Focus on Alternative and Complementary Therapies
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Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2007; 12:
Dear Editor,
It is true that RCTs are not appropriate for every question but are they really better than any other method when looking at effectiveness/efficacy? Ernst believes that there is no such thing as a bad study design, ‘only good and bad matches between the research question and research method’ (page 77). He shows six externalities outside of treatment that could contribute to the results when using qualitative observation studies and claims that RCTs negate these, forming the best solution to testing the effectiveness of CAT. Here there needs to be a definition of effectiveness. Whose definition of effectiveness should we use when looking at patient care? Surely it is arrogant to define effectiveness in terms which suit the medical profession or science but do not reflect patients’ experience?
Evidence-based medicine seeks effects greater than placebo, measured by RCT, and whilst for many CAT there is no satisfactory placebo to measure treatments against, absence of this type of evidence is nothing more than that and should not be interpreted as lack of efficacy.
To use Ernst’s example, if he wants to find out whether his wife still loves him, an RCT is not appropriate. Now it is possible to suggest that love is not a suitable topic for scientific research, a bad match between question and method, but that does not take away the human experience that being loved can impart. Perhaps love is just the placebo effect of encounters with a spouse, a personal perception of the impact of another’s actions or engendered by numerous externalities we cannot take into account. However real and life-enhancing love may seem, there is no placebo and it is not provable through an RCT, so can we recommend it to another person? If I were to conduct a study of love, using qualitative methodologies such as case study, observation and interview, Ernst’s own feelings and evidence, which are very real to him, would be acceptable, valid and valued, adding to the overall body of knowledge on the topic.
With CAT, some patients feel immense benefit from their treatment in aspects which are not all physical or measurable and are often dismissed as placebo. The sense of empowerment, the feeling of calm, the sense of well-being, which many find through CAM’s holistic approach to health, cannot be understood through RCTs. They are most effectively addressed through qualitative methodology and whilst the results are not in the quantitative format beloved by the scientific fraternity, the information they can impart is equally important for patient care. The hierarchy of evidence which relegates qualitative research results to a status below RCT undervalues patients’ lived experiences of health and treatment efficacy. Whilst RCTs are excellent to measure that which is measurable, we cannot ignore human benefits which we do not as yet have the science to isolate, quantify and measure.
