Memorandum submitted by Dr Ben Goldacre
Sugar pills which have been prepared in accordance
with the principles or rituals of homeopaths are physically indistinguishable
from untreated or "placebo" sugar pills, and these homeopathy
pills have overall been shown, repeatedly, in summaries of fair
clinical trials, to perform no better than dummy placebo sugar
pills. Any claims to the contrary rely on cherry picking the evidence
to selectively reference only positive findings, to reference
poorer quality studies which are not "fair tests" of
the pills, and so on. Almost any ineffective medical treatment
could be made to appear effective using these strategies: they
simply reflect misleading and partisan scholarship. These sugar
pills are not physically harmful, nor do they physically confer
benefit on patients. Where there are benefits (and indeed harms)
from these sugar pills, it is only in how they are presented.
I assume that this basic territory will be covered by others,
and confine my submission to issues that interest me particularly.
The Medicines and Healthcare Regulatory Agency
(MHRA) approved label on homeopathy sugar pills is misleading.
A great deal of effort has gone into making patient literature,
leaflets, and labels more easily understood, explaining the benefits
and risks of treatments clearly, so it seems perverse and anomalous
that the MHRA have settled on a plainly misleading convention
for labelling these homeopathic sugar pills. The MHRA may deploy
sophistry, or invoke technical readings of the statements, but
the public read these labels as saying that the homeopathic sugar
pills are effective for the conditions listed. They are not effective,
and the MHRA know they are not. The confused wording of the labels
is compounded by the fact that the government medicines regulator
is giving licenses to pills sold in pharmacies which have not
been shown to be effective, something few would expect a government
regulator to do, so this unusual state of affairs requires even
more explicit clarity than normal. As things stand, this labelling
system is misleading, ignores the evidence on best practise in
communicating risks and benefits to the public, and should be
The MHRA approval reinforces an unwelcome
situation in which pharmacists are misleading patients. Patients
and doctors should be entitled to trust pharmacists as a valuable
source of evidence-based information on the treatments they deal
in. Pharmacists hold themselves out as a valuable community resource
in this regard, for example in the Royal Pharmaceutical Society
of Great Britain's (RPSGB) "Scientist In The High Street"
campaign. Now they are selling placebo sugar pills to sick people
by misleading them. Each profession should be free to make its
own decisions, but it may be worth ensuring that the public are
told that pharmacists have abandoned their previous principles,
so that they are not trusted in error.
The obvious argument is that homeopathy, since
it works no better than placebo, should not be funded by the NHS.
Although homeopathy is certainly not the biggest example of resources
being wasted on an ineffective treatment, a recession should be
a time for rational disinvestment, homeopathy is a clear example,
and the NHS should be scanning its activities for other good candidates.
Although it is clear that homeopathy works no
better than placebo, I do however accept that circumstances might
occur in which it could arguably be desirable to have the option
of prescribing a placebo. There are often situations where an
individual may want treatment, for example, but where medicine
has little to offerlots of back pain, stress at work, medically
unexplained fatigue, and most common colds, to give just a few
examples. Going through a "theatre" of medical treatment,
and trying every medication in the book, will only risk side-effects.
A harmless sugar pill in these circumstances may seem to be the
However the limited benefits must be weighed
up against the risks:
1. Prescribing a placebo requires that a healthcare
practitioner misleads their patient, which is unethical, paternalistic,
and undermines the current emphasis on shared decision making
in medicine. It also undermines the credibility of healthcare
professionals' utterances, when it is widely known that doctors
and others will lie to you about a treatment.
2. Even if we accepted that it was desirable
and cost effective to prescribe a placebo, and responsible healthcare
practitioners could be found who were willing to work around the
ethical issues and do so, homeopathy may not be the best model
for delivering placeboes, for a number of reasons:
(a) It is routine marketing practice for homeopaths
to denigrate mainstream medicine, for example campaigning against
vaccination programmes, advising against medical treatments, undermining
treatments such as chemotherapy which are distressingbut
overall confer benefitby overstating the side effects,
and so on. One study found that more than half of all homeopaths
approached advised a client against the MMR vaccine for their
child. A BBC Newsnight investigation found that almost all the
homeopaths approached recommended ineffective homeopathic pills
to protect against malaria, and advised against medical malaria
prophylactics, while not even giving basic advice on bite prevention.
(b) Homeopaths who are not medically qualified
can miss fatal diagnoses, actively disregard them, advise patients
to avoid beneficial medications, and so on.
(c) Senior and respected homeopaths, and homeopathic
membership groups, promote irresponsible and extreme quackery.
One example of many is the Society of Homeopaths' symposium on
the treatment of Aids, featuring the work of Peter Chappell (a
man who claims to have found a homeopathic solution to the Aids
epidemic involving homeopathic remedies which are broadcast over
the radio). The state should not be encouraging the public to
trust people and organisations which go anywhere near such plainly
(d) The endorsement of these sugar pills by the
NHS is used by homeopaths as evidence that they work, and this
further misleads the public. There are also more specific examples.
Visitors to everyday NHS medicine clinics which happen to be held
in the building of the Royal London Homeopathic Hospital in Queen's
Square, walk past adverts proclaiming that homeopathy sugar pills
are effective for a range of childhood and adult conditions, in
an NHS setting. This is misleading and an abuse of the good faith
that people have in the NHS.
(e) Homeopathsand the marketing activity
around homeopathymislead the public by sending out false
messages on evidence in the name of marketing their pills, for
example making prominent arguments in popular media claiming incorrectly
that fair trials of homeopathy sugar pills cannot be done, or
that systematic reviews of the literature are biased. This is
corrosive. Ideally we would be encouraging patients to have a
greater understanding of evidence based medicine, of how we know
what is good for us and bad for us, to improve engagement in shared
decision making with doctors, and to encourage participation in
(f) Homeopaths have cut themselves off from normal
academic discourse on evidence based medicine by threatening critics
with legal action to silence them, failing to engage with criticisms
adequately in their literature, and shrouding their university
teaching in secrecy. I can find no evidence that any of the plain
criticisms I have outlined above with regard to the practise of
homeopathy are seriously discussed by homeopaths. This would be
unusual in other healthcare professions.
1. It is my view that the MHRA labelling
system is misleading, not evidence based, and should be overhauled
so that it unambiguously and explicitly states that homeopathy
sugar pills have not been shown to be effective.
2. If the government believes that prescribing
placebo sugar pills is a cost-effective strategy to manage a sub-population
of treatment-resistant patients, then they should specify the
characteristics of this population and commission a pragmatic
cost-effectiveness analysis, comparing "GP treatment-as-usual"
against "GP treatment-as-usual plus homeopathy". There
is no need for any further trials comparing homeopathy sugar pills
against untreated "placebo" sugar pills, as we already
know the answer to that question, and we know that homeopaths
ignore the results, so any further trials of that design are wasteful
Dr Ben Goldacre