Alternative Medicine – A Critical Assessment of 150 Modalities, written by Edzard Ernst, is a book focused on alternative medicine and sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. It is split into two main parts. Part 1 looks at general issues relating to alternative medicine and part 2 goes into 150 alternative therapies and diagnostic methods. Overall, this is a very good book and anyone reading it is going to be much better informed about the (un)suitability of most types of alternative medicine than they were before starting.
In part 1 there are some real “nuggets” of information about what makes alternative medicine attractive, the problems with alternative medicine and the approaches that alternative medicine practitioners use to promote their treatments. I’ll go through each of the 6 chapters in a little more detail shortly but I’d like to whet your appetite with something I think is critically important: the indirect risks of alternative medicine. This is highlighted in section 3.2 “Alternative Medicine Is Risk-Free”. The book says “Indirect risks are not caused by the treatment per se but arise in the context in which therapy is given. If, for instance, a completely harmless but ineffective alternative treatment replaces a vital conventional one, the harmless therapy becomes life-threatening.” Personally, I think this is really important and I believe that if the general public fully understand the level of indirect risk that seeing a homeopath, chiropractor, osteopath, naturopath, acupuncturist or other alternative practitioner presents most people would never go to see one again.
The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. It provides nice succinct summaries of many alternative therapies that you have probably heard of as well as a good number that you probably haven’t. Are you thinking about trying acupuncture, gua sha or chiropractic? Check out this section of the book first for a summary of each of these treatments and many more.
Chapter 1 Introduction
The first chapter highlights the large number of books on alternative medicine and how so many of them promote “bogus, potentially harmful treatments”. This book sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. As the book itself says this is a large and challenging task. Is Edzard the right person to take this on? The book claims that he is, and I agree. He arguably has more knowledge and experience in this area than anyone else including having published more peer-reviewed articles on the subject.
This chapter also explains the way that each of the 150 modalities are evaluated and the rating system used to assess each of them in the five areas of plausibility, efficacy, safety, cost, risk / benefit balance. The rating system is deliberately simple which doesn’t allow for much subtlety:
Personally, I think this simple approach is appropriate for the intended aims of the book – to provide information that is easily accessible for the lay-person. This is a good introductory chapter.
Chapter 2 Why Evidence?
This chapter aims to answer the questions “What is evidence?” and “Why is it important?”. To start with, this chapter tackles the notion that a patient getting better isn’t necessarily a result of the treatment they are receiving. Put another way, correlation does not equal causation. The book offers a few alternative explanations for a patient improving after treatment:
- the natural history of the condition (most conditions get better, even if they are not treated at all)
- regression towards the mean (outliers tend to return to the mean when we re-check them)
- the placebo-effect (expectation and conditioning affect how we feel)
- concomitant treatments (people often take more than one treatment when ill)
- social desirability (patients tend to claim they are better simply to please their therapist)
I agree with all of these points. However, I think the book has lost track of its intended audience a bit here: the lay-person. Would a member of the public who has no particular experience with science be expected to understand all of the above? Take for instance “regression towards the mean (outliers tend to return to the mean when we re-check them)”. I don’t think that most people outside the science / medical community would understand the term “regression towards the mean” and even the explanation in brackets is still rather “sciencey”. Perhaps a better lay explanation would be something like: “People often go for a treatment when they are feeling at their worst. Because many conditions have fluctuating symptoms, it is likely that with time they will return to something more like their average symptoms even without treatment. ”
The book then looks at what is suitable as evidence and why it’s important. The book, correctly, suggests that controlled clinical trials are the best way of determining if a treatment caused the improvement and the treatment is therefore effective. The book acknowledges that clinical trials are not perfect (they aren’t) but they are the best way that we have of assessing treatment effectiveness.
I think that overall this chapter is more science-focused than any other. That’s understandable as explaining what evidence is and why it’s important does require some science. However, I do wonder if members of the general public without any science background might find some of what’s in here a bit difficult to follow. Overall it’s still a decent chapter but perhaps some re-wording / additional explanation would have been beneficial in some parts?
Chapter 3 The Attractiveness of Alternative Medicine
Alternative medicine is undoubtedly popular and this chapter tackles a number of the unsubstantiated claims alternative medicine practitioners make in order to sell their services:
- Alternative medicine is effective
- Alternative medicine is risk free
- Alternative medicine is natural
- Alternative medicine is holistic
- Alternative medicine has stood the test of time
- Alternative medicine tackles the root causes of an illness
- Alternative medicine is inexpensive
- Alternative medicine is a small, innocent cottage industry
- Alternative practitioners are more human
- Conventional medicine does not live up to its promises
I often see alternative medicine practitioners making these sorts of claims. Edzard tackles each one in turn in his book. One point that he makes is of particular importance I think. He highlights that one important reason for the popularity of alternative medicine is the failings of conventional medicine (sections 3.10 & 3.11 in the book). That makes a lot of sense. How often do we see someone who has been told that their cancer is terminal going to a “cancer clinic” that offers fake “cures”. It’s unfortunate that sometimes there just aren’t solutions available through conventional medicine. When someone is told by a doctor that there is nothing that can be done to help them it’s entirely natural that they look elsewhere as they need someone to give them hope. That’s when alternative medicine practitioners step in and offer people false hope by claiming that they can help (even though they usually can’t).
Chapter 4 The Unattractiveness of Alternative Medicine
This chapter goes through the reasons why alternative medicine is unsuitable:
- It is not plausible
- There is no evidence
- The “Promised Land” for charlatans
The book highlights the large number of papers that have been published about alternative medicine. In most cases, those trials that are of high quality fail to demonstrate that alternative medicine is effective.
This chapter and the previous one should help members of the public to know how to spot misleading claims.
Chapter 5 Ethical Problems in Alternative Medicine
Ethics is a complex and important topic in the context of any medical treatment, including alternative medicine. This chapter highlights the numerous ethical problems with alternative medicine including informed consent, neglect, competence, truth and risk / benefit analysis. Informed consent is a particular challenge for all types of alternative medicine. For a practitioner of alternative medicine to take true informed consent they would normally have to admit that their treatments are not particularly effective and that there are other better treatments available. As the book explains this would be bad for business and means that alternative medicine practitioners have a powerful conflict of interest that keeps them from adhering to the rules of informed consent and medical ethics. The book gives a very good example of potential encounters with a chiropractor to help explain this.
Chapter 6 Other Issues
This chapter picks up on other issues relating to alternative medicine that don’t fit in the earlier chapters including patient choice, science cannot explain and integrative medicine. I think the last part of the chapter is particularly interesting as it covers what conventional healthcare professionals could say when asked about alternative medicine by a patient. The book suggest four different approaches, some better than others. One of the challenges for conventional healthcare professionals is that they often lack sufficient knowledge about alternative medicine to be able to talk about the evidence (or lack of evidence) behind them. Whilst the book is aimed primarily at the lay person it may also be helpful for conventional healthcare professionals to inform themselves about the evidence and risks of alternative medicine.
The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. The breadth of modalities covered here is seriously impressive. I’ve been tackling misleading claims in alternative medicine for a number of years and there were a reasonable number of therapies and diagnostic methods that I’d never heard of such as Jin Shin Jyutsu, Kirlian Photography and Eurythmy. As far as I can tell, the assessment of each of the approaches is fair and objective. In fact, I would say that on occasions the assessment is quite generous in favour of some of the alternative therapies. It is certainly not the case that every alternative therapy is criticised. Some are given a positive assessment such as St John’s Wort, Alexander Technique (for chronic low back pain) and Feldenkrais Method.
This section of the book is great for the reader to “dip into” when they want to find out about a particular therapy. It doesn’t go into any of them in great detail, and further reading would be needed here, but it serves as a great reference for a really wide range of alternative therapies and diagnostic methods.
Overall, I think this is an excellent book. It fills an important gap in the market to provide members of the public with objective information about a wide range of alternative medicine approaches. It should help to tackle the widespread misleading (promotional) information that exists around alternative medicine. Readers of this book will undoubtedly be much better informed about the reality of alternative medicine. I just hope the book receives the wide readership it deserves.