Trick or Treatment? Alternative Medicine on Trial

  • Simon Singh &
  • Edzard Ernst
Random House/Norton: 2008. 352 pp. £16.99/$25.95 9780393066616 9780593061299 | ISBN: 978-0-3930-6661-6

The international market for alternative therapies is estimated at US$40 billion. Because so many people use alternative medicine, it provides an excellent vehicle for discussing the nature of scientific research. Yet explaining the evaluation of evidence, balance of probabilities and risk is not easy.

Acupuncture: pain relief or placebo? Credit: J. FEINGERSH/GETTY IMAGES

Combining their communication skills and knowledge, writer Simon Singh and professor of complementary medicine Edzard Ernst set out for the lay person the scientific approach to testing alternative medical treatments. Trick or Treatment? starts by detailing the development and evolution of the double-blind, placebo-controlled, randomized controlled trial and its role in evidence-based medicine. The authors evaluate the evidence for four common alternative therapies — acupuncture, homeopathy, herbal medicine and chiropractic. They discuss the pitfalls of placebo-based medicine and ask who is to be blamed for spreading misinformation about unproven treatments. The book concludes with a manifesto for better regulation of alternative medicine and reliance on properly tested therapies.

Trick or Treatment? is thoroughly researched and clearly written. Historical descriptions sit beside detailed and lucid evaluations of the research evidence. Some stories are well known, such as how naval surgeon James Lind developed the first clinical trial to test the effectiveness of lemons for treating scurvy. Others are less familiar, such as Florence Nightingale's aptitude for statistics and her development of a variant of the pie chart, the polar area chart, to support the case that good sanitation dramatically reduced deaths in military hospitals. The description of the Nazis' adoption of homeopathy is particularly compelling and sobering. These tales make the book entertaining as well as informative.

In the discussions of the four therapies, the authors' combined strengths shine through. The examination of the evidence is comprehensive, forensic and, for champions of these therapies, damning. For each treatment, Singh and Ernst present the available randomized controlled trials. They describe and dissect good-quality evidence and dismiss the poor-quality stuff, giving their reasons why it should be discounted. The authors conclude that acupuncture works as a short-term analgesic and can relieve nausea but not much else; that some herbs such as Devil's Claw for musculoskeletal pain or garlic for high cholesterol are effective; chiropractic can improve back pain but less well than conventional treatments; and that homeopathy is no better than placebo. They summarize evidence for a further 30 therapies, most of which they find wanting.

Singh and Ernst base their evaluations solely on results from randomized controlled trials. Many advocates of alternative treatments argue that these trials are unsuitable. Some of these practitioners' arguments are easily dismissed, for example, the idea that alternative treatments are beyond science. Other criticisms come from respectable commentators and are harder to ignore; for instance, the difficulties of designing trials to investigate complex treatments with multiple variables, or whether these trials use test conditions that differ from a treatment as practised. Randomized controlled trials are powerful tools, but they are imperfect and it would have strengthened the argument of Trick or Treatment? had the book discussed these downsides.

Scientific research is intrinsically provisional; it may asymptotically approach a truth, but it is never unequivocal. Singh and Ernst, however, make repeated claims that they provide the truth, and have even included this word in the title of every chapter. The balance of evidence from randomized controlled trials supports their arguments, but the authors are not tendering a disprovable hypothesis. Many science communicators argue that to present science as the only truth does it a disservice. For now, the certainty expressed in Trick or Treatment? mirrors that of the proponents of alternative therapies, leaving each position as entrenched as ever.