Veterinary homeopaths like to present their efforts as beneficient and morally sound. They claim they are providing a needed service and that denying homeopathy to patients would be denying every chance at health and denying their owners freedom to choose the care their pets receive. I recently ran across a paper from a couple of years ago that summarizes nicely the reasons why homeopathy is actually inherently unethical. It also elucidates why the response of the veterinary community to the persistence of homeopathy in our ranks has been ethically inadequate.
Smith, K. Against homeopathy-A utilitarian perspective. Bioethics. 2012. 26(8): 398–409
The basic chain of reasoning seems obvious, though of course believers in homeopathy will refuse to concede the well-demonstrated premises:
- Homeopathy has no effect beyond that of a placebo.
- The placebo effects of homeopathy
- Are generally small
- Are short-term
- Are effective only on subjective symptoms, not the physical disease
- Are no greater than those accompanying truly effective therapies
- Require the patient be deceived about the nature of homeopathy
- Against the placebo benefits of homeopathy must be set the costs, including
- The loss of autonomy and informed consent when being deceived about the efficacy of homeopathy
- The risk of not receiving appropriate, effective medical care
- The waste of limited healthcare resources on an ineffective therapy
- The encouraging of irrational, unscientific beliefs, which supports other ineffective therapies and undermines confidence in science-based medicine
The reasoning is clear and well-expressed, so I will present a couple of examples.
Homeopathy Is Only a Placebo
This is a case I have made in detail before, and the author of this paper reviews it briefly with reference to a few of the key papers. This, of course, is the primary area of objection from proponents of homeopathy, whose ethical claims for their practice are based on the believe homeopathy works. However, the author does a nice job of explaining why the mistaken beliefs of homeopaths should not be allowed to undermine an ethical argument based on solid scientific evidence even if they refuse to accept this evidence.
…the fact that some people continue to believe in and advocate or practise homeopathy does not provide good reason to accept that homeopathy may have a rational basis. In face of the impossibility of convincing all proponents that homeopathy is without foundation, in order to make progress in considering the associated ethical implications I shall assume the premise that homeopathic medicines can have no direct biochemical or physiological effects on the body.
Homeopathy Negates Patient Autonomy by Deception
Placebo-only treatments depend axiomatically on the patient being led to believe an untruth: that the proffered treatment actually causes a physiological change. Thus, homeopathy-as-placebo would have to be based upon, in effect, lying to patients.
…patient autonomy is a key feature of utilitarianism: put simply, maximum utility flows from permitting competent patients to consent (or otherwise) to medical interventions. Autonomy requires the positive provision of full information (hence the term ‘informed consent’): therefore, causing patients to believe an untruth (that homeopathic preparations alter physiological functioning) serves as a substantial disutility by restricting patient autonomy. I suggest that the higher order utilitarian concept of autonomy trumps the narrower utility of immediate patient benefit: if this assertion is correct, then the homeopathy-as-placebo argument appears fatally damaged.
Of course, most practitioners of homeopathy are not intentionally lying to patients, since they believe their practice is actually effective. However, the author makes it clear that when patients are deceived, honest intentions on the part of the practitioners deceiving them do not undo the harm of the deception.
Agents can act in good faith but fail to recognize that the basis for their actions is erroneous…In making an ethical evaluation here, the negative consequences, in terms of a violation of patient consent, to some extent conflict with the deontological judgement [sic] that the homeopath is acting ethically, i.e. in good faith.
…in the medical context…, simply acting in good faith is not enough. Healthcare professionals – mainstream or homeopathic – have a positive moral duty to ensure that the treatment of patients is based upon sound evidence and theory. Homeopaths acting on the basis of their sincere (but unfounded) beliefs are not lying in the usual sense; nevertheless their behavior remains ethically unacceptable.
The author also addresses the ethical problem of healthcare providers who do not believe in the efficacy of homeopathy but who still offer or encourage the use of the therapy. This has direct relevance to veterinarians who know homeopathy is useless but refer for it anyway and to the position of the leadership of the American Veterinary Medical Association (AVMA), which acknowledges there is no reason to believe homeopathy works but which does not want to say so publically.
For mainstream healthcare professionals who, unlike homeopaths, do not believe that homeopathic preparations can have any direct biological effects, any decision to supply or support homeopathy-as-placebo would appear to amount to lying in the usual sense. It is difficult to allow, from either a utilitarian or deontological perspective, that such deceptive behaviour could be ethically acceptable.
Homeopaths will likely take comfort from the author’s position that patients should not be prevented from seeking homeopathic treatment if fully informed that it is merely a placebo since, in his view, individual autonomy is paramount and should not be restricted even to protect the individual from their own actions. While this is a complicated and controversial area of ethics, I would venture to argue that limiting the availability of homeopathy, by making it illegal, for example, would be justifiable since there is simply no realistic chance of it ever being offered on any basis except the deception of the patient. The author as much as admits this when discussing the problem of homeopathy being substituted for real medical care.
it is arguable that some (competent) patients may not be reliably informed about the ineffective nature of homeopathy. Evidence suggests that some CAM practitioners, including some homeopaths, may act as proponents of their therapeutic doctrine, rather than sources of reliable advice. It seems clear that such behaviour is ethically unacceptable.
In any case, if people are unprepared to understand and accept the powerful evidence that homeopathy is a placebo (due, for example, to inadequate science education), or if they are inclined to believe in it anyway out of desperation (when there are no truly effective treatments for their condition), is it acceptable to allow homeopaths to take advantage of patients by providing a placebo therapy, even if they were to make a pro forma acknowledgment that it is not supported by science?
Homeopathy Wastes Scarce Healthcare Resources
One problem with providing homeopathy, even if it does no direct harm and has some mild placebo benefits, is that it wastes money and other resources that could be devoted to evaluating and providing truly effective therapies.
Considering that homeopathy represents an intrinsically ineffective form of treatment, any resources expended on homeopathy represent a waste of resources that could otherwise have been expended on more effective healthcare. The utilitarian logic is clear: such expenditure is unethical…when no clinical benefit is obtained from homeopathy, patients are likely to return to conventional medicine: in this way, the public purse [or private purse, in the U.S.] pays twice.
Even if there is no effective treatment for a medical problem, it is doubtful that the cost of homeopathy as a placebo is justified given the other risks associated with it. Comfort care could easily be provided without perpetuating pseudoscientific nonsense.
The issue of wasted resources applies to research in homeopathy as well as to the clinical use of homeopathic treatment. Given the current robust evidence against it, further resources devoted to homeopathic research are a waste, and such resources should be turned to more promising avenues.
Firstly, credible scientific assessments of many claims for the efficacy of several homeopathy treatments already exist, and (as discussed earlier) the results have all been negative or highly equivocal. Secondly, investment in research into homeopathy implies that there is likely to be something medically worthwhile to investigate, or to be gained from such research. Thus, the act of formal investigation lends respectability to homeopathy.
At best, such research will generate only negative results, which are of minimal interest to medical journals and other disseminators of research findings, and which can be ignored by advocates of homeopathy. Where isolated positive results are obtained in homeopathy research, the best explanation is that a problem exists with the study in question…such false positive results are open to misinterpretation, and unwarranted credibility thereby afforded to homeopathy.
Rigorous trials cost between $1 million and $5 million each, and between 5 and 20 trials are needed to prove or disprove the effectiveness of each product or method. Expenditure of such amounts on homeopathy would be ethically unacceptable, given the extremely low likelihood of obtaining patient-benefiting results and the effective diversion of funds from more plausible medical research projects.
Considering the disutilities attached to homeopathy research, the ethically correct call might instead be one of ‘no more research’.
Conclusions-Homeopathy is Unethical
The balance of benefits and harms is clearly against homeopathy. The author illustrates the situation nicely with this analogy:
a medical tool gains moral content if by its intrinsic nature it is ineffective: for example, a cheap defibrillator that is unable to deliver a sufficient electrical impulse to restart the heart simply cannot be used in a morally acceptable fashion. Such a machine, in the context of medical practice, is ethically unacceptable, and its purchase or use would be morally unjustifiable.
In a similar way, homeopathy ought not to be regarded as a mere tool. Because it is inherently ineffective, homeopathy cannot be ethically neutral. It follows that the purchase, deployment or promotion of homeopathy is morally unacceptable.
Given this conclusion, it is clearly unethical for healthcare providers to offer homeopathic treatment. This is not a problem for most conventional practitioners, who do not offer it anyway, however it becomes a problem when they are pressured by clients to do so. The author argues that there is not only a passive duty not to provide such an ineffective and deceptive treatment, but an active duty to identify why the practice should be avoided.
Where any of the various agents experience pressure to provide homeopathy, this ought to be actively resisted. Appropriate behaviour in this context entails elucidating the reality of homeopathy – namely its ineffectiveness – in the direction of those who exert pressure for the provision of homeopathy. Thus, health professionals and educators will do well ethically where they endeavour to explain to the public, to patients and to peers why homeopathy ought to be avoided.
This is the step at which conventional veterinarians, and organizations like the AVMA, have generally failed in their ethical duty to clients and patients. It is not enough to shrug our shoulders and turn away as colleagues deceive our clients about this practice. We have a responsibility to educate the public and protect our clients and patients from such a deceptive and ineffective treatment.