Worse than its reputation?

Homeopathy does not correspond to its “good reputation” among the population, neither according to objective criteria nor as a mere placebo method. There can be no question of it representing – as is often heard from its proponents – an “additional therapy option” in medical practice. This applies equally to the solitary as well as to the complementary application of homeopathy.

In 2017, a study was published to survey the prescription frequency of homeopathy and associated expectations among practicing physicians in the Zurich area (n=4072, response rate: 38%) [1]. According to this, only half of the prescriptions were explicitly intended to produce homeopathy-specific effects. Moreover, the majority of prescribers recognize that the efficacy of homeopathy is not proven and attach little importance to its traditional principles. 23% believed that there was scientific evidence that homeopathy was effective. These results raise again the question of the relevance of homeopathy in medical practice. In the following, a positioning is attempted.

Homeopathy – a therapeutic option?

Homeopathy, invented over 200 years ago by the German physician Samuel Hahnemann, still enjoys widespread use, even recognition. It is in demand by patients, used as self-medication as well as offered by therapists, including physicians. More or less explicitly, political decisions give it a place in public health.

Such political-societal decisions beyond scientific validity are a major reason why homeopathy is perceived and trusted as a medically relevant method, it is after all “part of the health care system”. All this makes it difficult to deal with the subject of homeopathy, especially in the doctor-patient relationship.

For example, Switzerland has included pseudomedical methods, most notably homeopathy, in primary care despite a lack of evidence – by “deciding” scientific issues politically. Whereby it is not even a clear decision, but a reservation compromise in favor of the “complementary methods”, which neither affirms an evidence nor denies access to the health care system because of a lack of evidence [2]. This is widely misinterpreted – also outside Switzerland – to mean that homeopathy has evidence as a medical method, otherwise it could not have been implemented in the health care system [3]. German pharmaceutical law has privileged homeopathy since the Medicines Act of 1978. The scientifically valid proof of efficacy is replaced by an “internal consensus”, whereby a commission consisting of representatives of homeopathy decides internally whether a remedy receives approval and thus the drug property and market access. A legal fiction takes the place of scientifically proven efficacy.

The scientific consensus on homeopathy, on the other hand, is clear worldwide: no specific medicinal effect can be attributed to homeopathy. The major cross-indication reviews of homeopathy do not demonstrate evidence of specific efficacy for any indication. There are no differences between the results of homeopathic and other researchers.

This serious discrepancy between desire and reality implies the question whether homeopathy has any place in practical clinical application.

The medical effectiveness (clinical relevance)

Medicine was at all times in general view “that which helps”. Modern medicine, however, has methods to evaluate what really helps in an intervention and what is due to coincidences, overestimation of anecdotes, cognitive influences, parallel therapies, and the like. This is the basis of evidence-based medicine, which on the one hand pragmatically asks only for the outcome, the provable clinically relevant effect, and on the other hand expects proof of a specificity of the agent or method.

This delimitation criterion of specific efficacy is a central problem for at best nonspecifically effective methods such as homeopathy. In this respect, homeopathy operates a certain mimicry: it counts itself as medicine, but its representatives know that their remedies cannot stand up to the standard of a scientifically proven effect. They therefore rely on privileges such as access to the drug market without scientific proof of efficacy. This forces an inconsistent stance in some places. On the one hand, homeopathy strives for scientific recognition, which is clear from many statements of its proponents and its own research efforts. On the other hand, it has acceptance problems with research results it dislikes, ranging from ignoring and reinterpreting them to the postulate – refuted by homeopathic researchers themselves – that the scientific method is not suitable for investigating homeopathy. Thus, homeopathy itself raises the question of whether it can be located as scientific at all [4].

The lack of plausibility of homeopathy, its appeal to alleged effects and laws, which partly contradict scientific findings elementarily [5], is not even taken into account. This result is confirmed by all cross-indication reviews presented since 1991 [6]. This overall evidence certainly includes individual papers that seem to show an advantage of homeopathy in the verum group. Of course, the representatives of homeopathy try to gain reputation and to claim evidence with such studies. However, this fails, because

individual studies result in the best case Indication of possible evidence, but do not allow any conclusion to be drawn about its actual existence, all the more so if a study has not been independently replicated – which is rather the rule in homeopathic studies, the alpha error (Type I error) inevitably produces false positives within a population,
Deficiencies in design, implementation, and analysis inevitably shift the outcome of studies toward alpha error [7],
such deficiencies are found in virtually all reviews, which can lead to the problem of which papers can still usefully be included in a review at all [8],
clinically relevant effects are at best very weakly demonstrated even in such individual studies, which, in conjunction with the lack of replication and the overall evidence to date, rather suggests that these effects do not exist in reality.

In recent years, the evaluation and assessment of the study situation and the resulting overall evidence has led a number of scientific organizations and public services to the conclusion that homeopathy cannot claim a place within a public health system. As an overarching voice on this, the European Academies Science Advisory Council (EASAC), the association of 29 national European science academies, is cited [9], which postulated in 2017,

that with regard to scientific mechanisms of action, the claims made about homeopathy are implausible and contradict established scientific concepts;
that with regard to clinical efficacy, while a placebo effect may occur in individual patients, EASAC concurred with the conclusions of previous comprehensive evaluations that there was no robust, reproducible evidence of efficacy of homeopathy beyond a placebo effect for any known diseases; there were related concerns about patient consent (see also the section on “The Placebo Issue,” authors’ note) and safety;
that, with respect to the promotion of homeopathy, it was noted that there could be significant harm to patients if there were delays in seeking evidence-based medical care and that, in general, there was a risk of undermining public confidence in the nature and value of scientific evidence.

Homeopathy in medical practice

Patients and homeopathy

No physician is prevented from using homeopathy within the framework of therapeutic freedom. The question is, however, whether other limits must be observed here, independently of the freedom of therapy.

The honesty of medical practice and the requirement of honesty towards the patient demand information about the medical value or unvalue of the method. Without doubt, this means effort in the individual treatment case and possibly also meets with direct rejection by the patients with all conceivable consequences. However, a request for a prescription of homeopathy must not simply be given in because of this.

Regardless of the patient’s autonomy and participation, which are to be highly valued, the responsibility for the therapy decision does not pass to the patient. Patient “wishes” cannot be decisive. Accordingly, the terminology of evidence-based medicine does not recognize “patient wishes” (a frequent reading by representatives of homeopathy), but rather the “consideration of the patient’s legitimate concerns” in the therapeutic decision. Patients’ requests for sham treatment cannot establish such “legitimate concerns.” Especially since it cannot be the purpose of medical action to promote drug affinity in this way and to reinforce misconceptions, especially unjustified trust in pseudomedical methods.

On the contrary, there is considerable potential here for promoting health literacy among the patient population. Where homeopathy “works” – through the sum of context effects – no drug interventions are usually necessary, apart from symptom-relieving remedies, which include common home remedies.
Of course, the rejection of the sham method of homeopathy does not pursue the goal of “replacing” homeopathics with pharmaceuticals, this would be a gross misunderstanding. Rather, it is appropriate to convey that in the case of a large number of complaints, there is no need for drug intervention at all, but that “responsible waiting” may in many cases be the most sensible option. The fact that something like this comes as a surprise to many patients – especially those with an affinity for homeopathy – and is unfamiliar, shows precisely the deficits in general health literacy.

The “embarrassment prescription”, which for – often quite understandable – reasons aims to avoid a discussion with the patient and/or to save time, is in this respect not justifiable. On the contrary, this would be a disregard for the patient’s right to information and would not contribute in the slightest to the patient’s health competence and self-perception in the event of illness.

It can significantly reduce the individual time spent on education, for example, to provide information material in the practice explaining why homeopathy is not part of the practice portfolio. It is often effective to specifically inform patients that homeopathy is not the same as naturopathy and phytotherapy, as this may be the most common misconception. The desire for a “gentle and natural” therapy can, if necessary, be substituted by the recommendation of a measure from the portfolio of recognized natural remedies or the prescription of a suitable phytotherapeutic.

Ultimately, the authors believe, the patient base will come to appreciate that “their” physician values honesty with patients and uses scientifically valid means and methods out of conviction.

Homeopathy has no monopoly on medical empathy and attention

In the German health care system, the physician treating homeopaths is given the opportunity to bill for homeopathic services at much higher than usual rates outside of the flat-rate budgets. This creates an economic basis for a significantly higher time expenditure per patient than in the usual day-to-day business.

A certain benefit of a detailed homeopathic anamnesis discussion may perhaps be given to the patient, although according to homeopathic doctrine this has no therapeutic objective, but serves to find the remedy. This is also used to justify homeopathy. However, on the one hand, these are at best undirected, temporary – non-specific – effects. On the other hand, homeopathy does not have a monopoly on empathic attention of the physician to the patient (“holism”). This should be the core of any medical endeavor. If the economic framework conditions are shifted in favor of homeopathy, as is the case in the German healthcare system, this is by no means a positive development, because it is ultimately to the detriment of the rest of the patient population. After all, the physician’s total available time does not change. Improving doctor-patient communication doesn’t even necessarily require a much greater investment of time. A return to the elementary principles of doctor-patient communication, as formulated and conveyed decades ago by Michael Balint, would be very helpful [10].

The placebo problem

A significant problem for medical practice, as also evidenced by the study on prescribing behavior cited at the outset, is the view of homeopathy as placebo therapy. Therefore, the question will be investigated whether a justification for the use of homeopathy in medical practice can be derived from this.

The ethical implications – informed consent

According to today’s understanding of medical ethics, cooperation “at eye level” between physician and patient is an expression of the high value of patient autonomy and a central requirement for medical action. As every practitioner knows, this can only be realized in constant awareness of the inherent problems and the individual circumstances of each treatment case.

In many cases, homeopathy is justified as placebo therapy, which after all has an inherent “benefit”. On closer examination, this position proves to be a touchstone for medical ethics. The World Medical Association’s ethics guidelines [11] refer to informed consent , the “informed agreement” between physician and patient about a treatment decision, as “one of the central concepts of contemporary medical ethics.” In short, it is no longer possible, as it used to be in “patriarchal” medicine, to tell patients the untruth or to deliberately withhold information from them. Based on this, it would have to be clarified whether informed consent can be achieved at all in the case of homeopathy.

Homeopathy has – at least in German-speaking countries – an extensive reputation in the sense of a “gentle, natural and side-effect-free” genuine “alternative” to so-called “conventional medicine”. Various individual aspects (desire for self-efficacy, general tendencies towards individualization, etc.) additionally determine the predisposition of many people seeking healing [12].

How should informed consent about the administration of a homeopathic placebo be achieved with patients who have mostly internalized the general reputation of homeopathy? Informing the physician that the drug in question is specifically ineffective and that he nevertheless intends to prescribe it will cause disbelief, or at least considerable uncertainty – which in any case stands in the way of viable informed consent.

Informed consent is all the more precluded if the practitioner also assumes that homeopathic remedies have an effect in the specifically medicinal sense, for example, if he or she is subject to a classical confirmation bias as a practitioner of many years’ standing, or if he or she even considers an effect of homeopathy to be possible. From this point of view, it seems almost impossible to create a justifiable basis for a placebo treatment with homeopathics in the sense of valid medical ethics [13].

Placebo as a factor in treatment decision

Placebo, as explained, is only part of the contextual effects that give sham methods the appearance of efficacy. In order to arrive at an appropriate evaluation of placebo for practice, it is important to distinguish the “actual placebo effect” from other contextual effects and to be able to classify it correctly.

Placebo in the strict sense is the administration of a drug free of active ingredients or the use of a sham method. The actual placebo effect is to be understood as a psychotropic effect triggered by complex neurobiological reactions due to the process of attention and treatment (“care”). This process is by no means based on “imagination” and cannot be influenced voluntarily by the subject, but it can certainly produce physiologically measurable reactions. Nevertheless, the often invoked option of targeting placebo as a therapeutic modality is largely limited:

The specific contribution of placebo to context effects is probably greatly overestimated [14], and the main factor of observed “effects” is likely to be self-limiting disease progression.
Placebo researcher Ted Kaptchuk points out that “placebos may make you feel better – but they won’t cure you.” [15].
Indeed, it has been empirically demonstrated that placebo and related effects can mask actual health status in potentially dangerous ways [16].
The magnitude, the direction (“nocebo”) and whether placebo effects occur at all cannot be assessed in advance and often cannot be proven beyond doubt even in retrospect. Thus, placebo effects cannot be specifically directed “against” a particular disease.
Placebo as a regular therapy may promote drug affinity in patients.
For a large number of interventions, placebo treatment cannot be considered anyway; “the list of conditions that are not placebo-sensitive is almost endless.” [17].

Patient-centered care cannot consist of using placebo responses to make a patient believe that he or she is getting better, when in fact the disease-related impairment of a physiological function may be putting him or her at risk of serious complications.

We consider tendencies to justify sham methods such as homeopathy with a “benefit” of the placebo effect to be very problematic. This is also recognized within placebo research. Fabrizio Benedetti, renowned placebo researcher from the Neuroscience Department of the Turin Medical School, published an article in December 2019 [17], summarizing:

“The placebo phenomenon is still a paradox and an effect not easily handled today. [..]. Unfortunately, quackery today has another weapon on its side, paradoxically represented by the placebo mechanisms supported by exact science. This new ‘scientific quackery’ can do much harm, so we must be very careful and vigilant about how the findings of exact science are used […].

I believe that reflection is necessary to avoid a relapse of medicine into past times when quackery and shamanism prevailed. Unfortunately, the new findings of exact science on placebos are now producing backfire effects […] A crucial question to answer is: Is placebo research promoting pseudoscience?”

Some concrete implications congruent with these considerations have been elaborated above for the specific case of homeopathy. To use the placebo effect as a “justification” for the use of pseudomedicine/homeopathy, explicitly or implicitly, we therefore see as unjustified.

Conclusion

Homeopathy does not correspond to its “good reputation” in the population and even in health professions, neither according to objective criteria nor as a mere placebo method. There can be no question of homeopathy – as is often heard from its proponents – representing an “additional therapeutic option” in medical practice. This applies equally to the solitary as well as to the complementary application of homeopathy.

Take-Home Messages

The negative evidence base on the effects of homeopathy is broadly consensual in the scientific community: evidence for relevant clinical efficacy beyond context effects is not available for any medical indication.
The production of an informed consent required by ethical principles for the use of homeopathics as placebo seems almost impossible because of the anchored “public reputation” of the method.
The invocation of placebo effects to justify the benefit of remedies and methods without specific evidence of efficacy must be rejected both in general and in individual cases of treatment.
The general establishment of homeopathy as a valid medical method in the general consciousness is a socio-psychological phenomenon based on influence and misinformation of various kinds over a long period of time. This phenomenon – used by interested circles for advertising purposes – is combined with the tendency toward individualization and self-determination, even and especially where there is no self-competence or sufficient information.

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