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Journal of Bioethical Inquiry
March 2017, Volume 14, Issue 1, pp 87–96

How Should We Respond to Non-Dominant Healing Practices, the Example of Homeopathy

Ben Gray
Otago University Wellington, Newtown, New Zealand

Abstract

The debate around the ethics of homeopathy in recent issues of the journal has been approached as a binary question; is homeopathy ethical or not? This paper suggests that this is an unhelpful question and instead discusses a framework to establish the extent to which the dominant (medical) culture should tolerate non-dominant health practices such as homeopathy. This requires a sophisticated understanding of the placebo effect, a critical evaluation of what evidence is available, a consideration of the harm that the non-dominant practice might cause, and a consideration of how this might be affected by the culture of the patient. This is presented as a matter of cultural competence. At a clinical level clinicians need to respect the values and beliefs of their patients and communicate with all the practitioners involved in a patient’s care. At a societal level there are a number of factors to be considered when a community decides which practices to tolerate and to what extent.

https://link.springer.com/article/10.1007/s11673-016-9760-y

Excerpts:

"The debate around the ethics of homeopathy in recent issues of the Journal (Levy et al. 2014; Shaw 2015; Pickering 2015) approaches the issue as a simple binary question—is homeopathy ethical or not? Such an approach is unhelpful to both clinicians working with patients who use homeopathy and to the society at large, in deciding how to respond to the practice of homeopathy. There are many practices of minority groups that some in the wider society might find 'unethical': circumcision, chiropractic treatment of conditions other than back pain, prayer as the only treatment for physical illness, the use of traditional treatment by indigenous people."

"Parekh addresses this problem in some detail:

"In a multicultural society, different groups entertain different conceptions of the good life...This paper suggests that the principles of toleration cannot be laid down in advance, and are best elicited by means of an open-minded intercommunal dialogue aimed at evolving a reasonable consensus. (Parekh 1996, 251)"

"In New Zealand both groups have defined training that needs to be completed before being able to claim status as either homeopath or doctor. Both also have codes of ethics (New Zealand Council of Homeopaths 2010; New Zealand Medical Association 2014) that are remarkably similar in scope...The homeopathic code explicitly notes that referral to a medical provider must occur if indicated and that close rapport with that provider must be established for the patient’s best interest (New Zealand Council of Homeopaths 2010)."

"Homeopathic diagnosis is much more focussed on symptoms (Ehrlich 2015) although some practitioners who use homeopathy have other health practitioner training, and patients may present to a homeopath with a diagnosis already confirmed. A precise medical diagnosis is not needed to choose a homeopathic prescription. A problem with conventional medicine, that homeopathic medicine does not share, is the problem of over diagnosis (Moynihan et al., 2012) where people are harmed as a result of detection of problems that do not require treatment.

"If a serious cause can be excluded, the less certain the diagnosis, the less likely it is that evidence of efficacy of treatment will be useful. In this setting the patient’s satisfaction with the consultation (did they feel listened to, did they feel that the management provided helped them to feel better), becomes the best guide to judge the consultation by. It is likely in this setting that the outcome from homeopathic management would be similar to conventional management."

"The weakest part of Shaw’s argument is his limited understanding of the placebo effect. He argues that 'Interactions with practitioners are not homeopathy; they’re part of the practice of homeopaths. The treatment itself, however, is a placebo, and it is an error to conflate the two' (Shaw 2015, 551).

"In clinical practice of either doctors or homeopaths, all treatments are provided as part of an interaction, and the quality of the interaction enhances the effect of the treatment. It is an error to separate these entwined aspects of care. An understanding of the placebo effect is central to understanding the effectiveness of any clinical practice."

"In short there is evidence that the practice of homeopathy provides benefit, because it pays attention to the factors that enhance the placebo response. It is meaningless to say it is 'just the placebo effect'—the need for a lower dose of analgesic is a real benefit."

"The central argument that Shaw presents is the lack of evidence of benefit for homeopathic treatment (as opposed to homeopathic practice as discussed above)...In fact only around 11 per cent of many best practice guidelines are based on high level evidence (Tricoci et al. 2009). Instead the majority of each guideline is based on nothing more (or less) than expert opinion..."

"Sackett, who is seen as the founder of the evidence-based medicine (EBM) movement, always asserted that 'current best evidence' should be used but that unfortunately for much medical practice there is not a lot of high quality evidence (Sackett et al. 1996)."

"In addition to the limited evidence available there has been significant criticism of the whole idea of EBM. Greenhalgh and co-authors (2014) list several items describing the crisis in EBM..."

"Others have criticized the EBM movement for relying too narrowly on quantitative studies."

"Finally there is the problem of whether you can trust the evidence that is available. Richardson points out that up to half of all clinical trials never have their results reported and studies showing positive results are twice as likely to be published as those showing negative results (Richardson Elizabeth 2016)."

"Of course practicing medicine on the basis of evidence is more desirable than practicing it without evidence, but it is a serious misrepresentation to suggest that the practice of conventional medicine is based on evidence while in contrast the practice of homeopathy is not."

"Shaw and Levy agree that one of the attributes of homeopathy is that homeopathic treatments do not cause harm. This is in contrast to most of the treatments used by allopathic doctors; pharmaceuticals all have side effects of varying degrees, surgery inevitably involves some harm (from anaesthetic and cutting of tissues)."

"By contrast, while there may be considerable doubt as to how much a homeopathic treatment will help, there is at least a degree of certainty that it will not cause harm."

"In their ethical codes both the Homeopathic Council and the Medical Council of New Zealand require informed consent. Shaw rightly points out the systemic problem that homeopathy has a paucity of evidence supporting the efficacy of homeopathic remedies."

"However as discussed in the section on diagnosis [in the homeopathic code] if there is no clear evidence guiding the management of a particular problem, and the course of action chosen by the practitioner is made in good faith, then as long as the practitioner makes the basis of their recommendation clear then there has been no deception. In practice as a GP it is unusual for me to go into detail regarding the level of evidence behind my recommendation. In most circumstances my patients know and trust me and do not seek this detail."

"In practice I suspect that those seeking homeopathic care have chosen it in part because of an understanding of that modality of treatment, including its limitations, and often also because of a distrust of allopathic medicine."

"It is helpful to understand medicine as another culture and not just 'right'...The debate between Shaw and Levy is a matter of cultural clash between the culture of medicine and the culture of homeopathy."

"Suggesting that homeopathy is unethical to a person who believes in it, is the antithesis of culturally competent care. This does not mean that the clinician has to agree with or support practices that they do not like but that clinicians are able to work respectfully and constructively with patients with whom they disagree."

"Patients who have a belief in homeopathy gain benefit from receiving care from a homeopath as a result of the placebo response, even if there is no evidence that homeopathic treatments are effective. If they have a condition that cannot be diagnosed, where a serious cause has been excluded, homeopathic care may be as effective as allopathic care, with the added benefit that homeopathic treatments do not cause harm."

"Is homeopathic practice ethical? My view is yes but that it is an unhelpful question. More important is how we respond to homeopathy and other alternative practices when we encounter them."

"It is my view that telling the patient they are wrong is not an effective strategy and that the best strategy is to establish what the areas of agreement are, what the areas of disagreement are, and then to negotiate an agreed management plan taking all of these factors into account (for more detail on this approach see Gray 2016). This is nothing more or less than culturally competent care.

"Given that homeopathy is not effective for many important conditions it is vital that our patients feel comfortable discussing this with their doctor and this will be less likely to happen if we are judgemental."

"Shaw rightly notes the potential harm of medically treatable conditions being missed. Given that as a community we do not ban these practices the best way of mitigating that risk is by communicating both with our patients and the CAM practitioners."

"All therapies are seen by some people as having some benefit; otherwise no one would seek care from them. It is likely that all of them will lead to some benefit through the placebo effect. If patients are able to successfully discriminate which problems to take to which practitioner the outcome for that patient may be better. The risk of always seeing the homeopath is that an important diagnosis may be missed or available effective therapy is not used. The risk of always seeing an allopathic doctor is of unwanted side effects of treatment and over diagnosis."

"When considering whether to tolerate the practice of both conventional and non-conventional practitioners on a societal level there are a number of factors that need to be considered:

"...4.    Do the practitioners make unsubstantiated claims for the benefit of their treatment?

"5. Is the treatment the practitioner uses beneficial? If there is strong evidence that a particular treatment for a particular problem is beneficial then we need to ensure that that treatment is used."

"It is a benefit that there is a diversity of healthcare practitioners—they can be a source of innovation and discovery of new ways of managing problems. There are risks. Serious risks are managed by the use of regulations, and the professionalization of practitioners including codes of practice and ethics. Less serious risks in my view can be mitigated by tolerance and communication between practitioners."