Firstly, an acknowledgement to Simon Singh and Edzard Ernst for the title of this article. Much of the content in this article is drawn from their book of the same name [1]. The other primary sources of content for this article are the SGU website [2] and the Science-Based Medicine website [3].

This article differs somewhat from my previous articles on decision making in that the other articles aim to share important decision making concepts, while this article aims to demonstrate the practical application of these decision-making concepts. Decision making can be viewed as a four step process, viz. framing the decision to be made, generating alternatives, evaluating those alternatives, and planning for the execution of the selected alternative. In this article on alternative medicine, the emphasis is on the evaluation step and, more specifically, how to determine when, if ever, alternative medicine is a good choice.

This is a longer article than my others, so here is a quick executive summary:

1. We desire medicine that is effective and safe.

2. Conventional and alternative medicine differ in the quality of the product, with conventional medicine reliably being of high quality.

3. For some people, there is a reasonable basis for desiring solutions beyond conventional medicine.

4. To determine whether there are good solutions beyond conventional medicine requires a robust assessment of efficacy and safety.

5. With some exceptions, alternative medicines do not show better efficacy than conventional medicines, and in many cases do not even improve on placebo efficacy.

6. A placebo effect is an improper reason to prescribe alternative medicine.

7. In contrast to the perception of pure and natural, there can be real dangers to alternative medicine.

8. Imperative: when/if considering alternative medicine, increase the sensitivity of your “bullshit detector”.

And now follows the detail:

We desire medicine that is effective and safe.

· Most people would agree that medicine should be both effective and safe (or at least should have a favourable cost/benefit ratio).

Conventional and alternative medicine differ in the quality of the product, with conventional medicine reliably being of high quality.

· Let’s agree the definition of alternative medicine. There are many definitions, but I think this one should suffice: “Alternative medicine is any practice that is put forward as having the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science” [4].

· So, what’s the difference between conventional and alternative medicine?

· Let’s explore this question for herbal medicines.

· Modern pharmaceutical science is largely built upon herbal remedies, e.g. aspirin comes from the Willow bark. The Willow bark was taken for centuries as a treatment for headaches, pains, and so on. The problem is that you don't know what dose you're getting and there are other toxins in Willow bark.

· Science and modern industry have taken herbal remedies and created pharmaceuticals. This has been done by identifying the effective chemical; removing the toxins; working out the dosages, drug-drug interactions (admittedly not completely), and side effects; synthesizing the active ingredient; producing it under sterile conditions to ensure purity; and subjecting the product to rigorous testing. All of this has been done in the context of regulation that aims to ensure that only products with proven efficacy and safety can be sold to the public. Do efficacy and safety mistakes happen with conventional medicine? Yes, but the system is set up to be self-correcting and hence to continuously reduce such risks.

· Consequently, when it comes to herb-derived medicine there is no ideological issue at stake, just an issue of quality.

For some people, there is a reasonable basis for desiring solutions beyond conventional medicine.

· Why are people attracted to alternative medicine? Some possibilities:

o People use alternative medicine because it aligns with their philosophy, e.g. a perception that it is “natural” and “holistic”, and/or they simply want to expand their options.

o The desperation of being sick and not having a cure from conventional medicine.

o A mistrust of Big Pharma.

· Are these reasonable points?

o Natural does not equal safe. Cyanide, arsenic, belladonna, opium and hundreds of others are naturally occurring.

o I’m not sure what most people mean by “holistic”, but some in the medical profession will agree that many treatments in conventional medicine are too narrow.

o Understandably one might become desperate since conventional medicine does not solve all problems, but that doesn’t make any solution the right solution.

o Understandably there is a mistrust of industry given the profit motives and some previous disasters, e.g. Thalidomide. However, this should be weighed against the good that has been done (e.g. vaccination success) and the improvements in safety that have resulted from learnings of past failures.

To determine whether there are good solutions beyond conventional medicine requires a robust assessment of efficacy and safety.

· How do we determine efficacy? To keep it simple let’s consider two ends of the spectrum between science and pseudo-science.

o Science searches for the truth, regardless of what that might be. Science recognizes our susceptibility to cognitive biases and applies the scientific method to avoid us deceiving ourselves. Specifically, scientific testing uses the randomized, controlled trial. Published results need to be peer reviewed and replicated (not always). Is this fool-proof? Absolutely not! Scientists are human too – driven by greed, susceptible to biases, etc. But, the process is good and inherently self-correcting.

o Pseudoscience begins with a desired belief and then looks for evidence to support that belief. That evidence is typically anecdotal and is distorted by a range of biases, the placebo effect, and the dynamics of illness and cure, e.g. many illnesses are self-limiting and hence a medicine taken at the peak of the illness would give the impression that the patient is improving due to that medicine, when the patient would have improved anyway.

o Steven Novella [5] explains the necessity that the evaluation of efficacy be done using a scientific study rather than relying on anecdotal evidence: “There's a host of psychological mechanisms at work that overwhelm any perception of reality. Scientists know this. That's why you need to do carefully designed studies.

When a study is "carefully designed", what that means is it is designed to eliminate the effect of these biases that we know are there. The reason why anecdotal evidence is pejorative, is because it's not controlling for this host of psychological and biasing factors. Anecdotal evidence is worse than worthless, because it tends to lead one to conclusions they wish to be true”.

o Hopefully it is clear to the educated reader that robust testing is required. And you should therefore agree that efficacy should be determined by a scientific process, for which the gold-standard in medicine is the randomized, controlled trial (RCT) with associated statistical analysis. The RCT is a study in which people are allocated at random to receive one of two (or more) clinical interventions. One of these interventions is the “control” against which the other(s) are measured. The control might be the current standard practice or it might be a placebo, or it might even be nothing at all.

With some exceptions, alternative medicines do not show better efficacy than conventional medicines, and in many cases do not even improve on placebo efficacy.

· How do the alternative medicines and treatments perform when subjected to scientific testing, i.e. RCTs? Let’s explore four of the most popular alternative medicines. [1]

o Acupuncture: RCTs have found no effect beyond placebo. Not surprising since the underlying principles are deeply flawed as there is no evidence at all to demonstrate the existence of Ch’i or meridians.

o Homeopathy: RCTs have found no effect beyond placebo. Hundreds of trials have failed to deliver convincing evidence to support the use of homeopathy for any ailment. Not surprising when we recall that homeopathic medicine typically does not contain a single molecule of any active ingredient.

o Chiropractic: RCTs have found this to be effective for certain kinds of neck and lower back pain, but no more effective than other treatments. It has also been found to not be effective for any other condition.

o Herbal medicine: For some herbs there is good scientific evidence of efficacy. For others there is not. Some examples of evidence of efficacy: Good: Garlic, Echinacea; Medium: Ginger, Ginkgo; Poor: Chamomile, Ginseng.

o In other words, acupuncture, homeopathy, and chiropractic do not meet the efficacy requirements of being better than conventional treatments, and, in the case of acupuncture and homeopathy no better than a placebo. Some herbal medicines do show efficacy as expected – as per the Willow bark example earlier.

A placebo effect is an improper reason to prescribe alternative medicine.

· If alternative medicine just gives you a placebo response, and the placebo response is real and powerful, what's wrong with that [2]?

o You're lying to the patients.

o Slippery slope risk, i.e. once you allow people to rely on alternative medicine practitioners for some things, they might easily start relying on that practitioner for other things, e.g. homeopathic malarial cure.

o You don’t need alternative medicine for the placebo effect. Anything, including real medicine, that is believed by the patient to be medicine will benefit from the placebo effect.

· If you’re still of the philosophical persuasion that alternative is somehow better than conventional, despite it not offering more efficacy than conventional medicine (and less in the examples discussed in this article), then there is one last check: is it safe?

In contrast to the perception of pure and natural, there can be real dangers to alternative medicine.

· Injury / disease risk, e.g. liver failure from herbal products, transmission of hepatitis C from acupuncture needles, vertebral artery dissection from chiropractic manipulation, contracting malaria when using homeopathic malaria prophylaxis.

· Risk of toxicity / contamination, e.g. a recent Australian study looked at 26 different Traditional Chinese Medicine products purchased from stores. They performed three types of analysis: heavy metal screening, toxicological analysis, and DNA sequencing. They found that 92% of the products tested had at least one type of contaminant [6].

· Improper and/or delayed diagnosis. This is one of the most pernicious of the dangers of alternative medicine. Delays in seeking conventional treatment can result in the disease progressing in severity to the point that is far more damaging or even fatal.

· And, depending on efficacy, or lack thereof, it can simply be a waste of money.

Imperative: when/if considering alternative medicine, increase the sensitivity of your “bullshit detector” by looking out for the traits of pseudoscience.

If you are considering alternative medicine, then before you layout the cash:

· Check what your conventional medicine options are.

· Ask "how is it known?” when claims of efficacy and safety are made for the alternative medicine. An excellent source for an objective and comprehensive review is Cochrane [7].

· When receiving the response to the above question, increase the sensitivity of your “bullshit detector” by looking out for the traits of pseudoscience [8]. These traits include reliance upon anecdotal evidence rather than research; hostility towards scientific criticism; making a virtue out of ignorance; claims that promise easy solutions to complex problems; utilizing scientific sounding, but ultimately meaningless, language; using bold or absolute statements; and attempts to shift the burden of proof away from the provider of the alternative medicine.

In closing, the former editor of the Journal of the American Medical Association, George Lundberg, said it best when he argued that alternative medicine does not exist: “there is only scientifically proven, evidence-based medicine supported by solid data, or unproven medicine, for which scientific evidence is lacking”.

References:

[1] “Trick Or Treatment?: Alternative Medicine on Trial”, Edzard Ernst and Simon Singh

[2] http://www.theskepticsguide.org/

[3] https://sciencebasedmedicine.org/

[4] http://pallipedia.org/complementary-and-alternative-medicine-cam/

[5] https://en.wikipedia.org/wiki/Steven_Novella

[6] http://www.nature.com/articles/srep17475

[7] http://www.cochrane.org/

[8] http://www.theness.com/index.php/anatomy-of-pseudoscience

Acknowledgement: thank you to Sudeshan Govender and Elsa Borchardt (my wife) for their reviews and advice on this article