DOI: https://doi.org/10.4414/smw.2013.13722
Reply to the letter to the editor "Familiarity, objectivity – and misconduct Counterstatement to Shaw: Swiss Report" http://www.smw.ch/content/smw-2013-13720/
I am not surprised that the authors of the report have responded [1] to my article. Here, I provide a brief counterstatement to their counterstatement, following their structure:
When I stated that the government published the report, I meant simply that it appeared on a Swiss government website and that it was commissioned by the government. The authors and I are in agreement on this point: “The original HTA-report was shown for some time on the homepage of the BSV/BAG”.
I concede that many HTAs do not involve new research. However, the important point is that this HTA did not follow the objective procedures adopted by most other HTAs. The authors admit that most HTAs are based on the results of RCTs, yet expressly attack RCTs and avoid the use of RCTs in their homeopathy HTA; this indicates that this HTA was conducted quite differently from most others.
As already stated, most HTAs are based on RCTs; by choosing to abandon RCTs, the authors move the goalposts. Furthermore, the authors accuse me of mistaking absence of evidence for evidence of absence when I state, “Rather than accepting that the scientific method shows that homeopathy is ineffective, this they argue that the method itself is flawed and create their own method to produce the answers they want.” First, there is no strong evidence whatsoever for the effectiveness of homeopathy.
Furthermore, the authors themselves stated in the report that “If homeopathy is highly likely to be effective but this cannot be consistently proven in clinical trials, the question arises of what conditions are needed for homeopathy to show its effectiveness and realise its potential, and what conditions threaten to obscure this?” The authors have chosen to avoid providing an explanation for this sentence, which looks very much like an admission of bias. An objective HTA would not begin by assuming that homeopathy is highly likely to be effective; nor would it seek out the necessary conditions for effectiveness to be proven or attempt to remove barriers to a conclusion of effectiveness. As I stated in my original paper, it looks like a conflict of interest has infected this HTA.
The authors state that it is not true that they did not conduct an online review. However, I never stated that they had not done so. Rather than their selective quoting, here is the whole relevant section, “They did not conduct an online review because ‘just searching online would not have been sufficient to supply a representative overview of homeopathic research’. Hence they also included ’expert contacts and scanning of bibliographic references.’” It is clear from this passage that I stated that they did not onlyconduct an online review, but also included other, less reliable sources. In response to my claim that the use of expert opinion is suspect, the authors state that “The consideration of expert opinions was intended within the PEK approach because the specific situation in Switzerland should be reflected.” They neglect to state why the Swiss situation could not be reflected accurately using a normal systematic review.
I don’t have any response here, as the authors freely admit reinterpreting the results of studies in ways that some of the original researchers have specifically denounced [2].
I apologise for my omission of the word “individual” from the quote in my paper. Nonetheless, it remains remarkable that an HTA would not include a search for individual cases where safety is being assessed. Claiming that there was not enough time to do this when there was obviously time to spend an entire chapter attacking RCTs is surprising. Furthermore, the authors’ assurance that “’Homeopathic physicians […] act in accordance with the general guidelines of medical responsibility’; so no essential medical treatment will be kept from patients” is far from satisfactory. It has been pointed out several times in the literature that such guidelines would probably prohibit the prescription of any homeopathic remedy if applied correctly, as the lack of evidence of homeopathy’s effectiveness suggests that it would be deception to recommend such a treatment to a patient. Furthermore, people have died because they abandoned mainstream medicine in favour of homeopathic treatment. [3]
The authors fail to directly respond to the charge that most of them had a conflict of interest and denied that this was the case in the report. Here, I simply repeat their own words from the report: “Nobody involved in the compilation had any financial or other conflict of interest. Whenever expert advice was sought from a physician who himself uses the method in question, independent experts were also consulted.” This is an explicit denial of any type of conflict of interest. I was fully aware that the authors’ affiliations were included in Chapter 15. The point is that these affiliations were not reflected in the conflict-of-interest statement. If three doctors who were consultants to a pharma company mentioned this in their correspondence address on a publication while simultaneously denying a conflict of interest in the CoI statement, the paper would rightly be unfit for publication until this was remedied. Simply saying “We felt no necessity to make a statement of conflict of interest” does not excuse the fact that it should have been made. Even if there were no conflict of interest (which there clearly was), it is good practice to mention perceived conflicts of interest. And once again, I quote from my paper: “Note also that in the above quote the authors concede that a doctor’s use of homeopathy constitutes a conflict of interest; it is unclear why they do not apply this logic to themselves.” The reason for this asymmetry remains unclear despite the authors’ response to my paper. The failure to declare a conflict of interest is at the very least a technical breach of the Swiss Academies’ guidelines, and appears to be somewhat more substantial [4].
I will limit myself to pointing out that the “reference” provided by the authors, which claims that the House of Commons report into homeopathy was flawed, is to a pro-homeopathy website which quotes the non-peer-reviewed opinion of one politician.
The authors’ counterstatement ignores the key issues regarding scientific bias and conflict of interest that were raised in my original paper. The PEK review panel itself stated that “it is very obvious that all or some of the authors have a positive attitude towards the treatments in question or are convinced about their efficacy... even less sceptical academic doctors will regard many interpretations as very optimistic and not scientifically convincing” [5].
1 von Ammon K, Bornhöft G, Maxion-Bergemann S, Righetti M, Baumgartner S, Thurneysen A, Wolf U, Matthiessen PF. Familiarity, objectivity – and misconduct. Counterstatement to "Shaw DM. The Swiss Report on homoeopathy: a case study of research misconduct". Swiss Med Wkly. 2013;143:w13720. 2 S O’Meara, et al. Homoeopathy. Qual Saf Health Care. 2002;11:189–94. 3 http://www.guardian.co.uk/world/2009/sep/28/homeopathy-baby-death-couple-jailed 4 Swiss Academies of Arts and Sciences. Integrity in scientific research: principles and procedures. http://www.akademien-schweiz.ch/en/dms/E/Publications/Guidelines-and-Recommendations/e_Integrity.pdf 5 http://www.zenosblog.com/2012/05/that-neutral-swiss-homeopathy-report/ http://www.smw.ch/content/smw-2013-13720/