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# Rheumatology

# Homeopathy, non-specific effects and good medicine

Have we lost core medical values?

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This editorial refers to ‘Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial’, by Brien et al., doi:10.1093/rheumatology/keq234.

In this issue, Brien et al. [1] report the findings of a five-armed randomized controlled trial, which was aimed at differentiating between the effects of homeopathic remedies and patient consultations. The authors demonstrate that homeopathic remedies are placebos and show that ‘the benefits of homeopathy are attributable to the consultation’ [1].

Critics of homeopathy have always pointed out that homeopathic remedies are so highly dilute that they must be devoid of specific therapeutic effects. They are biologically implausible [2], and the ∼150 published trials collectively fail to indicate clinical effectiveness [3]. At the same time, we know from several observational studies (e.g. [4]) that patients do improve after consulting a homeopath.

Proponents of homeopathy insist that this is a contradiction. Moreover, they claim that the clinical trial is an inadequate research tool for testing their treatment (e.g. [5]) and that therefore the true picture is provided by the observational data (e.g. [4]). But the much more logical conclusion is what Brien et al. [1] have now demonstrated experimentally: patients benefit from a long and empathic encounter with a homeopath but not from the remedy. Homeopaths might argue that these results prove that homeopathy, even though it is not efficacious, is nevertheless effective. But I fear that this would be misleading: the effective element is not specifically homeopathy but the therapeutic relationship in general.

Yet Brien et al. [1] argue that the placebo effect of the consultation with a homeopath is specific to homeopathy and ‘dependent on the ritual of the collaborative and highly individualized consultation necessary to identify a homeopathic remedy and the associated symbolic meaning response for that patient’. Proponents of homeopathy tend to defend homeopathy in that way. More critical minds might, however, see things differently. They would doubt whether ineffective therapies can be vindicated through the non-specific effects they generate. They would also warn against the double standard this would establish. A useless surgical operation, for instance, does not become useful and recommendable because it generates a host of non-specific effects which are typical of that setting.

I therefore suggest that we avoid unnecessary complications and take the results of Brien et al. [1] at face value. Homeopathic remedies are ineffective and empathetic therapeutic encounters are helpful. So, we should discard the ineffective and adopt the helpful. If we do this, we must tell our patients that homeopathic remedies are both implausible and ineffective. Thus, they cannot be recommended. Of course, we should be equally clear that therapeutic relationships affect clinical outcomes.

The recognition of the therapeutic value of an empathetic consultation is by no means a new insight [6–8], yet it is knowledge that is in danger of being forgotten. Modern mainstream medicine frequently seems to neglect the importance of medical core values such as empathy, sympathy, time, understanding and holism. This creates a situation where alternative practitioners tend to provide the non-specific and mainstream doctors the specific effects. Clearly, this is wrong and may well be one reason why patients consult alternative medicine practitioners [9]. I would argue that any good medicine must offer both, and we should be sceptical of those clinicians who opt for providing only one or the other.

Disclosure statement: The author has declared no conflicts of interest.

1. Edzard Ernst 1

1. Correspondence to: Edzard Ernst, Complementary Medicine, Peninsula Medical School, University of Exeter, 25 Victoria Park Road, Exeter EX2 4NT, UK. E-mail: edzard.ernst{at}pms.ac.uk

- Accepted July 9, 2010.

- © The Author 2010. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

## References

1. ↵
   1. Brien S,
   2. Lachance L,
   3. Prescott P,
   4. McDermott C,
   5. Lewith G
   . Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial. Rheumatology 2010;49. doi:10.1093/rheumatology/keq234.
2. ↵
   1. Ernst E
   1. Born GVR
   . Homeopathy in context. In: Ernst E, editor. Healing, hype or harm? Exeter: Imprint Academic; 2008.
3. ↵
   1. Ernst E
   . A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol 2002;54:577-82.
   CrossRef Medline Web of Science
4. ↵
   1. Spence DS,
   2. Thompson EA,
   3. Barron SJ
   . Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005;11:793-8.
   CrossRef Medline Web of Science
5. ↵
   1. Milgrom LR
   . Gold standards, golden calves, and random reproducibility: why homeopaths at last have something to smile about. J Altern Complement Med 2009;15:205-7.
   CrossRef Medline Web of Science
6. ↵
   1. Di Blasi Z,
   2. Harkness E,
   3. Ernst E,
   4. Georgiou A,
   5. Kleijnen J
   . Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757-62.
   CrossRef Medline Web of Science
7. ↵
   1. Rao JK,
   2. Anderson LA,
   3. Inui TS,
   4. Frankel RM
   . Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 2007;45:340-9.
   CrossRef Medline Web of Science
8. ↵
   1. Haskard Zolnierek KB,
   2. Dimatteo MR
   . Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009;47:826-34.
   CrossRef Medline Web of Science
9. ↵
   1. Ernst E
   . The public’s enthusiasm for complementary and alternative medicine amounts to a critique of mainstream medicine. Int J Clin Pract 2010. (in press).

## Related articles

Original Article:

- Sarah Brien,
- Laurie Lachance,
- Phil Prescott,
- Clare McDermott,
- and George Lewith

Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial Rheumatology (2010) keq234 first published online November 13, 2010 doi:10.1093/rheumatology/keq234

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