Reflections of a A Scientist in Wonderland

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.”