When we think of conflicts of interest, we almost automatically think of money. In my area of research, complementary alternative medicine (CAM), there is no money—well, almost none (contrasted with most areas of mainstream medicine). Despite this fact, conflicts of interest are rife in CAM research. I am, of course, talking about a different type of conflict: the one that is created by strong belief and evangelic conviction.

Across the globe, I personally know many individuals who are full-time CAM researchers. They have different personalities, backgrounds, and skills. But they all have, as far as I can see, one characteristic in common: they are strong believers in the benefit of at least some aspects of CAM. On the one hand, this may seem entirely reasonable: if one didn’t believe in CAM, why would one dedicate one’s career to investigating it?

On the other hand, if the vast majority of CAM researchers are made up of CAM believers, things might not be quite right either. In other areas of medical research, the situation is—in my experience—very different. I know many pharmacologists, for instance, who are keenly aware of the dangers of medicines and extremely critical of some of the activities of the pharmaceutical industry. I cannot say that I know many CAM researchers who are truly concerned about the dangers of CAM or of the activities of those individuals or organisations that promote CAM uncritically.

Conflicts of interest are precarious because they tend to cloud judgment and generate bias—the type of bias that creeps in unnoticed and cannot be readily identified when studying a published paper. After some detective work, we might be able to find out, for example, that a certain paper that draws positive conclusions about the homeopathic remedy Traumeel® (Schneider et al. 2008) was coauthored by at least one “expert” who is on the payroll of the manufacturer of that very remedy—even if the paper itself fails to disclose this fact (Schneider et al. 2008). But what about more subtle yet potentially powerful conflicts of interest? I fear that they have far too much impact on CAM.

If the totality of researchers in one field is open to unidirectional bias, one has to worry about the area as a whole. The danger, then, is obvious: the field will collectively lose its balance and make serious and repetitive mistakes without even noticing them. In the absence of criticism “from the inside,” such an area of research can neither prosper nor mature. In my experience, CAM has very little internal criticism, as the following examples suggest.

Chiropractic

After the British Chiropractic Association (BCA) sued science writer Simon Singh for libel, the United Kingdom’s General Chiropractic Council (GCC, the regulatory body of its members) was inundated with about 700 complaints from skeptical bloggers about chiropractors who had made similarly bogus therapeutic claims. The GCC reacted by commissioning North American chiropractors to write an “evidence report.” Presumably, the GCC hoped that the report could clarify the evidence regarding the disputed claims. Bronfort et al.’s (2010) published report revealed no strong evidence for “manual therapies.” Despite this seemingly critical stance, the report is still not critical enough, in my opinion. The reason becomes clear upon a reading of its fine print. Even though the authors repeatedly mention the “quality of the evidence,” they fail to formally evaluate it. Thus, poor-quality primary studies are taken at face value, which inevitably leads to false-positive conclusions. Without the very obvious conflict of interest (chiropractors commissioned by the GCC), the report might have been far more critical than it turned out to be.

A similar situation occurs with systematic reviews of chiropractic as a treatment for specific conditions. Such articles are now emerging regularly, and they tend to display interesting discrepancies. For example, a review on the subject of asthma written by four chiropractors concluded that “chiropractic care showed improvement in subjective measures . . .” (Kaminskyj et al. 2010). Meanwhile, my own review, which included a critical assessment of the quality of the primary data, stated that “spinal manipulation is not an effective treatment for asthma” (Ernst 2009). Here I should mention perhaps that I, as an independent academic, have no conflicts of interest and receive no payments from Big Pharma or similar institutions that might have an axe to grind.

Years ago, I had already noted that reviews published by chiropractors tend to arrive at positive conclusions while those by independent experts do not (Ernst and Canter 2006). The explanation for this phenomenon seems to be simple: conflict of interest.

Acupuncture

Vickers et al. (1998) and others (Tang, Zhan, and Ernst 1999) have shown that 100 percent of all acupuncture trials originating in China report positive results. Recently, an in-depth analysis of acupuncture articles published between 1991 and 2009 revealed that China is now producing more acupuncture research papers than any other country (Han and Ho 2011). To make matters worse, this analysis also names the journals that publish the bulk of these articles: unsurprisingly, they tend to be the ones I have previously identified as publishing virtually no negative results (Ernst and Pittler 1997). Thus there is reason to fear that we are currently exposed to a mountain of research on acupuncture, much of which might be less than reliable.

Here the explanations might be more complex, and there could be more than one factor at play. Yet I have little doubt which one is the most important: conflict of interest.

What Can Be Done?

My message is clear: non-financial conflicts of interest can be just as powerful as financial ones, and in my area of research they seem to be quite overpowering. This problem will inevitably lead to significant distortions of the truth about the value of alternative medicine. The issue at hand is more than just academic: misleading results in health care endanger our health.

It is relatively easy to identify the problem, yet it is hard to solve it. I don’t pretend to have the ideal solution. All I can suggest is that journal editors consider making their authors’ conflicts of interest transparent and that readers of such papers apply a healthy dose of skepticism. Whenever there are two discrepant opinions (and that is the case more often than not), my advice is to determine which one might be prompted by a conflict of interest. In theory, this sounds fine; in practice, I am afraid, it will not be nearly enough to remedy the problem.

References

Bronfort, G., M. Haas, R. Evans, B. Leninger, and J. Triano. 2010. Effectiveness of manual therapies: The UK evidence report. Chiropractic and Osteopathy 18(3). doi: 10.1186/1746-13 40-18-3.

Ernst, E. 2009. Spinal manipulation for asthma: A systematic review of randomised clinical trials. Respiratory Medicine 103(12): 1791–95.

Ernst, E., and P. Canter. 2006. A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine 99(4): 192–96.

Ernst, E., and M.H. Pittler. 1997. Alternative therapy bias. Nature 385: 480.

Han, J.S., and Y.S. Ho. 2011. Global trends and performances of acupuncture research. Neuroscience and Behavioural Reviews 35(3): 680–87.

Kaminskyj, A., M. Frazier, K. Johnstone, and B.J. Gleberzon. 2010. Chiropractic care for patients with asthma: A systematic review of the literature. Journal of Canadian Chiropractic Association 54(1): 24–32.

Schneider, C., B. Schneider, J. Hanisch, and R. Van Haselen. 2008. The role of homoeopathic preparation compared with conventional therapy in the treatment of injuries: An observational cohort study. Complementary Therapies in Medicine 16(1): 22–27.

Tang, J.L., S.Y. Zhan, and E. Ernst. 1999. Review of randomised controlled trials of traditional Chinese medicine. BMJ 319 (7203): 160–61.

Vickers, A., N. Goyal, R. Harland, and R. Rees. 1998. Do certain countries produce only positive results? A systematic review of controlled trials. Controlled Clinical Trials 19(2): 159–66.

It is not difficult to set up experiments that seemingly “prove” that bogus treatments work. Health journalists, in particular, are regularly taken in by such bogus studies, and the misleading results are subsequently reported in the press, perpetuating the public’s belief in these treatments.

I will give several examples from the realm of “alternative” medicine. They are, of course, entirely fictitious. Not that there is a shortage of real ones, but these days one has to be careful not to end up in the hands of libel lawyers (see “Keep Libel Out of Science,” SI, May/June 2010).

Bogus Experiment No. 1

Most clinical trials test whether one treatment is better than another. These studies are called “superiority trials.” Other studies are aimed at testing whether one therapy is as effective as another. They are called “equivalence trials.” My first example is an equivalence trial comparing a highly dilute homeopathic remedy with an accepted and well-known drug, say paracetamol (known in the U.S. as acetaminophen). Take two hundred patients with a sprained ankle and randomize them to take homeopathic arnica (the experimental treatment) or paracetamol (the control treatment). One or two days later, measure the swelling of the injured ankle as an undeniably objective outcome measure. The results will show that the swelling diminished in both groups and that no difference between the two groups emerged. The conclusion, therefore, is that both are equally effective; however, homeopathy (not having any actual active ingredient) caused fewer adverse events. The headline in the papers might read: “Homeopathy Better than Paracetamol.”

The trick here is to select an outcome measure that is not affected by the “accepted and well-known” drug. Paracetamol does not reduce swelling, and few people would claim otherwise. Thus, it acts as a placebo. Comparing two different placebos should always result in equivalence. Yet the illusion can be quite convincing.

Bogus Experiment No. 2

My second fictitious study is also an equivalence trial. It compares homeopathic care against conventional medicine for a serious chronic condition, say Crohn’s disease. Twenty patients are randomized to be treated with either approach. The results demonstrate that the carefully chosen endpoint (e.g., a symptom score) reveals no differences between the groups. The conclusion: homeopathy is as effective as standard treatment of Crohn’s disease. The headline this time? “Homeopathy Scientifically Proven to Work for Life-Threatening Diseases.”

The trick here is to underpower the study dramatically. Underpowered equivalence trials will tend to (falsely) suggest equivalence between the two tested approaches—a safe bet for illusionists.

Bogus Experiment No. 3

Another approach is to conduct a “pragmatic” trial. Such studies are currently very popular because, according to their proponents, they best reflect the “real life” situation of clinical practice. In this trial, chronically ill patients are randomized to receive either standard care (the control group) or standard care plus homeopathy (the experimental group). The primary measure of outcome for that study could be patient satisfaction, well-being, quality of life, or some other subjective endpoint. Due to the regular, lengthy, empathetic encounters received by the latter group, patients are bound to feel better and improve. Illusionists will then interpret this benefit as being caused by the specific effects of the homeopathic remedies. The headline: “Homeopathy Proven to Help Chronically Ill Patients.”

The trick, in this case, is that A (standard care) plus B (homeopathy) is always more than A alone (A<A+B)—unless, of course, B is zero. But an empathetic encounter does, of course, have an impact on many subjective outcome measures. If, in clinical trials, we do not control for nonspecific effects, it is always easy to make a treatment look effective, even in a randomized trial.

Bogus Experiment No. 4

My last illusionists’ stunt is an animal study. Such experiments, it is often (falsely) claimed, are not affected by placebo effects. Ten experimental rats receive a diet to which either a homeopathic product or a placebo is added. The aim here is not to test for therapeutic effects but to find out whether homeopathy can cause a biological effect in principle. All conceivable types of bias and confounding are excluded. The study can be designed to be completely watertight. The rats receive the treatments and are observed for several weeks. At the end of this period, all rats in the homeopathy group have died, but all of the control animals are alive. The conclusion: homeopathy generates biological effects and is thus different from placebo. The headline: “Animal Experiments Prove the Principles of Homeopathy.”

The trick is simple: we need only to select the right “remedy” (and “hide” this in the small print of the experiment). For my fictitious experiment, I chose a “mothertincture” of arsenic. This is pure, undiluted, and very toxic arsenic, yet it is strictly speaking a homeopathic preparation.

The conclusion? Bogus experiments are not difficult to set up, and it is not difficult to fool uncritical people with their results. But they are still only tricks of illusionists who aim to mislead us. It follows that, if we fail to apply our skills of critical assessment or, worse still, we never had such skills, illusionists pretending to be scientists can be a menace.

Today the climate has changed fundamentally. Complementary therapies seem to be encouraged everywhere. A government-sponsored patient guide published by the Prince of Wales’s Foundation for Integrated Health reads like a promotional brochure for complementary practitioners. The recent “Smallwood Report,” which was commissioned directly by Prince Charles (and funded by Dame Porter), goes one decisive step further: it advocates homeopathy as “an alternative” to conventional asthma treatments. And in his WHO address, Prince Charles again spoke out in favor of complementary medicine: “We need to re-discover and re-integrate some of the knowledge and well-tried practices that have been accumulated over thousand of years.”

With all this plugging and promoting, few people seem to bother about the scientific evidence. Is there, for instance, reasonable proof that homeopathy treats asthma effectively? If not, such advice could actually kill hundreds of British asthma patients per year! The answer is that the totality of the best evidence available today fails to show that homeopathy works for asthma. We therefore have a case in which the current trend toward “integrated health” is disclosed as being detrimental to the health of the nation.

Nonetheless, “integrated healthcare” is being pushed at all cost as the new buzzword for providing complementary medicine to the masses. According to Prince Charles, “We need to harness the best of modern science and technology, but not at the expense of losing the best of what complementary approaches have to offer. That is integrated health—it really is that simple.” In his WHO address he put it differently: “I believe that the proper mix of proven complementary, traditional, and modern remedies, which emphasizes the active participation of the patient, can help to create a powerful healing force for our world.”

This statement, it seems to me, is in fairly good agreement with the view expressed in a recent letter by thirteen British doctors (I was one of them) to all National Health Service (NHS) trusts. We urged the NHS to use those treatments (complementary or orthodox) that are backed up by good evidence and abandon those that are not. In other words, we did something entirely obvious and legitimate: we advocated the application of the rules of evidence-based medicine and pleaded for a single standard in healthcare. One could argue that Prince Charles’s public statements are a lay person’s expression of the concepts of evidence-based medicine. Great! I am delighted. But let’s be honest. If he means what he says, he should forthwith instruct all who work for him to stop promoting unproven or disproven treatments.

My team and I have researched complementary treatments for thirteen years. We have found many that generate more good than harm and many that don’t. In the second edition of our Desktop Guide to Complementary and Alternative Medicine (just published by Elsevier), we summarize the evidence in fifty-two different situations where one complementary therapy or another is unquestionably effective and many others where effectiveness is likely. If we all, including Prince Charles and his Foundation for Integrated Health, use this type of evidence wisely we can maximize the benefits of complementary medicine with minimal risk. But this approach requires critical analysis rather than unquestioning belief—and we don’t even need a new name for it. It’s called evidence-based medicine.