Between 13th March and 19th May 2017 The Charity Commission held a consultation about whether an organisation which uses or promotes CAM (Complementary and Alternative Medicine) therapies should be allowed to be a charity. This was prompted by the work of the Good Thinking Society. Although the consultation closed over 12 months ago, The Charity Commission have yet to publish the outcome and have stated that they will do so “in the first half of 2018”. A summary of the feedback received is available on this page and makes for “interesting” reading.
The first thing that’s apparent is that The Charity Commission is surprised by the number and type of responses they received. They say “We received over 670 written responses, far in excess of the number usually received for a Commission consultation.” I’m struggling to understand why this was such a surprise. CAM covers a whole range of therapies such as homeopathy, chiropractic, osteopathy, acupuncture, reiki, reflexology, naturopathy and many others. There are a large number of organisations and individuals who have an interest in this area for a variety of reasons. Therefore it’s to be expected that there would be a large response. The Charity Commission also seem surprised by the number of individuals who responded. They say “The majority of responses received were from individuals apparently writing in a personal capacity”. Many individuals have relevant expertise in this area that enables them to usefully contribute to this sort of consultation even if they don’t work for an organisation that itself has an interest. Again, I’m not sure why The Charity Commission finds this surprising.
The Charity Commission say “A broad range of opinions were expressed in response to the consultation, some of which clearly are strongly held.” Indeed they are. Some of those responses are reasonable and make logical sense and some, quite simply, don’t. Reading through the responses gives an interesting insight to some of the highly illogical thinking of CAM providers.
Responses to the first question “Question 1: What level and nature of evidence should the Commission require to establish the beneficial impact of CAM therapies?” include those that think patient testimony is more valuable than scientific evidence. This is, of course, nonsense. It is well known that most CAM practitioners promote their services largely or exclusively based on testimonials. The trouble is that testimonials actually tell you very little about the effectiveness of a treatment and they should therefore not be used as a basis for making treatment decisions. It’s clear that CAM practitioners either lack an understanding of the science behind measuring treatment effectiveness or conveniently choose to ignore it because it conflicts with the weird and wonderful therapy that they happen to provide. The most sensible responses to this question are the ones that align with this “Some responders expressed the view that the evidence to be considered in respect of CAM therapies should be the same in nature as that to be considered in respect of any other therapies.” When assessing effectiveness of a therapy this should be done without bias. Therefore the level of evidence required should be the same regardless of the type of therapy. The suggestion by some respondents that “the breadth and/or history of use of a therapy” should be used as a measure of evidence is laughable. Should we go back to using leeches as a treatment because it has a long history? Of course not. Science and medicine gradually improves by accepting new treatments that are shown to be effective and dropping those that are shown to be ineffective or where the risk / benefit ratio is not acceptable. Unfortunately, what we are seeing here is the opinion of CAM practitioners and organisations who have failed to reject the things that don’t work and keep misleading people into taking them as “treatments” for a whole range of conditions.
The second question in the consultation was “Question 2: Can the benefit of the use or promotion of CAM therapies be established by general acceptance or recognition, without the need for further evidence of beneficial impact? If so, what level of recognition, and by whom, should the Commission consider as evidence?” This is a really strange question to ask because the only rational answer is clearly “no”. The suggestion that a benefit of any therapy can be established merely because it is accepted or recognised is nonsense. It requires only a basic understanding of science to realise that this is not how treatment effectiveness should be assessed.
The responses to “Question 3: How should the Commission consider conflicting or inconsistent evidence of beneficial impact regarding CAM therapies?” show an astounding lack of science comprehension from some respondents. For instance, some responders “urged the Commission to give applicants “the benefit of the doubt”, or to register CAM organisations unless and until their contentions are disproven.” Again, this is simply not how science works. The person or organisation making the claims needs to provide the evidence that they are valid rather than expecting that there should be proof that they are invalid first. This is really the only way that science can sensibly work and an example will help to make this completely clear. I could choose to make the claim that somebody on the planet is able to fly to the moon by flapping their arms. If we have to disprove my claim before it is seen as invalid then we would have to get every single person on the planet to try before we could do so. This is something that is clearly both impractical and very silly. Instead, we should assume that it’s not possible until someone proves otherwise. We can also use science to calculate the amount of force required to leave the earth’s atmosphere and conclude that even to try going to the moon by flapping your arms is an entirely pointless activity. No further research required. If only the same approach was used with CAM therapies, a lot of public money would be saved that is currently squandered on research into things that are completely implausible.
The next question was “Question 4: How, if at all, should the Commission’s approach be different in respect of CAM organisations which only use or promote therapies which are complementary, rather than alternative, to conventional treatments?” Some respondents “questioned whether there is a real distinction between the two categories referred to in this question, or whether it is possible to draw the distinction clearly.” If you study the way that CAM practitioners use their treatments it does indeed become difficult to separate these two things. Regardless of whether the particular type of CAM that a practitioner happens to use is homeopathy, acupuncture, chiropractic, osteopathy or anything else there is a need to believe in the treatment approach. In most cases this is in direct conflict with mainstream medical treatment and science. For instance, homeopaths believe that “like cures like” and that diluting a substance makes it stronger. Osteopaths and chiropractors believe that structure dictates function. Belief in any of these treatment approaches requires the practitioner to reject conventional approaches because it’s simply not possible to fully understand and accept science and medicine and to hold these beliefs. It’s therefore almost impossible for a CAM practitioner to apply their treatments in a complementary manner to conventional treatments. They will inevitably want to steer their patients away from conventional treatments that do not align with their belief system.
For “Question 5: Is it appropriate to require a lesser degree of evidence of beneficial impact for CAM therapies which are claimed to relieve symptoms rather than to cure or diagnose conditions” we have some further nonsense responses such as “Some responders thought that the Commission should assume that a benefit is provided by a particular therapy, unless it can be shown that it is harmful.” This is pretty ridiculous and again is clearly not how science and evidence actually works. Is it really okay to just use dubious unproven treatments on unsuspecting members of the public and continue to do so until harm is shown? Are we supposed to wait until people die or are suffer serious health consequences before putting a stop to a particular therapy? If conventional treatments were developed in the same way then lots of people would die. There is a reason why treatments are carefully developed and researched over a number of years before they start being used in routine care. Many initially promising treatments either turn out not to work that well or have harmful side effects. The same approach should be applied to CAM therapies. Why do CAM providers not want this? It’s very simple, most or all of them would not show sufficient benefit and have too many risks to recommend using them. CAM providers don’t want this research to be done because it would probably signal the end of their business.
Question 6 was “Do you have any other comments about the Commission’s approach to registering CAM organisations as charities?” Like the earlier questions, there are some responses that really make no logical sense. For instance, “CAM therapies are not susceptible to assessment in the same way as conventional treatments.” This is something that a large number of CAM providers claim. They say they don’t have evidence for their treatments because they can’t be assessed in the normal way or because they treat the individual not the condition. This is a complete cop out. With some thought it should be possible to test pretty much any treatment in a scientific and objective manner to see if it is effective. Again, CAM providers are making excuses because they know that when their treatments have actually been assessed they have been shown to be ineffective. This is the case with many CAM approaches that have been around for a long time such as homeopathy, acupuncture, osteopathy and chiropractic. They have actually had significant research carried out on them and the results are spectacularly uninspiring as they show that they have little or no benefit.
One of the answers to this question raises a classic argument from many CAM providers: “A decision which might result in the removal of CAM organisations from the charity register would compromise patient choice.” There are two key points here. Firstly, this consultation is about whether CAM organisations can be eligible as charities. Even if the decision is that they can’t that doesn’t stop CAM providers from existing, just that they can’t be registered as a charity and receive the associated benefits. Secondly, and more importantly, providing patients with a “choice” that includes treatments that don’t work is misleading and unethical. Imagine if you went to a doctor and they said “Would you like to try treatment A that has been shown to be effective or treatment B that hasn’t?” This kind of “choice” is a false balance argument that is absolutely not in the interest of patients.
At the end of the document is a list of organisations that responded to the consultation. It’s quite the collection of CAM organisations promoting a whole range of weird, wonderful and unproven therapies from homeopathy to reiki to osteopathy to meridian energy to acupuncture. There are also a small number of organisations that provide a more rational view such as the Good Thinking Society and The Nightingale Collaboration.
Charities are required to provide a “public benefit”. The benefit part states “a purpose must be beneficial – this must be in a way that is identifiable and capable of being proved by evidence where necessary and which is not based on personal views” (https://www.gov.uk/guidance/public-benefit-rules-for-charities). Many CAM charities fail this test as they actually promote treatments that have either been shown not to work or that have not been shown to work. I have written about a couple of examples previously: The Sunflower Trust and CORE of Clapton. An excellent article from Michael Marshall of the Good Thinking Society highlights several others. However, this really only scratches the surface and there are a whole range of charities offering unproven “treatments” from the whole spectrum of CAM. When The Charity Commission finally get around to reaching a conclusion from this consultation it is hoped that they will act in the interest of the health and safety of the general public and remove all CAM charities from the charity register.