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Professor Ernst invited me to present a supporting argument for the use of homeopathy in practice. I guess he believes that I believe it works. I suppose Kevin Smith, who is presenting the opposing argument, will be saying homeopathy is no better than placebo, and so should not be used. Instead of simply saying the opposite, I hope this essay will provide a third opinion, illustrating that what I believe in is science and honesty. And if science teaches us anything, it is to be suspicious of black and white dichotomies. So here goes.

In a remarkable 1903 essay by Harvard Professor Richard Cabot, entitled ‘The use of truth and falsehood in medicine’, published in American Medicine, Cabot states:

‘I was brought up, as I suppose every physician is, to use placebo, bread pills, water subcutaneously, and other devices for acting upon the patient's symptoms through his mind. How frequently such methods are used varies a great deal I suppose with individual practitioners, but I doubt if there is a physician in this room who has not used them pretty often.’1

In that era, many hospital pharmacies stocked sugar pills by prescription. They were sometimes labelled ‘obecalp’ (placebo spelt backwards) to clue the pharmacist without clueing the patient. Apparently, in 1903, most physicians believed that placebos could be effective, or alternatively, they did not believe deception was unethical. Most of Cabot's essay is a detailed attempt to refute arguments for deception in medicine. He ends his essay recommending that physicians develop the ‘. . . technique of truth telling . . .’, even if this is difficult.

In 2008, Jon Tilburt published in the British Medical Journal the results of a survey exploring placebo use among physicians.2 Over 50% of physicians reported that they prescribed substances known not to be effective, such as vitamin pills for fatigue or antibiotics for viral conditions. Apparently, the use of obecalp and sugar pills has gone out of style, but placebo has not. Deception of the patient is now clearly unethical, but self-deception looks to be acceptable. After all, one has to believe a therapy will be helpful to prescribe it, lest one be a charlatan. Now to homeopathy.

In 1991, Kleijnen, one of the world's leading methodologists, published in the British Medical Journal a systematic review of homeopathy, which tilted favourably toward its efficacy.3 Kleijnen (wisely I think) avoided combining these heterogeneous studies into a meta-analysis (MA). In 1997, Linde and I published in the Lancet a meticulous systematic review and (perhaps unwisely) combined them into a meta-analysis.4 I say meticulous because the paper had been through detailed peer-reviews at three top journals before getting to the Lancet; this improved the paper at every step. We could not eliminate a positive tilt in favour of homeopathy even with the strictest criteria we could devise. Hedges, one of the world's experts in MA and a co-author on the paper, calculated the number of reasonable-size trials needed to either prove or disprove that homeopathy was or was not placebo. That number was in the multi-hundreds and unlikely ever to be done. So it was mathematically highly improbable that we could ever use heterogeneous, randomised, double-blind trials to solve this dilemma.

Still, people tried. It took the Lancet 8 years to debunk our study,5 and the Journal of Clinical Epidemiology 3 years to debunk that debunking.6 At this point, we seem to be in almost perfect scientific equipoise, with the eight or so high quality meta-analyses evenly divided between showing that homeopathy is and is not placebo.7 I suspect the non-scientific world is in equipoise about this also. If you go to India, South America, Cuba, Italy and certain regions of England and France, you will likely find that most people and physicians believe that homeopathy works. At least they use it. If you go to Germany, the USA or other regions of England and France, you will find perhaps an equal number who do not believe it works. At least they do not use it (as much).

So, what is the ethical thing to do when both prior knowledge and the world is in equipoise? Some say one should only use an unproven treatment in the context of a clinical trial. This preserves evidence-based medicine. Some say you should leave it up to the patient and their physician. This preserves patient-centred care. I believe that both evidence-based medicine and patient-centred care are important. This is Solomon's dilemma if you are both a scientist and a physician. So the answer to the question of whether it is ethical to use homeopathy is simple: use it if you believe it works; do not use it if you do not believe it works. You will have to define what ‘it’ is for yourself and with each patient.

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Wayne B Jonas, MD, President and Chief Executive Officer, Samueli Institute, 1737 King Street, Suite 600, Alexandria, Virginia 22314, USA.