published in Skeptical Briefs volume 25 number, Summer 2016.
by Felipe Nogueira
Edzard
Ernst is a medical doctor and the world’s first professor of alternative medicine. I always thought that his
story is quite interesting. For years, Ernst has been a strong skeptical and
critical voice of the often extraordinary claims done by alternative medicine
proponents. In his blog he posts in a daily basis critical analysis of
alternative medicine studies. In his 2008 book Trick or Treatment, co-authored
with Simon Singh, Ernst had explained the history and evidence about different
alternative medicine therapies, from acupuncture to homeopathy to chiropractic.
However, this skeptical scientist had started his medical career as a
homeopath. How that happened? How did he change his mind?
The answers
to those questions and other interesting details of Ernst’s career are written in his latest and excellent book. A Scientist in
Wonderland was published in January and is “a memoir of searching for the truth and finding trouble”, as the subtitle says.
Ernst went
to medical school in Germany. I was amazed to know that he actually wanted to
be a musician, rather than a doctor. Even after he finished medical school he
recognized this passion: "I still felt much more like a musician than a
doctor". Around 1970, Ernst had difficulties when he was looking for a job
as junior doctor, but he found in the only homeopathic hospital in Germany.
He worked
in different places in Germany, including in the University of Munich, but it
was in London that he had his first job as researcher, in a blood rheology
laboratory at St George's Hospital. For the first time, he felt in the right
job, because he was working with several intelligent people, going to
conferences and publishing papers. Medical school was focused on clinical
medicine; he didn't learn to be a scientist there. Working in that laboratory,
he begun to realize that science of medicine was really important. With enough
time to think, read, and learn, for the first time he questioned clinicians'
most basic assumption that if a patient feels better, the cause is the
treatment. Differently, a medical scientist is trained to be skeptical, to
doubt, and to question this kind of assumption. In Ernst's own words, "An
uncritical scientist is a contradiction in terms: if you meet one, chances are
that you have encountered a charlatan. By contrast, a critical clinician is a
true rarity, in my experience. If you meet one, chances are that you have found
a good and responsible doctor".
The job as
a researcher was good, but Ernst missed clinical activities. He changed jobs a
couple of times, until he found a place where he could do research and clinical
activities, in Munich. The research was so productive that he achieved a PhD
without difficulties. At that time, around 1981, he published his first paper
on alternative medicine.
It was in 1992
that his life was about to change dramatically as he saw an advertisement of
the chair of complementary medicine at the University of Exeter. After one
year, he was nominated for that task. The mission of his research team was
to conduct rigorous research into the efficacy, safety and cost of
complementary medicine. However, as one can expect, alternative therapists
don't want that. Enrst wrote, "Some offered the opinion that alternative
medicine should not be scientifically scrutinized at all."
Ernst
promised he would investigate the most popular alternative therapies in UK. For
his surprise - and to my own as I read the book - spiritual healing was a
common alternative therapy. At that time, there were more healers than
chiropractors, osteopaths, acupuncturists, homeopaths and herbalists combined
and almost the same number of mainstream physicians. Ernst and the healers
agreed with the experimental methods to be used and the trial would test
healers’ efficacy for chronic pain.
A Scientist
in Wonderland explains why the best way to evaluate the efficacy of treatments
is through a randomized controlled trial. In this kind of experiment,
participants are separate randomly at least in two groups: the intervention
group (the therapy to be tested) and the control group. If the therapy to be
tested is a drug, the control group is given a pill that doesn't have any
effect, a placebo. However, when a non-drug therapy is being tested, the
"placebo" isn't that straightforward. We can't simply do nothing in
the control group, patients need to be given something that looks like the
therapy being tested but with no effects. Thus, when the trial is done,
scientists use statistics in order to compare the difference between the
groups. "Any effective treatment - effective beyond placebo that is - will
generate a specific effect plus a placebo effect", Ernst explains.
The
spiritual healing trial ended up with four groups: healing by one spiritual
healer; placebo-healing by a trained actor; healing by a healer in a cubicle
hidden from the patient's view; and, placebo-healing with no human present in
the cubicle. During the study, Ernst witnessed a pain relief so intense that
one of the patients stopped using his wheelchair. Remarkably, the pain
reduction was due to placebo effect, since the results showed that all groups
have considerable pain reduction with no statistically significant difference
between them. Ernst and his colleagues published the paper trial with a clear
conclusion: "a specific effect of face-to-face or distant healing on
chronic pain could not be demonstrated".
Readers
will also learn in Ernst book that the importance to investigate alternative
treatment is not only to know if it works or not, but also to know if it's safe
or not. The patient might be harmed by the treatment directly, which can
happen, for example, with acupuncture when the therapist causes a pneumothorax.
Every treatment has its risks, even homeopathy that has no active substance in
its pill. Why? Because patients might seek a not established treatments rather
than an effective one. Moreover, one of Ernst' research showed that half of
homeopaths would recommend against MMR vaccine. Thus, alternative therapists
might produce considerable harms and we must not neglect that.
Ernst has
received several awards due to the quality of his research. However, for
alternative medicine proponents, quality of research is not important. What is
important is to defend alternative medicine, even in the absence of evidence.
Speaking out the truth about the available evidence, Ernst criticized
statements from alternative medicine promoters, such as the famous Prince
Charles. At the time, the Dean of Exeter University questioned Ernst: “do you always have to be undiplomatic?” It certainly appears, for this question alone, that the Dean is more
worried with being political rather concerned with the truth and possible harms
of alternative medicine. What if the evidence from alternative medicine
research is undiplomatic itself? It turns out to be case, as Ernst put it, “our critical analyses of alternative medicine, once acclaimed locally,
nationally and internationally, seemed no longer wanted.”
What about
ethics? Ernst doesn’t let anyone forget that this is
critically important in medicine. Doctors occupy a position with authority and
power, and patients are vulnerable and often they’re suffering. Ernst is brilliant as he wrote:
when science is abused, hijacked or distorted in order to serve political or ideological belief systems, ethical standards will inevitably slip. The resulting pseudoscience is a deceit perpetrated on the weak and the vulnerable. We owe it to ourselves, and to those who come after us, to stand up for the truth, no matter how much trouble this might bring.
In fact, the
fight with Prince Charles generated much trouble. Despite the fact that Ernst
and his team had published more papers in peer-review medical literature than
the rest of the Exeter University together, disagreements with Prince Charles
culminated with Ernst’s team being isolated and with no
funding. Eventually, the situation became so terrible that the team was
disbanded and Ernst had to take retirement. He wrote, “The doctor and scientist may still be full of questions, but the
musician in me breathes a sigh of relief that the performance, with all its
impossible demands and fiendishly difficult passages, is finally over”.
Ernst
closes the book with a brief summary of the most important conclusions from his
research regarding the efficacy of acupuncture, chiropractic, herbal medicine,
and homeopathy. A Scientist
in Wonderland must be given to anyone that promotes alternative medicine. The
book mentions important principles regarding treatments evaluations. The book
shows the amount of trouble a team of scientists can face when their research
findings contradicts beliefs and opinions of people with power. Moreover, it
shows the importance of the truth.
I’d like to thank Edzard Ernst for having written this fascinating book
about his career, but also for having the courage to stand up for the truth and
for being the example of a scientist we need in all fields, especially in
alternative medicine. Ernst is, as Harriet Hall has said in her review of the
book on the Science-Based Medicine blog, “a true hero. He continues to be one
of our leading warriors in the battle to defend science and conquer unreason.”
