Complementary evidence

In her discussion on evidence in complementary medicine (September 2003, JRSM¹) Professor Higginson makes the point that patients consult complementary therapists ‘whose effectiveness, though not proven, is also not disproven, offering new hope when the “magic” of conventional medicine has faded’. Is she implying that it is all right to integrate unproven/not disproven therapies into routine healthcare as long as they offer hope? These are, of course, complex issues. It is nevertheless worth pointing out that, in certain circumstances, raising false hopes can be cruel and unethical. We should also remember that science cannot usually prove a negative. Thus, conclusively proving that homeopathy, spiritual healing, etc are ineffective (i.e. generate no effects beyond placebo) is an impossibility. This is why, in evidence-based medicine, treatments ought to be backed up by positive evidence of effectiveness rather than with a label of ‘not disproven’. We all know that absence of evidence is not the same as evidence of absence. However, to use this argument for integrating therapies that are not disproven (basically anything from bloodletting to gene therapy) into medical routine is tantamount to saying ‘anything goes’. If we take this stance in complementary medicine we must also take it in other areas of therapeutics. Imagine what this would mean in relation to the pharmaceutical industry.

I am sure that Professor Higginson did not mean to advocate any of this but we need to be aware of the indisputable reality that the integration of nonsense into routine healthcare is likely to result in nonsense. Therefore, I believe, the way forward in complementary medicine is not much different from that in any other area of healthcare: first conduct the research to test the value (effectiveness and safety) of an intervention; subsequently critically evaluate the data in the context of all the existing evidence, and finally, if the results are favourable, consider integration. To do it the other way round is, in my view, a disservice to everyone involved, not least the patient.