Mammoth Reads: Homeopathy, Philosophy, Monopoly

Water in the Pill

Pharmacist Scott Gavura reviews a paper titled “Against Homeopathy — A Utilitarian Perspective” from the journal Bioethics about when it might be ethical to use homeopathy in a clinical  setting.

Homeopathy is based on the “theory” that “like cures like.”  In essence, find a substance that produces symptoms similar to those of a cold, and that substance should help to cure the cold itself.  Furthermore, homeopathy states that the more a substance is diluted in water the  more potent it becomes, which is, of course, bunk.  Claims like these (and those of many other homeopathic fantasies) fly in the face of everything we know about basic physics.  (Here is a search for “homeopathy” from Neurologica Blog; Steven Novella has done more writing on the topic than anyone else I know of, and his blogs are a terrific resource for anyone interested in the evolving fight to keep homeopathy and other dubious “alternative” medicine practices out of so-called mainstream medicine.)

To Gavura’s point (and also Kevin Smith’s, the author of the Bioethics article): the decision to use homeopathy in a clinical setting would be contingent upon no other feasible treatments being available.  A placebo would provide only the advantage of psychological comfort to the patient.

Neither Gavura nor Smith appear too convinced that prescribing a placebo in such a scenario would be ethical.  Neither am I; and Gavura provides a terrific outline of why placebos generally don’t have a place in clinical treatment, tackling the ethical issues with more authority than I can pretend to.

As a patient, I don’t want my doctor to deceive me with a fairy-tale medication, even if it means I have to grapple with an inconvenient truth.  Bottom line: a patient has the  right to provide informed consent.  One can only do so if they’re provided with facts—not a vial of what’s really nothing more than water.

…And Then Someone Asked “Why?”

I don’t, frankly, have a whole lot to say about this one; I have been an outspoken, if somewhat intellectually lazy, critic of philosophy as a worthwhile endeavor, though I’ll admit to using the term loosely, often referring more to the lame mental ejaculate that commonly passes for insight.

Katja Grace on the matter, from Meteuphoric:

…It matters whether the methods that were successful at providing insights in what were to become fields like psychology and astronomy—those which brought definite answers within reach—were methods presently included in philosophy. If they were not, then the fact that the word ‘philosophy’ has come to apply to a smaller set of methods which haven’t been successful does not particularly suggest that such methods will become successful in that way.

At any rate, the utility of philosophy is worth considering.  My sneaking suspicion is that the conjecture and loose framing of conceptual questions provided by philosophical thought is an important starting point.  Eventually, though, scientific inquiry takes over, redefines, and, ideally, answers the  questions we’ve posed.  In some cases, science viciously neuters philosophies.  For instance, those philosophers who continue to idly ponder the nature of the universe—its structure, the implications of its existence, etc.—would probably do well to let physicists answer those questions.

Perhaps philosophy is, in some respects, more equipped to investigate social and intellectual issues than it is problems with supposedly quantifiable solutions.

The Freedom to Compete

I’ve tried to follow the Net Neutrality wars over the past year or so, and I’ve been an advocate of the FCC baring its teeth for once to stand up to the telecommunications corporations.  (How long can an organization be so preoccupied with tits on TV, after all?)  Sadly, they offered a watered down plan and made too many concessions to the oligopoly that currently owns the pipe.  My interest in this regard is not in more or less regulation, but in good regulation.  As I see it, if too much regulation ends up stifling positive competition, then it should be loosened or done away with.  If the opposite is true, then the market should be regulated accordingly.

In North Carolina’s case, municipalities and co-ops have been creating broadband networks that outperform—both in price and in speed—those of Time Warner and other commercial purveyors, but a bill passed the North Carolina House and Senate with veto-proof margins that restricts public competition.  Today, Gov. Perdue failed to veto the bill, perhaps because her veto would have probably been overturned.

Doc Searls explains the nature of the internet in its current capacity:

We also need to recognize that the Internet is a utility and not just the third act (after phone and TV) in the “triple play” that phone and cable companies sell. The Net is more like roads, water, electricity and gas than like TV or telephony (both of which it subsumes). It’s not just about “content” delivered from Hollywood to “consumers,” or about a better way to do metered calls on the old Ma Bell model. It’s about everything you can possibly do with a connection to the rest of the world. The fatter that connection, the more you can do, and the more business can do.

I think Searls is dead-on when he classifies the internet as a utility and then goes on to support the idea that competition related to broadband services, from whatever source, will be crucial to moving our web forward, especially in rural areas where broadband penetration is low.  Searls also posts a letter written to Gov. Perdue by Larry Lessig—whose books Code: Version 2.0 and Remix are two fantastic texts about the potential and future of the internet—that parses the issue as only Lessig could.

Searls’ post is still worth a read even though the bill has now formally become law.  He sketches out the basics of why net neutrality needs to be protected at the state level, not just in Washington, as well as why improving internet service will require a multifaceted approach that involves both the cable/telephone companies and municipalities.  Beefing up our broadband  capabilities is not optional; our future requires widespread access to fast, affordable internet.

 

June 14, 2011

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  • Mike Kew

    If you’re interested in homeopathy, I recommend Ben Goldacre’s blog at badscience.net.

    I don’t think physicians should ever dismiss the placebo effect (and I suspect practising physicians have a great deal more respect for it than researchers). If you’re worried about the ethics of it, then by all means tell the patient that it’s a placebo, but give it anyway. The form of words is something like:

    “At the moment, I don’t think I can prescribe anything for your specific condition. However, many patients who have had similar symptoms have said that these pills, called ‘sugar pills’, have been a great help to them. I suggest you try these pills – take one three times a day, after meals, for a week, and I think your symptoms will improve by the end of that time.”

    No lies necessary. Also, the pills don’t have to be made with all that seriously expensive homeopathic voodoo crap – they can be plain ol’ sugar, as cheap as you like.

    • http://www.slothjockey.com/blog/evilmammoth Evil Mammoth

      I swing by Bad Science every now and then; Goldacre’s done some interesting work, but I’m not sure I agree that placebo has a place in clinical practice. It should be studied, certainly, but should it really have a place in clinical practice? If so, to what end? Most of the placebo effect can probably be explained by observer bias and selective (subjective) pain reporting on the part of a patient. There is nothing that supports the use of placebo for any specific indication.

      So what’s the point? What would the point of telling the patient be? One sacrifices most of the “efficacy” of the placebo effect when this happens, and when would it be appropriate to prescribe placebo?

      The only scenario in which I can see it being legitimately considered is during palliative care, which is normally carried out with heavy sedatives anyway.

      I think the perception of the placebo effect suffers from the same mystic shroud people have thrown around quantum mechanics. Placebo, when there is a physical effect, amounts to the brain fooling itself.

      (Also, practicing physicians often rely on anecdotal experience a bit too much. Sometimes that’s all they have to go on, but it’s not clear to me&#8212not necessarily, anyway—that the distinction between a clinician and a researcher should affect our view of placebo as a treatment modality.)

    • Mike Kew

      I’m not a doctor, I’m going mostly by Goldacre’s writings on the subject, but I did pick up a couple of things that surprised me.

      One: it’s not true that telling the patient sacrifices the efficacy of the placebo. If you use a careful form of words, similar to what I’ve described above, to describe the pills – honestly, but without using words like “ineffective” or “placebo” – they can still work.

      Two: placebos can have real, measurable physiological effects. In Goldacre’s book he describes a study with stomach ulcer patients. I’ll try to find the full reference to the study, but the gist as I remember it is that patients “treated” with a placebo had a significantly improved chance of the ulcer diminishing and vanishing over the course of treatment.

      And even if it is just a trick to make the patient think they feel better – isn’t that a worthwhile goal in itself?

      Speaking for myself: around 1996, I went to a doctor with acute stomach pain. She diagnosed a viral infection, and prescribed pills that, in retrospect I’m reasonably sure, were placebos. They didn’t noticeably ease the pain, but there was still an element of comfort in feeling that I was taking a treatment. And I really don’t see why doctors should be judged or condemned for giving that kind of treatment.

      • http://www.slothjockey.com/blog/evilmammoth Evil Mammoth

        I’m not a doctor either, but I have some basic issues with a couple of these points:

        1. “…If you use a careful form of words, similar to what I’ve described above, to describe the pills – honestly, but without using words like ‘ineffective’ or ‘placebo’ – they can still work.” Placebos can still work if you tell someone who earnestly believes in them that sugar pills are rubbish and will never cure anything. The effectiveness is contingent upon the willingness of the patient to believe in the effect. Basically, you’re saying that a type of deception is still necessary to achieve the effect: the doctor has to pussyfoot around the real answer and say that other patients may have experienced benefit. Generally, there are a number of things (regression to the mean, self-limited illness, etc.) that can give the false impression of placebo being effective.

        2. “…placebos can have real, measurable physiological effects.” That ulcer study, as far as I know, doesn’t actually prove any measurable physiological effects. It studied placebo for a condition known to be affected by stress levels; a placebo’s ability to put a patient at ease (a psychological effect), thus decreasing said stress, could easily have contributed to the quicker resolution of the ulcers.

        If we agree that a doctor’s job is to treat someone and to provide effective treatment, then placebo has no place in clinical practice. Helping a patient deal with a condition psychologically can be achieved through other means, and any prescription a doctor makes should have a reasonable chance of affecting disease course. Placebo most likely does not; it only alters patient perception.

        As for your experience in 1996, there a few limitations to the interpretation of placebo’s role in your recovery: 1) you’re not sure they were placebos; 2) there is no objective confirmation of a viral infection, only the doctor’s impression (from what it sounds like); 3) even if you did have a viral infection, these types of infections are normally self-limited and will resolve in a reasonable period of time without intervention. There is no way of knowing that the placebo had anything to do with your recovery or how long you would have been sick if you hadn’t taken them at all. It’s good that you felt better during the illness, but it’s also possible you may have been prescribed antivirals of some kind, which may have had a noticeable impact on the duration of your infection.

        (I don’t mean to diminish your experience. I’ve had acute bouts of pain as well, and I know they can be frightening and extremely frustrating, especially when the cause remains unknown.)

        If the element of comfort is to be part of the rubric, then we have to pull back or temper our criticism of acupuncture, chiropractic, and other such modalities that rely specifically on the vagueness of the placebo effect in order to thrive.

        • Mike Kew

          Of course regression to the mean (etc.) can cause a false impression of placebos working. But that doesn’t mean they don’t work.

          You can read about the gastric ulcer effect on the Wikipedia page on placebos. Ulcers are a very popular effect to study, because they don’t rely on patient self-reporting – either you have an ulcer or you don’t, and there’s a very unambiguous clinical test to tell the difference. (Another twist which I didn’t know: of 31 trials included in the meta-study, two included followups to check on levels of relapse, and it turned out that patients treated – and healed – with placebo were much less likely to relapse than those treated with actual drugs.)

          So I think, if a doctor says to a patient “sugar pills never cured anything”, he is making a statement of faith that’s simply not supported by clinical evidence. It is both more encouraging and more truthful to say “we don’t understand why, but some patients respond well to this treatment.”

          I suspect (although I don’t have any direct knowledge) that clinical researchers are trained, from an early stage, to think of “placebo” and “ineffective treatment” as synonymous. A placebo group is a control group, it’s the group where you don’t expect to measure any improvement. And so when members of that group do improve, it’s attributed to normal regression. Similarly, you seem to take it as axiomatic that a placebo, by definition, can’t be an effective treatment. I think that’s a mistake, and one that undermines your scientific rigour.

          I think a doctor’s role is to provide a patient with the best available treatment for their condition. If there’s an appropriate drug to prescribe, then fine. If not (and there may be very valid reasons why not – if the diagnosis is uncertain, or the available drugs may be contraindicated for any number of reasons), then there is pretty good evidence that a placebo is still better than nothing. And sure, there may be other ways to induce the psychological benefit (if that’s what it is) of the placebo effect – but it’s not clear to me why that’s a reason not to use placebos. To make it so, you’d have to show that these hypothetical alternatives are actually more effective (taking into account the time they require, cost, likelihood of the patient actually completing the treatment, etc.).

          The point about my own experience is not whether the suspected-placebo was effective or not. (Because as you rightly point out, it would be ridiculous for me to come to that conclusion based on the total lack of evidence I have.) The point is that I, as a patient, believe my doctor lied to me – and I don’t mind.

          I know the fashion nowadays is for patients to be consulted and informed about all aspects of their treatment. But I’m not aware of any trials showing that this leads to better health outcomes. As far as I can tell, it’s a question of ideology, rather than medical evidence.

          • http://www.slothjockey.com/blog/evilmammoth Evil Mammoth

            To be clear, I’m not saying it can’t; I’m saying it’s highly unlikely that placebo does have any specific indication. If it does, that indication has not yet been identified.

            As for the ulcer meta-analysis: I checked the Wikipedia entry and began reading a couple of the references there. At least one study that I started on—plus, I’m fairly certain I heard mention of others like it—was non-randomized. Now, not being a doctor or statistician, I’m not sure if this puts the results in definite doubt, but I do know it’s a red flag. In addition, the positive effects of placebo seemed to be all over the map in many respects, and the seemingly improved rate of relapse for placebo could have been explained by unknown negative effects of the active drugs somehow promoting relapse. I simply don’t know enough to say, however.

            The point is not that the placebo effect shouldn’t be studied. You mentioned scientific rigor in your reply; I am by no means the poster boy for that, but I try to base my opinions on expert interpretation of the evidence as well as my own accumulated knowledge, the latter of which serves primarily to identify obvious red flags: I leave the complicated analysis up to those who know what they’re talking about. After all, doubt is the primary driver of science.

            It’s possible I’m being a bit axiomatic, but my point is mainly that the placebo effect has not been subjected—as a specific treatment—to sufficiently rigorous tests which would justify its use by a doctor. Most meta-analyses (such as those from Cochrane, which do have their problems sometimes) show no overall indication for placebo use in the treatment of disease with objective outcome parameters. (Again, those with subjective outcomes are a bit trickier.)

            Saying that something works but that we don’t know how means that the intervention is not likely ready for the big time. I hate to bring complimentary and alternative medicine (CAM) into this, but that’s the argument we hear too often from homeopaths and acupuncturists. “Well…something is happening, so it must be a justifiable treatment.”

            “then there is pretty good evidence that a placebo is still better than nothing” : I’m not sure this is true. Again, it depends highly on what disease you’re talking about. I could not imagine someone with Guillain-Barré Syndrome experiencing much relief due to a placebo.

            That being said, I like what Harriet Hall says in this comment about “comfort measures.” I’m all for comfort measures, but a doctor pretending to give a patient something for their disease—even a placebo described as “something that may make you feel better”—is a violation of the doctor-patient relationship.

            “I know the fashion nowadays is for patients to be consulted and informed about all aspects of their treatment. But I’m not aware of any trials showing that this leads to better health outcomes. As far as I can tell, it’s a question of ideology, rather than medical evidence.”

            I’m not aware that any trials of this kind are necessary. Agreeing on a treatment regimen in consultation with their doctor is a patient’s right, is it not? How can consent be mutual if the patient must be deceived—though this concept might differ based on our seemingly different definitions of deception. (The Patient’s Bill of Rights also gives the patient a right to have a say in their treatment decisions, so there is some legal framework for this as well.)

            There just isn’t enough evidence that placebo is an effective treatment option, and sanctioning its use for clinicians might open a door for widespread use of other dubious treatments. We’re already seeing some CAM creep into respected hospitals.

          • http://www.slothjockey.com/blog/evilmammoth Evil Mammoth

            By the way, I will read deeper into this to try and cover my blind spots. I’m sure they’re there.

            I think you should read the series of posts called something like “EBM vs. SBM Redux” over at Science-Based Medicine. It might be interesting and tangentially related to the differences in our opinions.

          • Mike Kew

            Interesting philosophical question here.

            You say “Agreeing on a treatment regimen in consultation with their doctor is a patient’s right, is it not?” – so basically, yes, this is an ideological position, not a scientific one.

            Assuming for the sake of argument that I agree to that (which I’m not at all sure I do), how does it reconcile with the doctor’s duty – which you’ve previously described as “to treat someone and to provide effective treatment”?

            I suspect your first reaction will be that the duty of honesty should trump the duty to provide effective treatment – i.e. if the doctor could provide better treatment by lying to their patient, they still shouldn’t. But how does that order of priorities affect the doctor?

            Speaking for myself, I want my doctors to be the sort of people who care about their patients and get fulfilment out of healing them. What I fear – although obviously there’s no research to back this up either – is that requiring them to get patient buy-in all the time is going to drive those kinds of people out of the profession, to be replaced with cooler, more detached types who are happy so long as they get paid at the end of the day.

            Anyway, I’ve spent quite enough time on this now – it’s time I did some work. Thank you for a very stimulating discussion. I’ll try to check out the posts you mentioned.

          • http://www.slothjockey.com/blog/evilmammoth Evil Mammoth

            The patient has the right to refuse medical service: This is codified and probably a good thing in order to prevent unwarranted/unwanted treatment. That being said, I usually take a doctor’s advice or get a second opinion if I’m not satisfied. However, I’ve had to refuse antibiotics in the past because a doctor prescribed them for an illness that was likely viral, despite knowing that I am allergic to most antibiotics.

            That was improper care, and without the luxury of patient consent, I would have unknowingly taken a drug that may have been dangerous for me.

            There are no absolutes in the doctor-patient relationship; a well-educated patient probably makes a better one, though.

            At any rate, I’m with you: There is more reading we both could be doing at this point.

            Thanks to you as well—for reading and for the discussion.

  • http://drnancymalik.wordpress.com/article Dr.Nancy Malik

    The word “pharmakon” translated as ‘drug’ and meaning both ‘remedy’ and ‘poison’. Pharmacopoeia is an official book published by the government containing list of medicines with information about sources, description, identification, preparation and standardisation. Pharma-co-logy is a branch of medicine that encompasses drug interaction, toxicology, pharma-co-dynamics and pharma-co-kinetics.
    Ref: http://drnancymalik.wordpress.com/article/science-based-pharmacy/