Number of Views: 4
Citation:
Ernst, Edzard, and Simon Singh. 2008. Trick or Treatment: The Undeniable Facts about Alternative Medicine. 1st ed. W.W. Norton & Co.
Rating:
10/10
Review:
Few non-fiction books I have read are as well-written and as clear in their message as is Trick or Treatment. I believe this book should be required reading in high school.
The book begins with a chapter on the importance of scientific thinking, illustrating that most people use scientific thinking every day in their lives – they develop a theory, gather evidence, then determine if their theory was correct (e.g., Is my child sick? Is the cake done?). But one area where critical, scientific thinking is not always used is in healthcare. This book is about the widely accepted but nonscientific practices often referred to as “alternative” or, worse, “complementary” medicine. The definition the authors use for alternative medicine is, “any therapy that is not accepted by the majority of mainstream doctors, and typically this also means that these alternative therapies have mechanisms that lie outside the current understanding of modern medicine. In the language of science, alternative therapies are said to be biologically implausible” (p. 1).
The authors also discuss how it is determined whether or not an intervention or treatment (e.g., a drug or procedure) works in science. The “gold standard” is a randomized, double-blind, clinical trial with the following characteristics:
1. A comparison between a control group and a group receiving the treatment being tested.
2. A sufficiently large number of patients in each group.
3. Random assignment of patients to each group.
4. The administering of a placebo to the control group.
5. Identical conditions for the control and treatment groups.
6. Blinding patients so that they are unaware to which group they belong.
7. Blinding doctors so that they are unaware whether they are giving a real or a placebo treatment to each patient.
If you’re unfamiliar with science, the book explains why such an approach is necessary. You need two groups to which people are randomly assigned in order to determine whether the intervention has any effect. But the control group receives a placebo (an inert version of a drug or sham procedure) to account for our brain’s ability to both help us heal and convince us that we are healing simply because something was done, regardless of the intervention’s actual scientific merits. Both the researchers and the patients must be blinded as well to insure that there is no difference in treatment of patients, which can bias the results. In short, the randomized, double-blind, clinical trial is the gold standard because the results from such trials are the most reliable of any scientific approach. Thus, the book, as it reviews alternative medicines, relies on such trials where available. It should also be noted that practitioners of alternative medicine do conduct their own “research”, but it rarely meets the criteria laid out above for sound research. In fact, there are numerous peer-reviewed journals for alternative medicines that allow these people to “publish” their research then cite their research to lend legitimacy to their mostly illegitimate work. So, practitioners of alternative medicine have done everything they can to imitate legitimate science except actually use the standards that legitimate scientists use to determine whether their interventions work. Alas, the average person may not be aware of these subtleties, which is why this book should be required reading!
The first alternative medicine they discuss is acupuncture. They give a lengthy history of this alternative medicine, but this short quote I think covers it adequately, “The first detailed description of acupuncture appears in the Huangdi Neijing, a collection of writings dating from the second century BC. It presents the complex philosophy and practice of acupuncture in terms that would be largely familiar to any modern practitioner. Most importantly of all, Huangdi Neijing describes how Ch’i, a vital energy or life force, flows though our body via channels known as meridians. Illnesses are due to imbalances or blockages in the flow of Ch’i, and the goal of acupuncture is to tap into the meridians at key points to rebalance or unblock the Ch’i.” (p. 43). In short, acupuncture claims to work by inserting needles into energy meridians to rechannel the flow of Ch’i.
Ironically, acupuncture was virtually extinct in the West in the early 1900s. It became widespread in China after the Communist revolution not because it works but because Chairman Mao promised cheap healthcare for everyone and he couldn’t provide cheap, Western, allopathic (or scientific) healthcare for everyone. So, he advocated acupuncture. He then engaged in a propaganda campaign to convince the Chinese it works. That propaganda leaked out of the country and found a home among the gullible in the West, leading to an increase in acupuncture (p. 46).
So, what’s the verdict on acupuncture using good, scientific tests? “[T]here is no significant evidence to show that acupuncture is an effective treatment for any of the following conditions: smoking addiction, cocaine dependence, induction of labour, Bell’s palsy, chronic asthma, stroke rehabilitation, breech presentation, depression, epilepsy, carpal tunnel syndrome, irritable bowel syndrome, schizophrenia, rheumatoid arthritis, insomnia, non-specific back pain, lateral elbow pain, shoulder pain, soft tissue shoulder injury, morning sickness, egg collection, glaucoma, vascular dementia, period pains, whiplash injury and acute stroke” (p. 77). Any perceived effect of acupuncture on these conditions is purely placebo.
One of the things that makes this book particularly compelling is that, while the authors are clearly skeptical of alternative medicine, they report the scientific findings, even if they may not agree with them. Thus, they do note that there is some questionable evidence that shows that acupuncture may be effective in treating, “pelvic and back pain during pregnancy, low back pain, headaches, post-operative nausea and vomiting, chemotherapy-induced nausea and vomiting, neck disorders and bedwetting” (p. 79). However, keep in mind that even these assertions of efficacy are couched in very tentative terms, as those reviewing the evidence (the Cochrane review) say that the quality and amount of evidence is not convincing (p. 79). What’s more, recent research employing better controls contradicts even these tentative positive findings, suggesting that any affect of acupuncture is purely placebo (p. 81)
That the results are placebo is not at all surprising given the fact that the proposed mechanism of acupuncture is completely non-sensical and wholly without scientific merit. There is, of course, no evidence of Ch’i or meridians in the human body. In short, when high quality trials are conducted using a comparable and convincing placebo (i.e., sham acupuncture), there is no effect beyond placebo. What’s more, acupuncture is not without its risks, “treatments can result in minor pain, bleeding or bruising, but these adverse reactions are only minor: they occur in roughly 10 per cent of patients and are transient. Slightly more serious side-effects include fainting, dizziness, nausea and vomiting, but again these events are rare and are usually associated with anxious patients who may have a fear of needles. Although most patients may accept such risks as an unsurprising consequence of being pierced with needles, there are two very serious adverse effects that patients should consider in advance of visiting an acupuncturist. The first of these is infection. This is a concern because there have been several documented cases of patients contracting diseases such as hepatitis… The other serious risk to patients is the danger that needles might puncture and damage a major nerve or organ. For example, needling at the base of the skull can lead to brain damage, deep needling in the lower back can damage a kidney, and there are over sixty reported cases of punctured lungs, known as pneumothorax” (p. 183). So, before you say that a placebo benefit is some benefit, keep in mind that there are a number of risks associated with this practice and no benefits beyond placebo.
The second alternative medicine discussed is homeopathy. Homeopathy, while surprisingly widespread in the U.S., isn’t widely recognized by the name “homeopathy”, even though homeopathic remedies are on the shelves of pretty much every pharmacy in the U.S. As with acupuncture, the authors give a short history of homeopathy, which was developed in the U.S. by Samuel Hahnemann who “experimented with other treatments and obtained the same sort of results: substances used to treat particular symptoms in an unhealthy person seemed to generate those same symptoms when given to a healthy person. By reversing the logic, he proposed a universal principle, namely ‘that which can produce a set of symptoms in a healthy individual, can treat a sick individual who is manifesting a similar set of symptoms’. In 1796 he published an account of his Law of Similars, but so far he had gone only halfway towards inventing homeopathy. Hahnemann went on to propose that he could improve the effect of his ‘like cures like’ remedies by diluting them. According to Hahnemann, and for reasons that continue to remain mysterious, diluting a remedy increased its power to cure, while reducing its potential to cause side-effects” (p. 95). The basic idea is, you give sick people something that would make a healthy person sick with the same symptoms and that will cure them. But, you don’t actually give them any of the substance that would cause such a reaction. Instead, you give them a diluted version of it.
How diluted, you ask? “The bottom line is that this level of dilution is so extreme that the resulting solution is unlikely to contain a single molecule of the original ingredient. In fact, the chance of having one molecule of the active ingredient in the final 30C remedy is one in a billion billion billion billion. In other words, a 30C homeopathic remedy is almost certain to contain nothing more than water” (p. 99). As noted above, you can purchase these “potions” or “magic pills” in most pharmacies. What you are purchasing is, of course, water or a sugar pill as there is nothing in the remedy if Hahnemann’s principles of dilution are actually followed.
Given the proposed mechanism (like cures like) and level of dilution, this alternative medicine should immediately become suspect as these two ideas run completely counter to modern, scientific thinking (p. 100). There is no evidence that either of these ideas has any scientific merit whatsoever. What’s more, when high quality clinical trials have tested homeopathic remedies, they have been shown to be no more effective than placebos (p. 139). In short, homeopathy is scientifically unsound and pure quackery.
The third alternative medicine examined at length in the book is chiropractic. Chiropractic is the most widespread alternative medicine in the U.S., where nearly $3 billion is spent on this therapy every year (p. 147). It’s so widely accepted that even some health insurance companies cover chiropractor visits (p. 147). So, what is it? As with the previous two alternative medicines, the authors provide some history, beginning with it’s founder, Daniel David Palmer in the late 19th Century,“The chiropractic approach to medicine emerged towards the end of the nineteenth century with a radically new view on health. The founders of chiropractic therapy argued that poor health was due to subluxations, by which they meant slight misalignments of the vertebrae in the spine. In turn, they believed that subluxations interfered with the flow of so-called innate intelligence (akin to a life force or vital energy), which then led to health problems of all sorts” (p. 147). By aligning the spine, it was claimed that all sorts of health problems could be cured, including: asthma, bedwetting, clumsiness, ear infections, gastric problems, hyperactivity, immune-system problems, learning disorders and respiratory problems (p. 180). Chiropractors will also “treat” children and even infants (p. 180).
There has been some change in the chiropractic profession over time, as some chiropractors (called “mixers”) have started to incorporate elements of mainstream medicine (p. 166). But the majority of chiropractors (somewhere between 70% and 80%) remain “straights,” claiming innate intelligence and spinal alignment can cure all sorts of ailments. Even so, the scientific evidence suggests that chiropractic is completely ineffectual for anything other than back pain (p. 167). And when compared with conventional medicine when it comes to the treatment of back pain, it is “just about as effective (or ineffective) as the other” (p. 156). It should be noted here, of course, that science-based medicine does not have good treatments for back pain. Thus, to say that chiropractic is as effective as science-based medicine is really to say that neither of them are very effective at treating back pain.
Chiropractic actually warrants additional criticism beyond simply being scientifically unsound. Chiropractic is big business and is often used simply to enrich the practitioner, “chiropractors, particularly in America, have earned a reputation for zealously recruiting and unnecessarily treating patients. Practice-building seminars are commonplace and there are numerous publications aimed at helping chiropractors find and retain patients. In many cases the emphasis seems to be placed on economics rather than healthcare: the chiropractor Peter Fernandez is the author of a five-volume series called Secrets of a Practice-Building Consultant, which starts with a volume boldly titled 1,001 Ways to Attract Patients and ends with How to Become a Million Dollar a Year Practitioner” (p. 170). In short, chiropractors can’t treat anything other than back pain, and they are not very good at that, but they can empty your wallet!
The last alternative medicine to receive lengthy treatment in this book is herbal medicine. The authors admit that herbal medicine is much trickier to examine because there are clearly medicinal properties in plants – plants have all sorts of drugs in them (p. 196). But herbal medicine practitioners, like other practitioners of alternative medicine, do not subject their practices and “medicines” to the rigors of scientific inquiry (p. 197). What’s more, herbal medicines are generally not regulated and there is no safety control; you don’t know what you’re going to get in a bottle of herbal medicine. In short, herbal medicines may or may not affect you, but they stand about as good of a chance of negatively interacting with other medicines you are taking or causing other negative complications as they do in helping you.
So, given the stunning lack of scientific support for alternative medicines, why do people use them? For some, they have run out of options from conventional medicine and are willing to try anything. But for many others it is ignorance compounded with the misinformation of practitioners of alternative medicine who are often motivated more by money than helping people. What’s more, alternative health practitioners, to bolster their market position, are often critical of mainstream science, hoping it will garner them more clients. Obviously such an approach is not in the best interest of public health, but lining their pocketbooks and fleecing the naïve is more important to many practitioners of alternative medicine than is actually improving the lives and health of people.
The authors ultimately suggest that alternative medicines should be held to the same scientific standards as is conventional medicine (pp. 281-282). Doing so would go a long way toward reducing quackery and the fleecing of the naïve. I whole-heartedly agree.
Overall, this book is superb. I recommend it without qualification. Everyone should read it. It is written at a very understandable level, includes many intriguing stories (e.g., George Washington was killed by alternative medicine practitioners), and is well-sourced. This book should be in every home library.
Note: The book also includes short blurbs on an additional couple of dozen alternative medicines, providing a very brief summary of what it is and what the scientific evidence is for those practices. That section makes for a very useful guide.
