Chapter 6: Wonderland

It has been claimed by some members of the lunatic fringe of alternative medicine that I took up the Laing Chair at Exeter with the specific agenda of debunking alternative medicine. This is certainly not true; if anything, I was predisposed to look kindly on it. After all, I had grown up and done my medical training in Germany where the use of alternative therapies in a supportive role alongside standard medical care was considered routine and unremarkable. As a clinician, I had seen positive results from alternative therapies. If I came to Exeter with any preconceived ideas at all, they were of a generally favourable kind. I was sure that, if we applied the rules of science to the study of alternative medicine, we would find plenty of encouraging evidence.

As if to prove this point, the managing director of a major UK homeopathic pharmacy wrote a comment on my blog in April 2014: “...I met you once in Exeter in the 90s when exploring a possible clinical study. I found you most encouraging and openly enthusiastic about homeopathy. I would go so far as to say I was inspired to go further in homeopathy thanks to you but now you want to close down something which in my experience does so much good in the world. What went wrong?”

The answer to this question is fairly simple: nothing went wrong, but the evidence demonstrated more and more indisputably that most alternative therapies are not nearly as effective as enthusiasts tried to make us believe. As my research progressed and as I acquired deeper knowledge of the field, I began to view alternative medicine in a more critical light. The more data we amassed, the more we had to realize how unsubstantiated were many of the claims in support of many of these treatments. As the scientific evidence mounted, I could not help seeing what was right before my eyes. In truth, the more time I spent immersed in the world of alternative medicine, the more disillusioned I became realizing how very few of these approaches had any real therapeutic potential.

But it was not the evidence alone that brought about this gradual shift of attitude. Two further, bizarre features of the alternative medicine scene significantly contributed to this development: the strange activities of other researchers working in my field, and the many fallacious arguments commonly used by the general public to promote outright quackery.

Through my own research, our annual scientific conference at Exeter, our journal FACT (Focus on Alternative and Complementary Medicine) and through the many lectures I was giving across the globe, I got to know most researchers in alternative medicine and befriended some of them. Scrutinizing the attitudes and publications of these investigators carefully, I realized how few of them had any real intention to ever seriously question their assumptions or truly test their concepts. With a degree of simplification and little exaggeration, I could categorize my fellow investigators in two different groups:

Research of this nature was either irrelevant for producing real progress, or it was even preventing it. To realize how very few investigators were actually willing or able to conduct rigorous research, with an appropriate dose of critical thinking that would have enabled them to challenge their own beliefs, felt like having landed on a different planet.

The second bizarre feature of this Wonderland was the ideological fervour that permeated so much of the public discourse on alternative medicine. The need to regularly defend my research against a constant barrage of criticism would not have been so wearying had the substance of the arguments been less fallacious. A great many of the criticisms levelled with such catechistic conviction by proponents of alternative medicine were quite simply based on flawed logic. Far too many of the arguments used to defend alternative medicine represented nothing less than the flight from reason into the absurd.

In the endless discussions about the virtues of alternative medicine, I began to feel like a fish out of water. I was a physician and a clinical researcher, not a public relations specialist. Yet it became increasingly difficult for me to ignore the sloppy or irrational thinking and sophistry which more than once reminded me of Voltaire’s bon mot that people who tolerate absurdities might also commit atrocities.

Alternative medicine had begun its remarkable ascent in a general climate of unreason. Incrementally, over the past two decades, we have seen the emergence of a culture that is curiously indifferent to the concept of truth. There is not one truth now, but many - all of them interchangeable, all of them of equal weight, and all deserving of equal consideration. In this Wonderland of relative facts, parallel truths and intellectual legerdemain, basing an argument on flawed reasoning does not automatically disqualify or even devalue it. To the contrary: logical fallacies are tolerated - indeed, often celebrated - as manifestations of a much-needed diversity.

Proponents of alternative medicine thrive in this kind of cultural environment since they tend to rely heavily on lazy reasoning and systematic oversimplification. Take, for example, the widespread notion that, if millions use a certain therapy, it can safely be assumed that it is effective - a prime example of what is known in logic as the “ad populum” fallacy.

A belief - even mass-belief - can be wrong; a widely accepted practice, habit or tradition can still be misguided. Popularity is certainly not a reliable barometer of effectiveness. The history of medicine is littered with examples demonstrating how dangerous this fallacy can be. Bloodletting, purges, mercury cures were all, at one time or another, widely practised and believed to be effective - and yet these treatments undoubtedly killed more patients than they ever cured. If we followed the logic of proponents of alternative medicine and allowed medicine to degenerate into a popularity contest, we would automatically jeopardize all the remarkable achievements that have been made in the last 150 years.

Similarly beguiling is the widespread confusion of cause and effect, exemplified by the notion that, because event B followed event A, event B must have been caused by event A. This kind of thinking, known as the post hoc fallacy, is nowhere more pervasive than in alternative medicine. If we receive a therapy while we are ill and soon afterwards get better, we automatically assume that the treatment was responsible for our improvement. Tempting though this conclusion may be, it can be dangerously misleading. A whole spectrum of phenomena, ranging from the placebo effect to the self-limiting nature of the illness itself, can contribute to the recovery of ill patients. Patients do usually get better after receiving a useless or even mildly harmful remedy. To assume a cause and effect relationship based on purely temporal associations of this kind is always unreliable and certainly does not provide a sufficient basis on which to draw conclusions about the efficacy of a therapy.

When apologists for alternative medicine have to concede that their treatment is ineffective, they usually insist that this does not really matter. Even if it were a pure placebo, it would nevertheless help patients by eliciting a placebo response, and that, in and of itself, surely must be a good thing. According to this fuzzy line of reasoning, the mechanism of the effect is of secondary importance; the only thing that truly counts is to help the patient by whatever means one can.

Superficially, the assumption sounds logical enough - and compassionate, too - but it ignores several important points. The administration of placebos to ill patients can be both unethical and dangerous. For example, as discussed in the previous chapter, some forms of alternative medicine are by no means inert: they can cause serious adverse effects in their own right. Also, in order to elicit a placebo response, it is not necessary to administer a placebo. If a clinician gives his patient an effective treatment with empathy and compassion, he will generate a placebo response in addition to the response to the effective treatment he has chosen for his patient. Only giving a placebo therefore deprives the patient of the benefits of a treatment that has specific therapeutic effects in its own right. In other words, the administration of placebo therapies would simply mean cheating the patient out of something that would contribute importantly to his recovery - and this, surely, is unethical and potentially harmful.

Another false but superficially convincing argument loved by proponents of alternative medicine holds that many conventional treatments are not supported by sound evidence. They point out that, since standard medical treatments are by no means always backed up by solid proof, it must be unreasonable to insist on a solid evidence-base for alternative therapies. As they see it, this reveals an entrenched double standard and an institutionalized bias against alternative medicine.

It is unquestionably true that many conventional therapies are currently not evidence-based, but this is by no means a justification for using untested or disproven treatments under the banner of alternative medicine. This logic would be like arguing that unreliable (or unsafe) railways are acceptable because many more people get stuck in traffic jams (or die in accidents) on the roads. If we identify treatments as being unproven, we have a duty to test them; and until the results are in we should stop using them in clinical routine. This is precisely what is happening in conventional medicine. However, in alternative health care, the opposite is usually the case: here apologists try to push their treatments regardless of the evidence, arguing that, as long as their therapy is not disproven, it is fine to use it. Far from decreasing the total number of non-evidence-based therapies, this approach would dramatically increase it.

Another version of this argument alludes to the fact that one of the most frequent causes of illness is the harm caused by prescription drugs. I hear it with unfailing regularity when I lecture about the risks of alternative medicine: in comparison to the number and seriousness of adverse effects attributable to prescription drugs, those caused by alternative medicine are vanishingly small. The implication here is, of course, that researchers should just stop worrying people with their concerns about the safety of some alternative therapies.

It is undoubtedly correct that the risks of some conventional treatments are far greater than those of most alternative therapies: chemotherapy has more side effects than aromatherapy, for instance. But this platitude is entirely beside the point. The true value of a treatment is definitely not determined by its absolute risk but by the balance between risk and benefit. If a treatment is potentially life-saving, even substantial risks will be offset by the benefit to be gained. If, for instance, the aim is to cure a cancer, patients will gladly put up with all sorts of dramatic and unpleasant side effects. If, however, a therapy has no, or very little, proven benefit - and this seems to be the case with many alternative treatments - even a small risk must weigh heavily.

An all-time favourite argument of alternative medicine’s more passionate adherents holds that, somehow, alternative medicine defies science or extends beyond the boundaries of science as it is currently understood. Therefore, they claim, it cannot be tested in the same way one would test a conventional treatment. Some practitioners argue that their particular therapy is holistic, individualized and complex; that it relies on subtle, unquantifiable energies, etc. These attributes, they insist, mean that it cannot be squeezed into the straightjacket of reductionist science. After all, they say, science is not the only way of knowing or finding the truth: there are many things in heaven and earth which science will never be able to explain.

It is true that science does indeed have its limitations; nobody would deny that. Yet, when it comes to testing therapeutic claims, science provides us with a fairly comprehensive set of tools for checking their validity. Even if the hypothesis is that a particular holistic, individualized and complex form of energy healing makes patients somehow feel better, live longer or experience life more wholesomely, the hypothesis is scientifically testable. And even if, for a particular claim, no validated outcome measure exists, scientists would certainly be able to develop one. The notion of “my therapy defies scientific testing” merely discloses a lack of understanding as to what science can achieve - or, more likely, a fear of being tested and found wanting - or, even more likely, an attempt to mislead consumers.

In health care it is unwise, dangerous and arguably unethical to give “the benefit of the doubt” to under-researched therapies. In the best interest of patients, we should ideally employ only treatments that are supported by sound evidence; and this clearly means that we have to consider all interventions to be ineffective until sound data to the contrary are available. Yet many proponents of alternative medicine like to stress that the absence of evidence of an effect does not constitute evidence of the absence of an effect. In other words, just because we have no evidence on the effectiveness or safety of a particular type of alternative medicine, we cannot simply assume that it is ineffective or unsafe.

The principle is, of course, theoretically correct: we have not identified life on other planets, for instance, but we cannot be sure that no extraterrestrial life exists. However, the conclusion some enthusiasts of alternative medicine draw from this principle is fallacious. They like to argue that, until evidence emerges which proves that a treatment is ineffective, it is reasonable or in the best interest of patients to continue using the treatment in question. Intriguingly, the people using this argument are usually the quickest to decry scientists’ attempts to evaluate the very methods that they espouse so passionately.

A particularly seductive idea - often one that need only be subtly implied rather than overtly stated - is that alternative medicine is intrinsically more compassionate than conventional medical care. This argument has instant resonance with a public that is all too familiar with the harried physician whose time is always limited and who often does a less than perfect job of answering questions and anticipating patients’ concerns. Indeed, one of the major influences fuelling the growth of alternative medicine during recent decades has been the quest for a lengthier and more personal interaction with the caregiver.

In my experience, it is true that many alternative practitioners are full of good intentions and often manage to cultivate a friendly and empathetic therapeutic relationship with their patients which may well have useful potential in its own right. However, to extrapolate from this that alternative therapies are therefore effective or useful is little more than a self-serving delusion. There is nothing intrinsically heartless about conventional medicine, nor does alternative medicine have a uniquely gentle, caring ethos. Compassion, empathy and good patient–clinician interactions are not the exclusive purview of any particular branch of medicine. On the contrary, they are the hallmarks of any good health care, whatever its philosophical or therapeutic orientation.

Many forms of alternative medicine have a long history, and proponents use this undeniable fact to convince the public of its value. Any treatment that has passed the test of time, they say, must be effective and safe - after all, people are not stupid: why would they persist in using such treatments if they did not work or if they caused harm? Some alternative medicine enthusiasts even view the “test of time” as more relevant than any objective evaluation. Clinical trials, they insist, are of necessity artificial and relatively small-scale, while tradition is real and large-scale. A long history of use is therefore a more conclusive test than science can ever provide.

An established tradition can, of course, be a valuable indicator suggesting that a treatment is safe and effective, but it can never provide solid proof. A long history might simply mean that the origins of that particular therapy reach back to the days when the basic medical sciences such as anatomy, biochemistry and physiology were not well understood; in this case, it might merely disclose a significant weakness in its foundations.

In an attempt to promote wider acceptance of their particular alternative model, devotees often invoke the support of authority. They may, for instance, state that the UK National Health Service endorses their particular modality; or that, in China, acupuncture is supported by the government; or that respectable nationwide pharmacy chains sell their products; or that the Royal family or some other celebrities use this treatment; or that Nobel Prize winners support it, etc. These claims might well be true, but one cannot infer from them that the treatment in question must therefore be valuable. The fact that any person or institution, however well respected, praises or adopts something never constitutes proof of anything. It might merely illustrate that even well-educated people or powerful institutions can sometimes commit the silliest and most obvious of mistakes.

An entire industry has developed around the fallacious concept that, because something is natural, it cannot do any harm. Implicit in this notion is the perception that conventional medicine is somehow inherently unnatural, relying heavily on drugs that are derived from harmful synthetic chemicals. Nature, by contrast, is seen as benign, and natural remedies are therefore not just intrinsically superior but also safer.

While undoubtedly clever for marketing purposes, this argument is nevertheless false and in many instances even dangerous. By no means are all forms of alternative medicine natural or benign. For instance, there is nothing natural in sticking needles into a patient’s body (as in acupuncture), or endlessly diluting and shaking a medicine (as in homeopathy), or in introducing gallons of tepid coffee to the large intestine via the rectum (as in the coffee enemas so beloved by many alternative practitioners). Moreover, nature is by no means always benevolent, as anyone who has been out at sea through heavy weather or had the misfortune to be hit by lightning knows all too well. Even “natural” plant extracts are not necessarily safe - just think of hemlock.

It is perhaps not surprising that such irrational worldviews often include a hefty component of paranoia. Conspiracy theories and persecution complexes are the preferred way of some alternative medicine zealots to explain why mainstream medicine continues to ignore their anointed approach to health care. With unfailing regularity they claim that powerful forces are at work to suppress their time-honoured wisdom about health care. The pharmaceutical industry - Big Pharma - is almost invariably implicated as the chief villain in this context. The fevered plot has it that the pharmaceutical industry is systematically sabotaging alternative medicine because it would lose substantial amounts of revenue if the true value of this or that form of alternative medicine were to become general knowledge.

During my many years of researching alternative medicine, I have never seen a scintilla of evidence to suggest this allegation to be true; nor can those who make such charges ever produce good evidence to substantiate them. In my experience, the pharmaceutical industry is barely aware of the alternative medicine industry - when it is, it usually finds ways of profiting from it, for example by marketing “natural” dietary supplements.

Next to the arch-villain Big Pharma, the medical profession comes a close second. Oncologists in particular are singled out as ruthless conspirators, single-mindedly suppressing alternative cancer “cures”. So far, I have not met one oncologist who would not be delighted to have access to further effective cancer cures without caring a damn whether they originated from the field of alternative medicine or from any other source. Furthermore, if there were indeed effective natural, alternative cancer cures known to - but suppressed by - oncologists, no oncologist, nor any friend, colleague or family member of an oncologist, would ever die of cancer. Yet they are just as likely as anyone else to fall victim to this category of diseases.

We live in times where political correctness regularly drives us to look for the middle ground in areas where there simply is none. Journalists are particularly apt to kowtow to ideological orthodoxy in this way. For example, a health journalist writing an article about homeopathy might diligently present all the facts about the implausibility of the rationale on which homeopathy is based, and the lack of evidence to suggest that it has consistent, replicable value in the treatment of illness. But, obedient to the zeitgeist of cultural relativism, the journalist would also feel obliged to “balance” this with input from the “other side” - i.e. with quotes from a homeopath who says that science cannot know everything and his personal experience is more important than scientific data.

This would, of course, be fair enough, provided there were a reasonable “other side” whose arguments had weight and substance. If, however, the “other side” is not of equivalent substance, this insistence on balance creates the erroneous impression that there is a continuing, valid scientific debate between two equal hypotheses, while, in fact, there is complete consensus and the science has long been settled. The discussion as to whether the earth is flat or a sphere is as closed as is that concerning homeopathy. Imagine that National Geographic were to publish an article “balancing” existing scientific knowledge by presenting the opinions of a member of the Flat Earth Society. Who would take it seriously? Yet we regularly accept the equivalent when discussing homeopathy. In some areas of alternative medicine, the insistence on a middle ground approach is not only unreasonable but also misleading and potentially dangerous.

When the enemies of reason run out of arguments there is always the time-tested ad hominem fallacy to fall back on. The sole purpose of ad hominem attacks is to discredit one’s opponent - and, in pursuit of this noble end, the ad hominem assailants need not trouble themselves with inconvenient little details such as ethics or truth. Instead, they can give their imagination free rein to invent whatever fanciful possibilities they need in order to lend weight to their assaults. During the 20 years I spent researching alternative medicine, I was on the receiving end of more than my fair share of such personal attacks, and one of the most insistently repeated assertions is the myth that I was being paid by Big Pharma to tarnish the reputation of alternative medicine. It goes without saying that this allegation is untrue; but how can I prove it? Perhaps the fact that my unit had to close because of lack of financial support might convince my detractors - according to their own logic, research funds from Big Pharma should have been endless.

All of these disparate smokescreens, errors, conspiracy theories, follies and fallacies are used in Wonderland as tools with one common purpose: to mislead the public such that even the most extravagant absurdities of alternative medicine appear plausible. Collectively they help foster and perpetuate a culture of unreason that is essential for the survival of alternative medicine. In essence, they constitute an attack upon rationality and a treason against progress in health care.

But undoubtedly the most useful tool of all is an influential person, a figurehead behind whom the enemies of reason can be counted on to rally obediently, a leader who can motivate and direct them in their rejection of science and the ideas of enlightenment. Different countries and different historical tides bring forth their own figureheads; in the UK the alternative medicine lobby and the forces of irrationality must surely count themselves lucky to have found their supreme champion, their unlikely Goliath, in the person of the Prince of Wales.