Perception of Effectiveness of Homeopathy and Other Alternative Medicine Relies on Placebo Effect

The world of alternative medicine – nowadays more fashionably known as complementary and integrative medicine (CIM), replacing the erstwhile CAM (A = alternative) – encompasses a wide range of practices. Some of these practices involve physical motion of parts or whole of the body, such as massage, Yoga, and Tai Chi; if one subtracts the dollops of mysticism, especially of Eastern origin, that have come to be associated with these practices, one finds that they perform much of the same functions as any other regular exercise regimen, providing similar benefits. A few practices employ dietary supplements (vitamins, minerals, various salts, et cetera) and folk-remedies based on herbal medicine (Traditional Chinese Medicine/TCM, Ayurveda, Siddha, Unani, Amachi, and so forth) – some of which may and do contain biologically active substances, but the evidence for those being functional, safe, and effective therapeutic modalities in actual clinical situations is extremely scant, and the wide-ranging claims made by the practitioners are mostly never backed up by solid, scientific empirical methods. (Further reading: 1. Veteran ScienceBlogger Orac explains how the multi-billion dollar Supplements Industry takes their adoring clients for a ride; 2. I argue how the recent accolades for work stemming from the use of herbal medicine as a resource is not a context-less validation that herbalism works.)

Most of the others are more dubious. The practices of Chiropractic and Osteopathy are modalities that interact with the physical body by manipulating specific parts; while a few procedures therein may be useful for musculo-skeletal issues, the claims made by the practitioners (respectively, chiropractors and osteopaths) oftentimes far, far outweigh the compendium of actual evidence in their support. (Further reading: In a brilliant, brilliant cartoon series, British cartoonist/author and science communicator Darryl Cunningham provides a valuable insight into the history and practices of Chiropractic.)

Acupuncture, a modality of Chinese origin which has gained popularity in the West, also interacts with the physical body using needles that are pushed into the skin; stripped of its aura of Eastern mysticism, the practice is based on prescientific, inaccurate ideas about vertebrate anatomy. (Further reading: In an editorial, scientists and science educators Steven Novella and David Colquhoun argue conclusively in favor of removal of acupuncture from therapeutic considerations, because the outcomes don’t match the claims.)

A few CIM practices are so completely outlandish that they beggar description; based on myths, mysticism, superstition and wishful thinking – compounded by a soupçon of ignorance about physics and other natural sciences – the modalities of Reiki, therapeutic touch, magnet therapy, distance healing and intercessory prayer should not only be excluded from any therapeutic armamentarium, but should be considered actively harmful, because they often keep the patient from seeking actual medical care. (Further reading: Orac explains why, despite Reiki being nothing more than a mystical belief system, it appeals to certain quarters.)

That brings me to the king of magical remedies, so beloved of alt-med aficionados…

HOMEOPATHY!

A Homeopathic Medicine Chest, Northamptonshire, England, 1801 (Photo © Wellcome Images, Welcome Trust, used under CC v.4 license)

Homeopathic preparations often claim to be related to herbal medicines or organic/inorganic substances, but the impossible level of dilutions advocated in homeopathy make it physicochemically implausible for them to contain any molecule of the original solute beyond the solvent. When faced with this conundrum, an enterprising modern homeopathy-aficionado (in the person of the late French immunologist, Jacques Benveniste) came up with the theory of ‘Water Memory‘, which stated that water retained the memory of molecules that were once placed in it. Well debunked during his lifetime, the implausible theory nevertheless became a lightning rod for homeopathy-peddlers and aficionados alike, and many have continued to try proving it thereafter by various means – with, not surprisingly, no success. But none of that has stopped homeopathy from making tall claims about curing all possible sorts of diseases.

Scientific facts and explanations – tools employed by skeptics to debunk homeopathy – are merely inconveniences to the Homeopathy TrueBeliever™ who is armed with anecdotes of how homeopathy works/has worked ‘for generations’, and how they themselves were cured of their XYZ condition by using homeopathy. The tenaciously persistent question why homeopathy and generally alternative medical modalities seem to work for some people does have some rational, and maximally likely, answers, such as:

1. Post hoc fallacy: Event B following Event A is considered proof of Event B being a result of Event A, even in absence of any causal association. This is a fallacy because it doesn’t allow for the sequence of events simply arising out of chance or coincidence.
2. Regression to the Mean: This is a statistical phenomenon in which repeated measurements made on the same subject for a large enough number of times tend to have values that drift towards the mean value, thereby evening them out. This is often observed in the symptoms of patients afflicted with chronic conditions; the severity of those symptoms tends to fluctuate randomly – go up or down – based on pure chance. In clinical studies, the effect of this phenomenon is minimized by inclusion of a placebo control (see next).
3. Self-correcting conditions: Homeopaths often focus on various self-correcting ailments; this situation, much like the regression to the mean, allows them to claim treatment efficacy as the severity of symptoms decrease. One example is the use of homeopathy for hemorrhoids.
4. Placebo effect: Placebo, in the context of medical treatment, is a pharmacologically inert substance or a nonfunctional procedure, that is ordinarily not expected to produce an effect that is comparable to a defined therapeutic treatment or procedure (such as surgery). However, in practice, the group in which the placebo is applied ends up demonstrating measurable, observable effects, in terms of improvements of a health issue. This effect, known as Placebo Effect, is an ill-defined complex phenomenon, that is influenced by a multitude of different factors, not all of which are quantifiable and consistent – which is why the placebo effect cannot be relied upon as a valid mode of therapy.

Factors responsible for Placebo effect

The ill-defined factors which lead to the placebo effect include factors related to:

1. The condition itself – such as regression to the mean, and the natural progression of a self-correcting disorder;
2. The treatment – such as additional treatment, considered not relevant to the condition under study, being given in a clinical setting to the placebo group due to ethical considerations;
3. The evaluation methodology – such as investigator bias in sampling, choice of irrelevant variables as indicators of response, interpretation and selective reporting bias, and so forth; and MOST IMPORTANTLY
4. The subjects themselves – such as subject bias due to improper blinding, expectation from the therapeutic regimen, expectations due to the very situation of being included in a treatment group (which often happens when patients are desperate for a cure from some devastating disease), responses/answers conditioned by social cues (politeness, feeling of awe towards the treating physician, incorrect self-assessment, repetitions per expectation, and so forth) – amongst other factors.

Placebo Effect: A psychobiological phenomenon

How do we know this? Scientists have systematically tested – and provided evidence for – the hypothesis that placebo effect is a psychosomatic or psychobiological phenomenon, in which certain psychological and/or neurological mechanisms associated with the human experience (belief, behavior, values) are able to influence the direction and outcome of physiological processes, including those involved in the amelioration of a pathological condition; for instance, it has been demonstrated that cognitive states (such as the expectation of pain relief with treatment) can influence the perception of pain, reducing it via activation of endogenous painkillers in the brain – regardless of whether the treatment delivers an analgesic or not.

Notwithstanding the protestations of the alt-med aficionados to the contrary, it is pretty well understood that pretend-medicine such as homeopathy, implausible procedures such as acupuncture, and other assorted alt-med modalities appear to work in some people due largely to the placebo effect. So why not use the placebo effect of CIM/CAM to the advantage of the patients?

The answer is quite simple. Medical ethics, and good clinical sense. As those alt-med modalities which may have biological activities (see above), risk/benefit analysis – a cornerstone of modern medicine – is almost never performed or is even possible, because – as Professor Edzard Ernst, Emeritus Professor and former Chair of Complementary Medicine at the University of Exeter in UK, pointed out two decades ago – “… neither the potential benefits nor the risks have been investigated to the full… in CM, where evidence is more scarce than in mainstream medicine, therapeutic decisions are more likely to be based on opinion rather than evidence.” This is especially true for most herbal medical preparations, whose safety profiles are not known, and heavy metal toxicity – a serious condition – following use of herbal remedies is well documented. Therefore, using those in therapy contravenes the ethics of good medicine. As for the array of implausible, evidence-poor, pseudoscientific CIM modalities such as Homeopathy and Acupuncture, the practitioners rarely, if ever, communicate to their potential clients the facts of biological implausibility and lack of convincing evidence of clinical effectiveness. Professor Ernst, in another essay, has pointed out the significant lacunae in CIM research studies/case reports in relation to adherence to ethical standards expected of medical practices.

Harm from Homeopathy (and other alt-med)

To be sure, classical homeopathy with its impossible dilutions (at or beyond 12C or 24X) is safe and harmless, because it is inert. However, the harm is wrought when reliance on alternative medicine pseudoscience prevents a patient from accessing and receiving the benefits of science-based, tested and proven medical interventions. Homeopaths and Chiropractors have been known to be dismiss the benefits of vaccination against infectious diseases, thereby contributing to a serious public-health challenge. The mainstream treatments of most common pathological conditions, such as infections, inflammatory disorders such as asthma and diabetes, cardiovascular disorders and cancer, are based on well-established medical paradigms, and what’s more, patients respond to – and consequently, lives are saved by – these therapeutic interventions. Reliance on alternative medicine to the exclusion of real medicine, therefore, does not bode well for the health and well-being of the patients, and homeopaths and other assorted peddlers of alt-med – who are wont to make tall claims of efficacy and safety without providing empirical evidence – do these vulnerable people a great deal of disservice.