Tuesday, 12 April 2011

HOMEOPATHY: A PRACTICING PHYSICIAN'S PERSPECTIVE. Richard Moskowitz, MD

For anyone looking for a safer and more effective medical therapy, this is an eminently sensible and well-argued article. Richard is a Medical Doctor, who uses homeopathy by choice. Every patient should read what he has to say about homeopathy. What he says about homeopathy's opponents shows them up for what they are. Certainly, reading this article makes a refreshing change from reading some of the arrant nonsense posted to this blog from 'homeopathy denialists'!
I have Richard's permission to publish here, and I do so, with many thanks.
"I am writing in response to "Against Homeopathy: a Utilitarian Perspective," (1) by Kevin Smith, Ph. D., whom I commend for the clarity of his writing and the thoroughness of his logic. I suppose I should also derive some comfort from the fact that, contrary to the advice he gives to his readers, he takes homeopathy at least seriously enough to go to such trouble to denounce it. 
Long familiar to every homeopath, his main argument that homeopathic remedies are nothing but placebos was already current in Hahnemann's time, decades before Oliver Wendell Holmes made it famous 150 years ago, (2) and has since been incorporated into the conventional wisdom.
When I was in medical school, the term "homeopathic dose" was used almost affectionately to signify an amount of medicine far too small to have any noticeable effect; and even today, as various modalities of alternative and complementary medicine enter the mainstream, and many American physicians aspire to broaden their outlook in order to accommodate them, most would probably still agree with Dr. Smith, at least in private, that homeopathy defies common sense, ordinary logic, and some basic laws of chemistry. 
Indeed, I often feel a bit uncomfortable with patients who swallow the whole package without any hesitation or skepticism, as if they don't really grasp the implications of what I'm asking of them. For Hahnemann's Law of Similars, Similia similibus curentur, "Let likes be cured by likes," the fundamental principle of homeopathy, is still far from intuitively obvious, even to those of us who use it every day, and remains essentially a postulate, by definition not amenable to conclusive proof or disproof, as a scientific hypothesis must be. Nor has anyone ever satisfactorily explained how medicines diluted beyond the level of Avogadro's number could possibly have any effect on a patient, let alone a curative one. 
But the mere fact that homeopathy is based on a mystery as yet unexplained by the science we have now is by no means sufficient to prove that it is a nullity, a fake, and therefore a false belief, indeed a delusion, on the part of anyone who takes it seriously enough even to entertain the possibility that there might just be something to it. It almost embarrasses me to have to say that Dr. Smith's entire argument boils down to one defective syllogism, that because homeopathy can't work, it therefore doesn't work.
Once that premise is accepted, to be sure, his reasoning seems persuasive. For if it could be shown that the homeopathic phenomenon does not exist, that medicines do not in fact have the power to elicit or provoke the same symptoms that they help to cure, and that remedies diluted beyond the level of Avogadro's number are simply inert and have no effect whatsoever on any living system, then he would be entirely right to insist that such beliefs are utterly groundless, that those who persist in them are delusional, and that public funds should not be provided for the medical care of indigent people based on them, or even for further research as to their efficacy, since more than enough would already have been carried out to disprove the need or value of proceeding any further along this path. 
As a final flourish, as if all that were not enough, he concludes that homeopathy is not only ineffective, but indeed immoral, according to the utilitarian standard of doing the greatest good for the greatest number, mainly to the extent that it dissuades people from seeking the kind of heavy artillery that really does work. 
Such a virtuoso display of logical reasoning might have been more persuasive had he not named as authorities on the subject the likes of Wallace Sampson (3) and Stephen Barrett, (4) professional "quackbusters" who have made discrediting homeopathy their life's work, and who automatically offer the most damning possible interpretations of everything pertaining to it.
Proudly acknowledging Prof. Sampson as his main inspiration and source of information, (5) and basking in the absurdity of infinitesimals, he sheds all pretense at even-handedness, making quick work of the alleged benefits of the method, and deducing a number of serious faults ex cathedra without any knowledge of or interest in such practical details as how the interview is conducted, how the various possible reactions to the remedy are identified and followed, and so forth.
In any case, all his excellent reasoning goes for naught, because the postulate that it all depends on, the common assumption that the remedies are nothing but blanks, turns out to be simply and demonstrably false. The basic claim of the Law of Similars, the phenomenon of drugs causing the same symptoms that they are designed to relieve, is familiar even in allopathic medicine, where "paradoxical" effects, such as antihypertensives raising blood pressure, antidepressants making depression worse to the point of suicide, and so on, are commonplace and well-documented in standard reference texts like the Physicians' Desk Reference, (6) just not proclaimed as a general rule.
As for those absurdly infinitesimal doses, experiments have repeatedly shown that highly diluted remedies are capable of both stimulating and inhibiting colony growth in bacterial cultures, (7) in vitro enzymatic activity in tissue culture and cell-free extracts, (8) seed germination and growth in various plant species, (9) and other global properties of living organisms. (10) While such unambiguous results are much more difficult to attain with human subjects in clinical situations, it is nevertheless irrefutably clear that highly diluted homeopathic preparations are capable of significant biological activity.
No matter what the correct explanation of these mysteries may prove to be, it is also undeniably true that dedicated physicians have continued to follow the same principles and to practice medicine on the basis of them for more than two hundred years, and now do so on every continent and in most countries of the world. In the face of determined opposition and the sacrifice of more prominent and lucrative careers for its sake, such a long period of continuous growth and development cannot be satisfactorily accounted for as a delusion, as Dr. Smith and the other quackbusters assume. At the very least, the fact that homeopathy has continued to attract licensed doctors from all over the world at a time when allopathic medicine has risen to become the dominant model of health care indicates that there must be something interesting and valuable about it.
That it has even managed to survive intact for so long and under such adversity not only represents a major historic achievement, but indeed argues persuasively for the validity of the Law of Similars, the efficacy of Hahnemann's infinitesimal doses, and the authenticity of the homeopathic phenomenon itself. 
I have practiced general and family medicine for 44 years. No matter what type of treatment we prefer to use, all physicians are obliged to know what Dr. Smith seems to have overlooked, that our reputation and livelihood depend on the extent to which our patients are benefited by our efforts on their behalf. For the past 37 years, I have treated mine with homeopathic remedies more or less exclusively, not because I believe that pharmaceutical drugs have no value: I often refer patients whom I have not been able to help to my colleagues who offer such treatment, and am certainly grateful for what they do. I have chosen to practice homeopathy in part because I prefer to try a gentler and safer approach first, whenever possible, but mainly because matching the treatment to the individuality of the patient allows and encourages a deeper and more comprehensive level of healing than is possible with drugs that merely counteract a specific symptom or correct a particular abnormality by applying superior chemical force at that strategic point.
I will give a few examples from the early years of my practice. The first was an eight-pound baby girl who was born covered with thick meconium, took one gasp, and then breathed no more. Brisk suctioning produced only more of the same. At this point the child lay limp, white, and motionless, with a heartbeat of 40 per minute, responding feebly to mouth-to-mouth resuscitation but unable to breathe on her own. I put a few tiny granules of Arsenicum album 200C on her tongue,(11) and almost instantaneously she awoke with a jolt, crying and flailing, her heart pounding at 140 per minute, her skin glowing pink with the flame of new life. The whole evolution took no more than a few seconds. After a night in the hospital to be on the safe side, mother and baby went home in the morning with no outward sign that anything untoward had happened.
Experiences like these are imprinted for life in every practitioner's mind.(12) Of course, I am well aware that this could have happened spontaneously without any remedies at all, for the child was well-formed and appeared normal in every other respect; and anyway, it was just one patient, a mere "anecdote," utterly without statistical significance. But all of us who were present, including my nurse and the baby's mother and father, and indeed I daresay the baby herself, by now fully-grown and undoubtedly steeped in the legend of her birth, know as surely as we can know anything on this earth that the conjunction of the infinitesimal dose and her abrupt awakening was no mere coincidence. 
My second case was that of a 34-year-old R. N. who had been plagued with severe endometriosis since her teens. Already a veteran of four surgeries to remove large blood-filled cysts from her bladder and pelvic organs, and several courses of male hormones to suppress the condition, she came seeking only to restore her menstrual cycle, having long since abandoned any hopes of  childbearing. While intensely painful at first, her periods had become "dead," dark-brown, and scanty from so many years of surgery and hormonal treatments in the past.
After a few remedies, her menstrual flow became fuller and richer, and within six months she was pregnant. By the next time I next saw her, for a different ailment eight years later, she had had two healthy children after uncomplicated pregnancies and normal vaginal births, and had remained in good health ever since.13 While no one can attribute such an outcome to a homeopathic remedy or any other agency in precise, linear fashion, my patient has never stopped thanking me for it, which is reason enough to be thankful for a process that by its very nature acts catalytically and persuasively rather than by force or compulsion.
Still less can these happy endings be imputed to any unusual skill of mine, since they are entirely comparable to what every competent prescriber has seen or could easily duplicate, and I could just as well have cited other patients whose conditions were far from hopeless, who believed in the remedies and in me, but whom I was nevertheless unable to help. 
As Dr. Smith is at pains to insist, homeopathic remedies are safe, economical, simple to use, and gentle in their action, with notably few serious or prolonged ill effects. What he does not say and clearly does not know is that they are also capable of acting thoroughly, deeply, and for a very long time, requiring only infrequent repetition of the dose, and posing minimal risks of chronic dependence. Patients, friends, and loved ones alike often notice a general improvement in vitality and a sense of well-being, such that recurrence seems less frightening and indeed less likely. 
To be sure, it is far from a panacea for all ills. Homeopathy is a difficult and exacting art, and even after years of study and practice a skilled prescriber may need to try several remedies before obvious benefit is obtained, while in other cases, despite the most devoted efforts, there is little or no benefit at all. But if the ultradilute remedies can be seen to have worked often and well enough to sustain me in a general practice for 37 years, like so many others over the past two centuries, that is surely enough to refute Dr. Smith's blanket assertions that they are no treatment at all. Much as I'm flattered by his contention that we heal our patients solely by some kind of magic or shamanic spell that we cast over them unawares, my experience suggests that the "placebo effect," that starved and tattered remnant of the innate self-healing capacity, is an essential and inseparable component of all healing, even with pharmaceuticals, but certainly not the whole of it. 
For allopathic drugs, the current standard of their effectiveness is the Random Controlled Trial, in which the subjects are randomized into two groups, one receiving the drug, the other only a placebo or inert imitation, with both patients and doctors blinded as to who gets which. In these experiments, the causal power of any drug against a particular symptom or abnormality equals the extent to which patients actually taking it outperform their placebo controls; and rather than an optimal qualitative fit with the illness of each patient as a whole, as homeopaths aspire to, the best drugs and the ones most diligently sought after are simply the most potent ones, those with the most chemical power to compel the organism to function in whatever ways the profession decrees that they should. 
Modern physicians are equipped with the latest chemical weapons to attack a vast array of diseases and abnormalities as if they were enemies on a battlefield: antibiotics to kill bacteria, antihypertensives to lower the blood pressure, anticonvulsants to control seizure activity, antimetabolites to destroy cancer cells, antihistamines to suppress the allergic response, and so forth, all developed to act as selectively as possible, with little or no regard for the individuality of the patient. In advanced cases, such drugs may indeed save life, give miraculous relief, buy valuable time, or do the best that can be done under adverse or extreme circumstances.
Leaving aside the bottom-line question, whether most patients taking such drugs will actually feel better, live longer, and suffer fewer complications as a result of taking them, I will simply stipulate what is not always true in practice, that many of the drugs in common use do indeed have the power to accomplish at least some of what we ask and expect of them, in the hope that these more subjective and personal goals will eventually follow. But the high and often exorbitant price that we pay for such seemingly precise and overriding causal power is threefold. 
First, when a drug really works to suppress or counteract the target symptom or abnormality, the condition is likely to reappear with equal or greater intensity as soon as the drug wears off. Using chemicals to force the issue, rather than assist whatever self-healing processes are already under way, thus automatically poses the substantial risk of needing to continue using them for long periods of time, if not indefinitely. 
Second, targeting drug treatment to abstract pathological "entities" without also rebalancing the energy dysfunction of the patient as an integrated whole regularly leads to polypharmacy, the need for still other drugs to correct or control as many other identifiable diseases and abnormalities as will appear in the future. 
Third, drugs powerful enough to do what we expect them to do are also capable of acting coercively on various other physiological functions, even though these undesirable "side effects" typically vary quite a lot from patient to patient, according to their unique tendencies and predispositions, and will therefore be somewhat more difficult to attribute unequivocally to the action of the drug.
The ubiquity and relative invisibility of such adverse reactions make it easier to understand why homeopathy has become so popular with patients either caught in the center or having fled to the periphery of the medical system, yet so easily dismissed by those who administer that system as ineffective, impossible, or unworthy of serious study. In pointed contrast to allopathic drugs, which are developed solely for their power to force the organism to do what it has no natural inclination to do, homeopathy seeks rather to assist and enhance the innate self-healing capacity that is synonymous with life, continually at work in every patient, and encompasses precisely the same individualising tendencies, sensitivities, and predispositions which as physicians we are conditioned to ignore in our diagnoses, outperform in our research, and override in our treatment.
That is also the reason why, even when homeopathic remedies do act curatively, the results are simply dismissed or written off as isolated cases, perhaps "miraculous" at times, but in any case merely "anecdotal evidence" without scientific import, and therefore always located on the placebo side of the ledger, because medical science as presently constituted restricts the term "cause" to those interventions that force things to happen, and measures that power against the idiomatic tendency of patients to recover without it.
Even in the case of well-designed RCT's that demonstrate a statistically significant benefit from homeopathic treatment, the result still "feels" unscientific and unpersuasive to most people, simply because no chemical force was exerted and no resistance had to be overcome, while to trained scientists its looser interpretation of causality and its major emphasis on subjective and individual variables similarly disqualify it from serious consideration as a force potent, measurable, and consistent enough to count as "hard science."
So the standard argument that homeopathic remedies are merely placebos actually cuts both ways. To begin with, it's simply wrong, as we saw. From my own experience and that of my colleagues, I would add that homeopathic treatment has an impressive track record in the treatment of animals, newborn babies, and comatose patients, in whom the influence of suggestion is universally agreed to be negligible. In addition, if giving placebo or natural remedies or nothing at all can achieve clinical results better than or even comparable to those obtainable with suppressive drugs or crippling surgery, who of sound mind would not prefer the cheaper, gentler, and safer alternative, at least to begin with? Finally, when homeopathic remedies do act curatively, our patients rightly feel that they have healed themselves, and may sometimes wonder if they might have done so without our help. To my mind, that "delicious quandary" is no cause for complaint or ridicule, since I can imagine no higher compliment to pay to a medicine than that its action cannot be distinguished from a gentle, spontaneous, and long-lasting cure requiring no further treatment.
Indeed, I submit that the irony lies wholly on the other side, given that this optimal response is relegated to the placebo side of the equation, while pharmaceutical drugs are valued and considered effective only to the extent that they can overpower the physiology of as many patients and for as long a time as possible. I find it absurd and contemptible to boast of standards that prize brute force over elegance of fit, and subordinate healing the sick to manipulating their life functions artificially, whether for the sake of science, ambition, mastery over nature, or some equally abstract, hypothetical goal that we are obliged to take on faith.
That is why, for the present at least, I am thankful that our cures tend to remain snugly ensconced on the placebo side of things, because until we develop a kinder, more accurate, and inclusive model of causality, and a workable notion of the unified life energy of the patient as a whole, that is precisely where they belong. What the nuclear physicist J. Robert Oppenheimer once told a group of psychologists seems even more apposite for the medical community as a whole:
We inherited at the beginning of the Twentieth Century a notion of the physical world as a causal one, in which every event could be accounted for if we were ingenious, a world characterized by number, where everything interesting could be measured, and anything that went on could be broken down and analyzed. This extremely rigid picture left out a great deal of common sense which we can now understand with a complete lack of ambiguity and phenomenal technical success.
One [such idea] is that the world is not completely determinate. There are technical predictions you can make about it, but they are purely statistical. Every event has in it the nature of a surprise, a miracle, or something you could not figure out. Every pair of observations taking the form "we know this and can predict that" is global and cannot be broken down. Every atomic event is individual: it is not in its essentials reproducible.(14)
For all of these reasons, rather than competing with the placebo effect in order to defeat it, I believe that the highest goal of medicinal treatment, whether homeopathic or otherwise, is instead to assist and indeed to maximize it, by doing everything possible to promote healing in a more global sense, not merely to correct abnormalities, and by cultivating a more intimate knowledge of our patients, instead of ignoring, circumventing, or overriding what they have to teach us. While certainly admiring the ingenuity and dedication of my colleagues who conduct RCT's to try to demonstrate the effectiveness of homeopathic treatment in the approved manner of established biomedical science, I would like to propose a very different model for clinical research, based on self-healing, which to my way of thinking would be more suitable for allopathic medicine as well:
1) Nobody is blinded: all subjects know whether they are receiving homeopathic or allopathic treatment, having chosen it beforehand precisely because of their interest, belief, or faith in it.
2) Nobody gets placebo: everyone gets the treatment they select, while the doctors giving it out are matched to them by their beliefs, and encouraged to use prayer, suggestion, exhortation, shamanic incantation, or whatever they or their subjects believe will most effectively assist them on their healing path. In other words, each group will serve as the control of the other.
3) Using the totality of signs and symptoms over time, including both subjective and objective criteria, and reports of family, friends, teachers, employers, etc., both homeopathic and allopathic subjects will be followed for a period of months or years, depending on the condition, and extending beyond the acute phase to include the chronic dimension. Both groups will then be evaluated as to how well or badly they are measuring up in their own lives, by their own standards and those of their community, and also with respect to appropriate clinical and pathological criteria. 
4) Qualified judges not exclusively or doctrinally committed to either point of view will then ascertain which form of treatment proves more beneficial in which respects, and will publish the results in a friendly, fair, and unbiased journal of good repute, to be selected and agreed upon in advance. (15)
For myself, and my colleagues who also practice it, homeopathy has stood the test of time as a philosophy, a coherent, logical system of thought, derived from the self-evident unity of the life force, a mere truism, and the "Law of Similars," a bold postulate, neither of which follows logically from anything else, or is therefore subject to experimental proof or disproof, like ordinary scientific hypotheses, as in Bertrand Russell's whimsical definition: 
". . . the point of philosophy is to start with something so obvious as not to seem worth stating, and to end with something so paradoxical that no one will believe it. (16)
I freely admit, as I think even Dr. Smith would heartily agree, that homeopathy fits this description perfectly. Yet the authenticity of the homeopathic phenomenon, the enduring relevance of the point of view it offers, and the obvious effectiveness of minute doses when competently used, all imply the existence of a bioenergetic science that is still in its infancy, and that will undoubtedly add to the atomic theory of matter and the laws of chemistry as we know them, just as Dr. Smith has foretold, a further set of rules, laws, hypotheses, and predictions as it develops in the future. Homeopathy thus also looks beyond itself, to a more open and inclusive conceptual scheme that can accommodate both points of view, as well as perhaps others as yet unknown to us. Helping to envision, identify, and elaborate this new synthesis is therefore our highest mission, which we share with like-minded physicians and healers of all persuasions and in every part of the world.
NOTES. 
1. Smith, K., "Against Homeopathy -- A Utilitarian Perspective," Bioethics, 14 February 2011, pp. 1-12.
2. Holmes, O. W., "Homeopathy and Its Kindred Delusions," 1847, included in Medical Essays, Houghton Mifflin, Boston, 1895, pp. 1-102, passim. 
3. Cf. Sampson, W., The Braid of Alternative Medicine, Prometheus, New York, pp. 21-31, and "Homeopathy Does Not Work," Alternative Therapies in Health and Medicine 1:48-52, 1995. Cf. the Health Care Reality Check website, www.hcrc.org:
"Dr. Sampson is Professor of Medicine (Emeritus) at Stanford, Editor-in-Chief of Scientific Review of Alternative Medicine, and teaches about unscientific and aberrant medical claims. He sits on the Board of Directors of the National Council Against Health Fraud, and is affiliated with other organizations that protect consumers from bogus healthcare claims and products." 
4. Cf. Barrett, S.,"Homeopathy's 'Law of Similars' " and "Homeopathy's 'Law of Infinitesimals,' " Homeowatch Home Page, www.homeowatch.org, posted March 20, 2002; and "Homeopathy: the Ultimate Fake," Quackwatch Home Page, www.quackwatch.org, revised August 23, 2009.
5. Smith, op. cit., p. 12, Acknowledgement: "The author would like to thank Wallace Sampson, M. D., for valuable comments and criticism."
6. Physicians Desk Reference, 63rd Edition, 2009, Montvale, NJ. Cf., for example, "Catapres, Overdosage," p. 842: "Hypertension may develop early . ."; and "Prozac, Warnings: Clinical Worsening and Suicide Risk," p. 1854: "Patients with major depressive disorder may experience worsening of their depression and/or the emergence of suicidal ideation and behavior . . ."; et passim. 
7. Cf., for example, Noiret, P., "Activity of several dilutions of copper sulfate (Cuprum sulph.) in different microbial species," Proceedings of 31st Congress, International League of Homeopathic Physicians, Athens, 1976, pp. 137-147; and Brack, A., et al.,
"Effect of ultra-high dilutions of 3,5-dichlorophenol on luminescence of the bacterium Vibrio fischeri, in Biochim. et Biophys. Acta 1621:253-260.
8. Cf., for example, Davenas, E., et al., "Effect on mouse peritoneal macrophages of orally-administered, very high dilutions of Silica," in European Journal of Pharmacology 135: 313-319; Petit, C., "Effect of homeopathic dilutions on subcellular enzymatic activity," Human Toxicology 8:125-129; and Shabir, S., et al., "Effect of homeopathic drugs on in vitro activity of alpha-amylase from human saliva," Indian Journal of Homeopathic Medicine 31:93-98.
9. Betti, L., et al., "Effect of high dilutions of Arsenicum album on wheat seedlings from seeds poisoned with the same substance," British Homeopathic Journal 86:86-89, 1997; and Binder, M., et al., "Effects of Arsenicum album 45X on wheat seedling growth," Forschende Komplement√§rmedizin und Klassische Naturheilkunde 12:284-291.
10. Banerjee, P., "Comparative efficacy of two dilutions of Arsenicum album to ameliorate toxicity by repeated sublethal injections of arsenious trioxide in mice," Pathobiology 75:156, 2008; Fisher, P., "The influence of the homeopathic remedy Plumbum metallicum on the excretion kinetics of lead in the rat," Human Toxicology 6:321, 1987; and Doutremepuich, C., et al., "Aspirin at ultra-low dosage in healthy volunteers: effects on bleeding time, platelet aggregation, and coagulation, Hemostasis 20:99-105.
11. The 200C, or 200th centesimal dilution, means a dilution on a scale of 1:100, carried out 200 times, for a concentration on the order of 10-400! 
12. Cited in Moskowitz, R., Resonance: the Homeopathic Point of View, Xlibris, Philadelphia, 2001, pp. 14-15.
13. Ibid., p. 15.
14. Oppenheimer, J. R., "Analogy in Science," The American Psychologist 2:134, March 1956.
15. Moskowitz, op. cit., p. 342.
16. Russell, B., "The Philosophy of Logical Atomism," in Logic and Knowledge: Essays, 1901-1950, Allen & Unwin, London, 1968, p. 193.