L.R. Milgrom. Homeopathy and the New Fundamentalism: A critique of the critics. J Altern Complement Med 2008; 14: 589. 15 K. Sikora. 2009. Complementary Medicine Does Help Patients. Times Online, 3 February. Online document at: www.timesonline.co.uk/ tol/life_and_style/court_and_social?article5644142.ece [Accessed 18 February 2009]; G.C.S. Smith & J.P. Pell. Parachute Use to Prevent Death and Major Trauma Related to Gravitational Challenge: Systematic Review of RCTs. BMJ 2003; 327: 1459–1451: D.L. Sackett et al. Evidence Based Medicine: What It Is and What It Isn’t. BMJ. 1996; 312: 71; J.M. Leggett. Medical Scientism: Good Practice or Fatal Error? J R Soc Med 1997; 90: 97–101. 16 Smith & Pell, op. cit. note 15; Sackett, et al., op. cit. note 15; Leggett, op. cit. note 15; D. Holmes et al. Deconstructing the Evidence-based Discourse in Health Sciences: Truth, Power, and Fascism. Internat J Evid Based Healthc 2006; 4: 180; I. Devisch & S.J. Murray. ‘We Hold these Truths to be Self-evident’: Deconstructing ‘Evidence-based’ Medical Practice. J Eval Clin Pract 2009; 16: 950–954; M. Rawlins. De Testimonio: Harveian Oration Delivered to the Royal College of Physicians, London. 16 Oct 2008. http://www.rcplondon.ac.uk/news/ news.asp?PR_id_422. [Accessed 1 Nov 2008]. 17 Sackett et al., op. cit. note 15. 18 Leggett, op. cit. note 15; Holmes et al., op. cit. note 16; Devisch & Murray, op. cit. note 16; Rawlins, op. cit. note 16. 19 See BMJ Clinical Evidence web-site. Online document at: http:// clinicalevidence.bmj.com/ceweb/about/knowledge.jsp [Accessed 19 Feb 2011]. © 2012 Blackwell Publishing Ltd. 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 JOBNAME: No Job Name PAGE: 3 SESS: 8 OUTPUT: Tue Feb 21 11:59:45 2012 /v2501/blackwell/B_journals/bioe_v0_i0_newstyle/bioe_1948 Is Homeopathy Really ‘Morally and Ethically Unacceptable’? 1 2 3 4 5 suspect. To avoid accusations of bias, might he consider similarly rejecting conventional medicine? We suggest an alternative strategy. Biomedical commentators like Smith could for once try forgetting their limited scientistic world-view,20 and join in calling for an integrated 6 7 8 9 10 11 12 13 14 15 20 T.J. Kaptchuk et al. Placebos without Deception: a Randomised Controlled Trial in Irritable Bowel Syndrome. PloS ONE, 2010; 5(12): e15591; S. Brien et al. Homeopathy has Clinical Benefits in Rheumatoid Arthritis Patients that are Attributable to the Consultation Process but not the Homeopathic Remedy: a Randomized Controlled Clinical Trial. Rheumatology 2010; 49: doi:10.1093/rheumatology/keq234: [Accessed 19 Feb 2011]; L.R. Milgrom. Journeys in the Country of the Blind: Entanglement Theory and the Effects of Blinding on Trials of Homeopathy and Homeopathic Provings. eCAM 2007; 4: 7. © 2012 Blackwell Publishing Ltd. 3 approach to medicine. Its fundamental lesson: that while no one therapeutic modality provides the magic elixir for all of humanities ills, we stand a better chance and can do a better job if we work together for our patients’ benefit. 16 Lionel R. Milgrom PhD, CChem, FRSC, MARH, RHom, researches, practises, teaches, and comments on chemistry and homeopathy. His main research interests include targeted photodynamic therapy in the treatment of cancer, developing models of the therapeutic process based on the quantum theoretical discourse of non-locality and complementarity, and the underlying philosophical basis of challenges to complementary and alternative medicine. 21 22 23 24 25 26 27 Kate Chatfield, MSc, is a researcher and teacher at the University of Central Lancashire. She is currently undertaking a PhD analysing ethical challenges to complementary and alternative medicine. 28 29 30 17 18 19 20 JOBNAME: No Job Name PAGE: 4 SESS: 8 OUTPUT: Tue Feb 21 11:59:45 2012 /v2501/blackwell/B_journals/bioe_v0_i0_newstyle/bioe_1948 Journal Code: BIOE Article No: 1948 Page Extent: 3 Toppan Best-set Premedia Limited Proofreader: Elsie Delivery date: 21 February 2012 MARKED PROOF Please correct and return this set Please use the proof correction marks shown below for all alterations and corrections. 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