The ethics of homeopathy was once again thrust into the spotlight yesterday after a leaked draft of the National Health and Medical Research Council’s statement on homeopathy revealed the agency was considering condemning the practice of this alternative therapy.
The NHMRC’s draft statement argues that it’s “unethical for health practitioners to treat patients using homeopathy, for the reason that homeopathy (as a medicine or procedure) has been shown not to be efficacious”.
It’s certainly appropriate for the NHMRC to make a statement on homeopathy. But it’s wrong to suggest that homeopathy itself is unethical.
Limited scope
The NHMRC claims its statement is based on a recent report on homeopathy by the United Kingdom’s Science and Technology Committee, which is similar to Senate committees in Australia.
So, rather than bringing scientists together to assess the evidence, the five-member committee (all MPs) heard from a number of experts before formulating their recommendations.
The UK government’s response noted the findings were controversial and there was significant disagreement within the scientific community. The government actively disagreed with some points, including the committee’s argument that the government should refrain from funding any further research involving homoeopathy.
It’s unclear why the NHMRC has based its draft statement on this report and ignored others from the World Health Organization, and Swiss and Canadian governments.
Informed consent
The key to the ethical practice of any therapy is informed consent – practitioners need to make patients aware of the evidence for and against their therapies.
Both manufactures and practitioners also need to make consumers aware that highly diluted homeopathic remedies do not contain pharmacological doses of medicine.
But then it’s up to the consumer to make a choice. As Steve Hambleton, president of the Australian Medical Association, stated in response to the NHMRC yesterday, if consumers are fully informed that there is no evidence a treatment is any more effective than placebo and still wish to use it, that should be the end of the matter.
And, of course, efficacy isn’t just an issue for homoeopathy. As medical writer Ray Moynihan noted recently in the British Medical Journal, most modern medicine lacks a strong evidence base, including most of the 5,000 treatments Medicare rebates are provided for.
Would the NHMRC be similarly willing to label these therapies unethical?
Critics may concede this point but say homeopathy is different – as science tells us that there is no possible way it can work. But population studies suggest homeopathy can affect patient outcomes.
It’s about practitioners, not potions
For therapies such as homeopathy, the problems don’t come from the remedies themselves; they come from unethical practitioners who put patients at risk.
The deaths of 45-year-old cancer-sufferer Penelope Dingle and nine-month-old Gloria Thomas weren’t caused by taking homeopathic remedies. Both died because they delayed more effective therapies, on the advice of their homoeopath (or in Gloria’s case, her parents delayed treatment for her eczema and eye infection).
Similarly, the public is placed at risk from homeopathic vaccinations – not because of what they contain, but because of the opportunity costs when they’re used as an alternative to real vaccination.
Problems occur when practitioners make claims for which there is no evidence, financially exploit their patients, refuse to refer when necessary and delay effective treatments for serious conditions.
Most homeopaths do not support such acts – the Australian Register of Homoeopaths supports full vaccination rather than homeopathic vaccination. But being an unregulated profession, there are always rogue operators who need to be held accountable.
In evaluating the ethics of homeopathy, the NHMRC should highlight the importance of the practitioner and the implications of Australia’s failure to regulate this industry. This has been the approach in the many countries and regions that regulate homeopaths. Ontario, Canada, for instance, is currently developing a regulatory body for homeopaths to ensure minimum standards of practice and accountability.
Does homeopathy have an effect?
The answer is no… and yes – by tweaking existing analyses and trials, you could probably make a case either way.
German insurance companies have been using population health and observational studies to investigate whether homoeopathy is an effective allocation of their resources. Studies have demonstrated good patient outcomes – as good as or better than conventional care for some conditions, even after eight years of follow-up – though results on cost-effectiveness and health service utilisation have been mixed.
The Swiss government also initiated a report that went beyond looking at clinical trials and included population heath and observational data. It concluded that homoeopathy could be both clinically and cost effective.
As I’ve written previously on The Conversation, homeopathic consultations themselves may also have some benefit, even if the medicine doesn’t.
If homoeopaths can get patients to improve without an effective medicine, we need more research to understand how this occurs.
Homeopathy as unethical
So, what would a statement that homeopathy is unethical mean?
Well, we don’t really know. It would probably mean the end of any research involving homeopathy in Australia, given that it would be hard for any research ethics committee to allow a researcher to explore a therapy deemed unethical by Australia’s major health body.
It would certainly place pressure on private health insurers to stop including homeopathy in their extras packages. But Australian private health insurers don’t pay for complementary medicine only because of their efficacy – they also offer it because it draws patients to their health plans.
In the end, branding homeopathy as unethical is unlikely to affect patient use. Most complementary medicines are patient-driven phenomena, and consumers already make the choice to use them despite mainstream medical opposition.
It may, however, stop them discussing this use with health professionals, increasing potential risks.
The NHMRC says it plans to release its final statement on homeopathy sometime this year. In the meantime, the agency should consider conducting its own investigations, and base these on a variety of international benchmarks. Simply labelling homeopathy unethical based on a single parliamentary review in the United Kingdom – and not even a scientific one – just doesn’t cut it.