Trick or Treatment? Alternative Medicine on trial.
by Simon Singh & Edzard Ernst.
Corgi Books, May 2009.
Paperback. 408 pages. Price &163;8.99.
In 1163 the then Pope banned monks from blooding patients. It took 700 years for this papal edict to overcome anecdotal medical success stories and to oust the practice of blooding (taking significant amounts of blood from patients to relieve symptoms) from mainstream, and conventional medical practice. In the meantime bloodletting, or leeching, claimed such notable victims as George Washington. Bled to death for a common cold. Or was it flu? Or ???
The Washington anecdote is reported by Simon Singh and Edzard Ernst in their book, "Trick or treatment? Alternative medicine on trial?" Bantam Press published the book first in 2008 and Corgi reissued the book in May 2009, just as an English Court was ruling on Simon Singh's use of the word bogus in respect of the British Chiropractic Association. If press reports are to be believed this action has so far cost Mr Singh deep in the pocket. And his publishers, by republishing his book in May this year, are showing support for his work, or at the very least support for the importance of the issue that he and Ernst have raised. That issue? What is the truth about alternative medicine? So, too, has the Court taken the question seriously by taking on this libel action against Mr Singh and not chucking out the BCA's case as vexatious.
The word - bogus - and its context of specific offence to the BCA - was reportedly used by Mr Singh in an article in The Guardian on 19th April, 2008. Either Singh or Ernst have a track record of fondness for the word bogus, which is scattered like shotgun pellets throughout their book about alternative medicine. For all I know in the pub they call non-CAMRA beers bogus. By republishing the book, even as the Judge was writing his ruling about the word purportedly in The Guardian's article, Corgi is showing considerable backing for its authors. If Corgi's faith is misplaced, lawsuits might yet follow against the authors from acupuncturists, homeopathy and the World Health Organisation. This time, and post Justice Eady's ruling - but please see my caveat later in this piece - the publishers, not only the authors, are likely to be in the dock. One has to hope that the authors have watertight contracts protecting them from being stand alone defendants in libel cases. And those up in arms on behalf of Simon Singh and furious with Justice Eady might like to consider that the &163;100 000 that reports say this case has so far cost Mr Singh might be a drop in the ocean and that the ruling might have come in time to prevent much, much worse.
If Mr Singh is to go on and appeal his publishers now need to step foward with their libel lawyers and the publishers' bank accounts. That is the reason for the masssive profit margins in publishing. One never knows when the hammer blow of libel action will fall. If the publishers do not step forward they are not taking their job seriously nor Justice Eady's ruling, and his conclusion that the seemingly defamatory might turn out to be defensible by a full hearing of Singh's supporting evidence for his assertion in The Guardian.
The story in The Guardian seems at the moment to have disappeared either sub judice or sub a non-legal internal newspaper ruling, because when I looked for the story online via The Guardian's search engine on Saturday night (4th July) the story was not returned in my search. And when I logged on to Her Majesty's Court Services and tried various searches of the site and the Queen's Bench Division for rulings by Justice Eady on 7th May 2009 I was not able to figure out how to negotiate the site to extract the information I needed, namely his ruling and reasoning as a whole. Certainly the ruling was not returned in response to my searches for "Justice Eady" and BCA V. Singh, nor various other combinations. This means I am relying on the following url for my understanding of the law's current judgment of the situation:
Jack of Kent reports (Link to Jack of Kent disabled for non contentious reasons, 22.10.11. Ed).
I have no idea who Jack of Kent is nor what he (she?) does with the text of his/her blogs before s/he posts them on line. But if Jack of Kent is reporting verbatim then Justice Eady has made available in his ruling the offending words that I could not find via The Guardian's search engine and which prompted the libel suit.
The sentiment Justice Eady ruled on is not different from the views Singh and Ernst express in "Trick or treatment? Alternative Medicine on Trial." In the book the word appears as part of an anti alternative-medicine polemic. By the time I realised Singh's and Ernst's penchant for the word bogus it was too late for me to start counting and noting all its uses and different contexts, and I was beginning to be irritated by the editor who had not introduced some variety from the lexicon or nailed the word and its meaning in context more precisely.
That said Ernst and Singh have written an important book. It is to me irritatingly lacking in logicality, consistency of argument, awarness of the variety in medicine and medicine's changing nature, but it makes up for that with passsion and an obvious aspiration to do good. Clearly aspiration does not always guaranetee one is doing good, but surely intent matters - theirs and that of those they criticise in their book - and I am loath to mock and denigrate good intentions. Polemic is a legitimate tool of debate and provocation of a search for political and rational informed consensus. Especially in such an important matter of public interest. We have only one life. So if any group within alternative, conventional or complementary medicine, and against the evidence, as Ernst and Singh argue in this book (lack of evidence is not in itself evidence), and in a position to act on their words is knowingly advocating or advising a course of action that may cause harm and proveably has caused harm then we need to know.
Given that there is on the one hand a £40 billion global industry in alternative medicine, according to both this book and a google search. Neither gave the source of their figures. And on the other hand an industry approaching a trillion, and that both wish to influence the purchasing power of nations and continents, and that life, health, employment and pensions ride on the debate it seems to me Justice Eady might have delivered his ruling in time to let the publishing and newspaper industry get their act together on behalf of their authors. They, not Mr Singh (or Singh and Ernst in the case of the book) have the deep pockets. And if their editors are uncritical and unquestioning of adjectives they need to step up to the plate in defence of those adjectives as much as do the authors.
In addition could I make a polite request to Her Majesty's Court Services to make the rulings of its judges more accessible. Possibly aiding and abetting the libelling of a judge expert in defamation is not my first choice for a Sunday only hours before deadline. And given that I found the search engine of HMCS unhelpful might I suggest that readers of this review beware of my opinion and go and buy the paperback for themselves.
The book is damning of alternative medicine, rides roughshod over the distinction between alternative and complementray medicine, castigates acupuncturists for reusing needles (I think they might have moved to disposable needles) and homeopathy as the work of charlatans. I might be misremembereing their words. But for the life of me I cannot, with the exception of clathrate structures, imagine a plausible mechanism for homeopathy. It might simply be that the relevant research questions and clinical trials have not yet been conducted.
Their book holds up as the gold standard the double-blind, randomised clinical trial, conveniently forgetting thalidomide. Their tone on placebo is not unkind, but is vaguely condescending. Where now is medical thinking on the subject of placebo? From my reading of his book, Mr Singh and Mr Ernst are less respectful of this "wild card" of medical practice than they perhaps ought to be. And their faith in science, though touching, might be misplaced. Last time as a science writer I read anything about what the biomedical community was saying about placebo was at the annual meeting of the American Association for the Advancement of Science (AAAS) in Boston in 2002. I recall sitting through some detailed hypothesis exploration of a possible underlying biochemical mechanism for placebo. At this distance in time the only thing I recall is that the presentation of potential mechanisms was as complicated to me as some of the explanations that a Ph.D/post doc immunologist kindly gave me in an effort to help me grasp the basic principles of immunology.
Then there was the malaria expert who took time to outline her hypotheses. She was doing science. Serious science, at the National Institutes for Health in Bethesda Maryland, on secondment from a French University, and there is no way that what she was telling me could have been called on in a Court of law nor by the General Medical Council. But it was science.
My overall criticsm of the book, therefore, is that it gives undue emphasis to science as authority and the double-blind, randomised clinical trial -- fine for highly specific questions in the context of informed consent and very well known circumstance -- but not the only mechanism of medical exploration. And it gives science a role in medicine it has no right to. Yes, medicine is now, thank goodness, based often on science, but medicine is still an art and not a science, and good medicine does not always go by the book.