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“A gentle ethical defence of homeopathy” by Levy et al. was recently published in an ethics journal. A full-text preprint is available online. They say:

Utilitarian critiques of homeopathy that are founded on unsophisticated notions of evidence, that adopt narrow perspectives on healthcare assessment, and that overstate the personal, social and ontological harms of homeopathy, add little to our understanding of the epistemology of medicine. But when they are used to denounce the ethics of homeopathy – they are not only ill-considered and counterproductive, but philosophically and socially perverse.

I found their arguments unconvincing.

They acknowledge that the evidence base for homeopathy is “insufficient” and its “efficacy cannot be broadly demonstrated.” Proponents have argued that homeopathy has utilities such as non-invasiveness, cost-effectiveness, holism and agent autonomy. Critics have argued that any benefits are minimal compared to negative features like failure to seek effective healthcare, waste of resources, promulgation of false beliefs, and a weakening of commitment to scientific medicine. Others have argued that homeopathy does not and cannot work except through contextual (“placebo”) effects, and that homeopaths are unethical because they deceive their patients by claiming specific effects.

And homeopathy is ethical because…?

Levy et al. argue that homeopathy is ethical because:

It offers significant value and benefits to patients [based on reports of patient satisfaction rather than on any objective measurements of outcomes. Translation: patients say they like it. Argument from popularity.]

It facilitates a diagnostic process that culminates in treatment or referral. [I don’t see how that claim could be substantiated. Homeopathic diagnosis is based on mythical miasms, homeopathic treatments are based on principles that are not valid, and they present no evidence that homeopaths give appropriate referrals to other providers or that they can even recognize conditions that would warrant referrals. How many of them even use a stethoscope?]

It is founded on a caring, therapeutic relationship between the clinician and patient. [True, but that is true of all good science-based clinicians too, and of charlatans, and of medieval blood-letters. That doesn’t mean it is ethical to use any random snake oil or to perform bloodletting to balance the humors. A caring relationship isn’t worth much by itself unless it is accompanied by an effective treatment.]

It is guided by the freedom of choice of consenting patients [essentially the old autonomy/health freedom argument. I would argue that patients can’t choose freely and rationally unless they are aware of all the pertinent facts and able to give truly informed consent].

Most of their claims refer to treatment by a homeopath. There is no diagnostic process or caring relationship involved in over-the-counter sales of homeopathic remedies to self-diagnosed customers in pharmacies.

Tu quoque and other fallacies

They argue that placebo or contextual effects of treatment are not valueless or irrelevant, and they are not equivalent across all healthcare contexts. They say homeopathy privileges time, listening, and therapeutic relationships, while conventional medical practice is systematically unable to attend to these domains of care and so to manifest these benefits. To my mind, that is not an argument for homeopathy but an argument for reducing time constraints and improving bedside manner in conventional medicine.

They downplay homeopathic deaths and failures to refer, claiming that conventional medicine commits the same sins, and that many thousands of patients die each year from medical errors and adverse events. This is the old tu quoque and “death by medicine” fallacy. Examination of harms mustn’t be separated from examination of benefits, and the subjective benefits of patient satisfaction with homeopathy can’t begin to compete with the objective benefits of science-based treatments.

They argue that homeopaths are guided by both moral and professional virtues in their practice. I’m willing to accept that most homeopaths truly believe in the efficacy of their treatments and believe they are doing what’s best for their patients. But is belief enough?

They argue that conventional doctors often mislead patients too, and overstate their claims of efficacy. They say “the absence of evidence may not mean that the therapy does not work,” and that many mainstream health practices are not based on definitive evidence. Clearly, it is unethical for anyone to mislead patients by making claims that go beyond the evidence. But don’t essentially all the claims of homeopaths go beyond the evidence?

Autonomy, experience, anything but evidence

They argue that the choice to seek care from a homeopath can be just as valid and as ethically sound as any other healthcare choice. But can the choice be truly valid if it is based on a misunderstanding? They decry paternalism, but is it paternalistic to assist others in identifying misinformation from biased sources so they can give truly informed consent? I don’t see paternalism there; I see true autonomy and respect.

Finally, they want to re-define “evidence” to suit their own purposes, to include nebulous things like “values,” personal experience, and patient satisfaction.

Conclusion

In my opinion their arguments are fallacious and amount to a kind of tortured special pleading. They don’t even try to answer the criticisms of homeopathy that they list. They offer no evidence from controlled studies, only vague platitudes. They say it is non-invasive and cost effective; but how can it be cost effective if it isn’t effective?

It is unethical for any health care provider to lie to patients or to go beyond the evidence in representing the efficacy of their treatments. If homeopaths truly believe what they tell patients, they are not deliberately lying and so may be considered to be acting ethically. But it could be argued that it is unethical to withhold pertinent information, to not fully inform patients about how mainstream science views homeopathy, and about its incompatibility with the established body of scientific knowledge. And surely it is unethical for those who understand that homeopathic remedies have no specific effects to recommend them without full disclosure. For instance, I consider it unethical for pharmacists to put Oscillococcinum on the same shelf as Tylenol, Advil, and FDA-approved cold remedies.

Finally, the real question is whether a homeopath has anything to offer that couldn’t be better provided by the kind of science-based clinician who truly cares for the whole patient and knows how to take best advantage of the contextual effects of the therapeutic encounter. In my opinion, the answer to that question is a resounding “NO.” Science-based medicine is clearly more effective than homeopathic remedies; isn’t it unethical to provide second-rate treatment?