Some complementary and alternative therapies are too implausible to be investigated

Scientific testing cannot prove anything. The maximum that can be achieved is that a hypothesis becomes more or less probable. Scientific testing is especially useful when there is doubt and much less if the hypothesis that is put to the test is practically unassailable or, conversely, absurd. It is even a defendable position to say that scientific research is only ethically justified if there is genuine doubt about its outcome. Amateurs of research into improbabilities (alternative medicine, paranormal phenomena, UFOs, etc.) frequently justify their efforts by referral to scientific revolutionaries of the past, such as Galileo, Darwin and Einstein. The great men mentioned function as romantic examples for vain people, hoping to compare to these heroes, who do not realise that scientific progress in this era emerges from a scientific community consisting of mutually competing research groups, where the genius, who in isolation is producing ‘breakthroughs’, is extinct.

It was Petr Skrabanek who, at an early stage, warned against the application of ordinary scientific methods in alternative medicine: ‘Randomised clinical trials of absurd claims are more likely to mislead than illuminate’. He referred to homoeopathy and acupuncture, which both suffer from such a priori improbability that no RCT would be able to dispel scepticism of insiders. He was right because how can succussion and repeated dilution cause the ‘transubstantiation’ of an inert substance into an effective drug, and how could one possibly reconcile the principles of acupuncture (meridians, Yin and Yang, and so on) with the anatomy and physiology of the human body?

Skrabanek’s passionate pleas failed, because many RCTs of absurd claims are being performed. I published an article on this topic in Human Reproduction,¹ triggered by a paper in which the beneficial effect of intercessory prayer on the outcome of in vitro fertilisation treatment was ‘proven’ in a seemingly impeccable trial. There are more examples of this type of ‘impeccable’ research in which absurd claims are demonstrated: prayer in coronary care units, acupuncture of the small toe to achieve version of the unborn child in breech presentation, effects of severely diluted substances on hay fever and in vitro on basophilic leucocytes, to mention but a few. Obviously, these papers have not led to the overthrow of the present successful biomedical model, necessary to explain the demonstrated effects. Rejection of these results by the medical world could have been predicted beforehand and this fact takes away the rationale of these trials. They will not change the opinion of experts, despite the concomitant presentation of supposed – usually quite farfetched – mechanisms of action that fit with common medical knowledge. Editors of medical journals should not accept these papers at all, since the main result is excitement in the lay-press.

Should all research into the efficacy of alternative medicine be stopped? We think so; not only is this type of research deemed to remain a solipsistic hobby of believers without a chance of spreading into regular medicine – we are not aware of precedents of that type – but it also has negative side-effects. As long as serious research is going on, the alternative treatment under test will easily be considered by the layperson as enjoying an experimental status. In normal medicine, experimental treatments sometimes become part of the accepted regular medicine. Hardly anyone realises that this has never been the fate of rigorously tested alternative treatments. The testing itself will encourage the practise of then unproven therapies.

Common characteristics of alternative treatments are the lack of evidence for its efficacy and the usual absence of a priori plausibility within the biomedical model. In this respect, alternative treatments form a broad spectrum, with acupuncture, homoeopathy, anthroposophical medicine, paranormal therapy and past-life-therapy being completely absurd. At the other end of this scale are herbal therapy, orthomolecular medicine and manipulative medicine for which traces of proof can now and then be found in the literature, although the added value in comparison with placebo is usually marginal. This fact is in glaring contrast to the confidence of the practitioners offering these treatments and with the actual scale of consumption already established. The research into these fields could, and should, be left to regular scientists in pharmacology, nutrition and orthopaedic medicine. The academic modesty and broader view of these scientists will guarantee a more balanced way of presenting results and will at the same time – when priorities in the research have to be considered – lead to a marginal position of the alternative fringe. So be it.

Reference

1. Renckens CN. Alternative treatments in reproductive medicine: much ado about nothing. ‘The fact that millions of people do not master arithmetic does not prove that two times two is anything else than four’: W.F. Hermans. Hum Reprod 2002; 17: 528–33. [Abstract]

Remember the days, a little longer than a decade ago, when gastritis was a textbook example of a disease caused by stress? When an Australian researcher then found strange bacteria in tissue samples of gastric mucosa from patients with gastritis, professional sceptics like Skrabanek or Renckens, who I respect highly, might have argued that this was absurd and did not merit further study. Luckily, however, further research did occur and today we know that this bacterium, Helicobacter pylori, is the prime cause for gastritis and a potential contributor to intestinal cancer, and perhaps even atherosclerosis.

This story is only vaguely related to CAM. The Australian researcher that made the discovery certainly was no homoeopath, acupuncturist or spiritual healer, but he was researching a subject that was totally out of line with the accepted thinking of his time. In other words, he was researching something absurd and should, according to the Renckens of this world, have been stopped or at least declared a ‘low priority’ – a verdict which is tantamount to discontinuation of activity.

Yet, in theory, there is little wrong with Rencken’s argument. Research funds are invariably scarce, therefore, we have to define priorities. For efficiency’s sake, priorities should be areas where plausible theories exist. A priori improbability or absurdity renders any research topic unfundable and thus unresearchable. The problem with this theory lies in the question of who is sufficiently objective and wise to decide based on the two criteria Renckens lists: (1) absence of a priori plausibility within the biomedical model and (2) lack of evidence of efficacy. The problem is aggravated by the fact that the advocates of this type of reasoning usually argue with the benefit of hindsight. Renckens probably would not classify the Helicobacter story as an example of research into the absurd. He, of course, knows its outcome. However, had he applied his logic to it when it first emerged he would have had little choice but to see it differently. Relying on hindsight makes the whole argument somewhat circular. A priori implausibility never fails to be correct because it judges plausibility not before but after the test.

What about his second criterion, the lack of evidence of efficacy? I am certainly not in favour of equating history of use with efficacy (e.g. ‘acupuncture has been around for thousands of years and therefore has to work’) but I am also against totally ignoring it. History of use, in my view, can amount to some sort of a priori plausibility or formulation of a hypothesis. Admittedly, such a hypothesis is quite different from a rigorously developed hypothesis. Yet, it is more than nothing at all and, together with other evidence, can form a sound basis for research.

In the context of EBM, a priori plausibility has become less and less important. The aim of EBM is to establish whether a treatment works, not how it works or how plausible it is that it may work. The main tool for finding out is the RCT. It is obvious that the principles of EBM and those of a priori plausibility can, at times, clash, and they often clash spectacularly in the realm of CAM. In a way, it is a contest between open-mindedness and closed-mindedness. Skrabanek reminded us that the danger of an open mind is that your brain may fall out. But the danger of a closed mind, I fear, is that your brain starves and simply stops functioning adequately.

Of course, things would be easy if there was some almighty person to tell us with foresight, objectivity and accuracy what is plausible and what is not. Sadly, no such person exists. In our longing for a substitute, we cling to concepts such as a priori plausibility or to EBM. Perhaps we should realise that, as so often in life, the truth lies somewhere in the middle.