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The safety of homoeopathy
British HomoeopathicJournal October 1995, Vol. 84, pp. 193-4
Our cover The children's ward of the London Homoeopathic Hospital at Christmas in the 1880s. See the paper by Leafy in this issue.
Guest editorial
The safety of homoeopathy Accepting the invitation to write this editorial is an e a s y w a y to m a k e enemies. This, h o w e v e r , is not m y i n t e n t i o n . On the contrary, by addressing this (clearly underresearched) issue I hope to do a service to homoeopathy, increase its credibility and stimulate discussion. ' H o m o e o p a t h y is a low-cost, non-toxic system of medicine'. 1 It is not difficult to find such quotes, indeed the notion that homoeopathy is virtually risk-free is widespread among both patients and homoeopaths. But is it true? For the purpose of this discussion I will distinguish between direct and indirect risks potentially associated with homoeopathy. 2 Direct risks Direct risks are essentially adverse drug reactions (ADRs). Most but not all homoeopathic medicines are too diluted to bring about toxic effects. Potentially toxic concentrations of arsenic 3 and c a d m i u m 4 in h o m o e o p a t h i c medicines have been described. Concern has also been voiced relating to potentially carcinogenic effects of low potencies of Aristolochia. 5 Quite obviously low potencies can also cause allergic reactions. The literature holds several such reports. 6, 7 Interactions are conceivable in concomitant drug treatments, though to the best of my knowledge there is no published evidence for or against this. G e n e r a l l y speaking ADRs to h o m o e o pathic medication are probably rare. Yet the fact is that we cannot, at present, tell their true incidence as (again to the best of my knowledge) no definitive study has ever been
carried out. We know that under-reporting in m a i n s t r e a m medicine is huge, with only about 5-10% of all ADRs reported. We know virtually nothing about under-reporting in homoeopathy--or indeed any other form of complementary medicine--but there is little reason to assume that it is less than in conventional medicine. Indirect risks The indirect risks are even more complex. Whereas homoeopathic medicines might on the whole be fairly safe, the homoeopath might not be. In all professions there should be a balance between responsibility and competence. 8 Therefore, if homoeopaths take full clinical r e s p o n s i b i l i t y for a patient (which they normally do), they should be medically competent. This, of course, also includes diagnostic skills. If competence is insufficient, disasters may take the form of: --critical missed diagnoses; --misdiagnoses; --losing valuable time; and - - h i n d e r i n g access to (other) e f f e c t i v e treatment. The last point may be of particular concern: deterioration might easily be confused with aggravation. A review of the medical literature indicates that these indirect risks are not an academic matter but a sad reality. Distressing case reports, some with fatal outcome, abound. 9,1~ The German Heilpraktiker, an N M Q healthcare professional, usually employs homoeopathy, and indirect risks incurred by this practice seem particularly high. 193
194 V a c c i n a t i o n is a special s u b j e c t for homoeopathy.11, 12 Some NMQ homoeopaths hinder access to mainstream immunization by advocating homoeopathic vaccination, which is not documented to be effective. 13 Our own survey shows that not one of 12 NMQ homoeopaths recommends conventional v a c c i n a t i o n whereas seven out o f ten homoeopathic physicians do. 14 This suggests that some British homoeopaths do not behave in the best interest of their patients.
British Homoeopathic Journal
benefits clearly outweigh risks. Thus we urgently need to establish h o m o e o p a t h y ' s benefits and its potential risks to a much higher degree of certainty before definitive answers to the complex question of safety can be given. It seems to me that this call for randomized controlled trials and studies on the safety of the practice of homoeopathy must not be ignored if we truly want to advance medicine and help our patients. EDZARD ERNST
Self-medication A further safety issue emerges when one looks at homoeopathic self-medication. In most of the lay literature homoeopathy is pictured as a panacea, 1 a cure for everything from abdominal pain to cyanosis. The patient cannot be expected to be medically competent to the point of questioning the printed text. Used in an indiscriminate way, homoeopathic self-medication m a y well do more harm than good. One might argue that direct risks are more prevalent in pharmacotherapy and indirect harm can also be done in mainstream medicine. This may well be true. Yet it should be borne in mind that pharmacotherapy has its well-established safety nets 15 most of which do not apply to homoeopathy. One also has to stress that proper medical training and professional conduct are the most effective ways of minimizing indirect risks. Again these mechanisms are securely installed in mainstream, but not in all areas of homoeopathic medicine.The risks of any type of medicine cannot be seen in isolation. Whenever we prescribe a treatment, we ought to weigh the benefits against the risks. If the former are small, the latter should be minute so that on balance
References
1 Chopra D. Alternative medicine, the definitive guide, p. 272. Puyallup Wash.: Future Medicine 1994. 2 Ernst E. Bitter pills of nature: safety issues in complementarymedicine. Pain 1995; 60:237 8. 3 Kerr HD, Saryan LA. Arsenic content of homoeopathic medicines. Clin Toxicol 1986; 24: 4514. 4 De Smet PAGM. Giftige metalen in homeopathische preparaten. Pharm Weekbl 1992; 127:125 6. 5 0 e p e n I. Kritische Argumente zur Hom6opathie. Dtsch Apoth Ztg 1983; 123: 1105. 6 Van Ulsen J, Stolz E, Joost T. Chromate dermatitis from a homoeopathic drug. Contact Derm 1988; 18: 56-7. 7 Forsman S. Homeopati kan vara farling vid hudsjukdomar och allergier. Liikurtidningen 1991; 88: 1672. 8 Ernst E. Competence in complementary medicine. Comp TherMed 1995; 3: f~8. 9 Goodyear HM, Harper J1. Atopic eczema, hyponatraemia and hypoalbunimaemia. Arch Dis Child 1990; 65: 231~. 10 Zimmer P. Heilpraktiker. Vers Med 1994; 46: 171-4. 11 Fisher P. Enough nonsense on immunization. Br Horn J 1992; 79: 198~00. 12 English J. The issue of immunization. Br Horn J 1992; 81:161 3. 13 Burgess M. Homoeopathy and vaccination. Lancet 1994; 344:1168. 14 Ernst E, White A. Unpublished results. 15 Rawlins MD. Pharmacovigilance, paradise lost, regained or postponed? JRoy Coil Phys 1995; 29:41 9.
Our cover The children's ward of the London Homoeopathic Hospital at Christmas in the 1880s. See the paper by Leafy in this issue.
Guest editorial
The safety of homoeopathy Accepting the invitation to write this editorial is an e a s y w a y to m a k e enemies. This, h o w e v e r , is not m y i n t e n t i o n . On the contrary, by addressing this (clearly underresearched) issue I hope to do a service to homoeopathy, increase its credibility and stimulate discussion. ' H o m o e o p a t h y is a low-cost, non-toxic system of medicine'. 1 It is not difficult to find such quotes, indeed the notion that homoeopathy is virtually risk-free is widespread among both patients and homoeopaths. But is it true? For the purpose of this discussion I will distinguish between direct and indirect risks potentially associated with homoeopathy. 2 Direct risks Direct risks are essentially adverse drug reactions (ADRs). Most but not all homoeopathic medicines are too diluted to bring about toxic effects. Potentially toxic concentrations of arsenic 3 and c a d m i u m 4 in h o m o e o p a t h i c medicines have been described. Concern has also been voiced relating to potentially carcinogenic effects of low potencies of Aristolochia. 5 Quite obviously low potencies can also cause allergic reactions. The literature holds several such reports. 6, 7 Interactions are conceivable in concomitant drug treatments, though to the best of my knowledge there is no published evidence for or against this. G e n e r a l l y speaking ADRs to h o m o e o pathic medication are probably rare. Yet the fact is that we cannot, at present, tell their true incidence as (again to the best of my knowledge) no definitive study has ever been
carried out. We know that under-reporting in m a i n s t r e a m medicine is huge, with only about 5-10% of all ADRs reported. We know virtually nothing about under-reporting in homoeopathy--or indeed any other form of complementary medicine--but there is little reason to assume that it is less than in conventional medicine. Indirect risks The indirect risks are even more complex. Whereas homoeopathic medicines might on the whole be fairly safe, the homoeopath might not be. In all professions there should be a balance between responsibility and competence. 8 Therefore, if homoeopaths take full clinical r e s p o n s i b i l i t y for a patient (which they normally do), they should be medically competent. This, of course, also includes diagnostic skills. If competence is insufficient, disasters may take the form of: --critical missed diagnoses; --misdiagnoses; --losing valuable time; and - - h i n d e r i n g access to (other) e f f e c t i v e treatment. The last point may be of particular concern: deterioration might easily be confused with aggravation. A review of the medical literature indicates that these indirect risks are not an academic matter but a sad reality. Distressing case reports, some with fatal outcome, abound. 9,1~ The German Heilpraktiker, an N M Q healthcare professional, usually employs homoeopathy, and indirect risks incurred by this practice seem particularly high. 193
194 V a c c i n a t i o n is a special s u b j e c t for homoeopathy.11, 12 Some NMQ homoeopaths hinder access to mainstream immunization by advocating homoeopathic vaccination, which is not documented to be effective. 13 Our own survey shows that not one of 12 NMQ homoeopaths recommends conventional v a c c i n a t i o n whereas seven out o f ten homoeopathic physicians do. 14 This suggests that some British homoeopaths do not behave in the best interest of their patients.
British Homoeopathic Journal
benefits clearly outweigh risks. Thus we urgently need to establish h o m o e o p a t h y ' s benefits and its potential risks to a much higher degree of certainty before definitive answers to the complex question of safety can be given. It seems to me that this call for randomized controlled trials and studies on the safety of the practice of homoeopathy must not be ignored if we truly want to advance medicine and help our patients. EDZARD ERNST
Self-medication A further safety issue emerges when one looks at homoeopathic self-medication. In most of the lay literature homoeopathy is pictured as a panacea, 1 a cure for everything from abdominal pain to cyanosis. The patient cannot be expected to be medically competent to the point of questioning the printed text. Used in an indiscriminate way, homoeopathic self-medication m a y well do more harm than good. One might argue that direct risks are more prevalent in pharmacotherapy and indirect harm can also be done in mainstream medicine. This may well be true. Yet it should be borne in mind that pharmacotherapy has its well-established safety nets 15 most of which do not apply to homoeopathy. One also has to stress that proper medical training and professional conduct are the most effective ways of minimizing indirect risks. Again these mechanisms are securely installed in mainstream, but not in all areas of homoeopathic medicine.The risks of any type of medicine cannot be seen in isolation. Whenever we prescribe a treatment, we ought to weigh the benefits against the risks. If the former are small, the latter should be minute so that on balance
References
1 Chopra D. Alternative medicine, the definitive guide, p. 272. Puyallup Wash.: Future Medicine 1994. 2 Ernst E. Bitter pills of nature: safety issues in complementarymedicine. Pain 1995; 60:237 8. 3 Kerr HD, Saryan LA. Arsenic content of homoeopathic medicines. Clin Toxicol 1986; 24: 4514. 4 De Smet PAGM. Giftige metalen in homeopathische preparaten. Pharm Weekbl 1992; 127:125 6. 5 0 e p e n I. Kritische Argumente zur Hom6opathie. Dtsch Apoth Ztg 1983; 123: 1105. 6 Van Ulsen J, Stolz E, Joost T. Chromate dermatitis from a homoeopathic drug. Contact Derm 1988; 18: 56-7. 7 Forsman S. Homeopati kan vara farling vid hudsjukdomar och allergier. Liikurtidningen 1991; 88: 1672. 8 Ernst E. Competence in complementary medicine. Comp TherMed 1995; 3: f~8. 9 Goodyear HM, Harper J1. Atopic eczema, hyponatraemia and hypoalbunimaemia. Arch Dis Child 1990; 65: 231~. 10 Zimmer P. Heilpraktiker. Vers Med 1994; 46: 171-4. 11 Fisher P. Enough nonsense on immunization. Br Horn J 1992; 79: 198~00. 12 English J. The issue of immunization. Br Horn J 1992; 81:161 3. 13 Burgess M. Homoeopathy and vaccination. Lancet 1994; 344:1168. 14 Ernst E, White A. Unpublished results. 15 Rawlins MD. Pharmacovigilance, paradise lost, regained or postponed? JRoy Coil Phys 1995; 29:41 9.