complementary and alternative medicine between evidence and

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Edzard Ernst

Complementary andAlternative Medicine

between evidence and absurdity

Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, 25Vic-toria Park Road, Exeter EX2 4NT, United Kingdom.E-mail: [email protected].

Perspectives in Biology and Medicine, volume 52, number 2 (spring 2009):289–303© 2009 by The Johns Hopkins University Press

ABSTRACT Complementary/alternative medicine (CAM) has become impor-tant, particularly because it is widely used. This article outlines CAM’s positionbetween evidence and absurdity. It discusses misconceptions that often mislead thepublic and shows how CAM can and should be submitted to the principles of evi-dence-based medicine (EBM). Employing the example of acupuncture, the evidence asit currently stands is described. But there are numerous obstacles to applying EBM toCAM. EBM is defenseless against absurdity.We should, therefore, demarcate the absurdin order to avoid wasting time and resources.The new fad of “integrated”medicine hasbeen proposed as a potential replacement for EBM.

COMPLEMENTARY/ALTERNATIVE medicine (CAM) has been defined as “diag-nosis, treatment and/or prevention which complements mainstream med-

icine by contributing to a common whole, by satisfying a demand not met byorthodoxy or by diversifying the conceptual frameworks of medicine” (Ernst etal. 1995, p. 45). It has become a hugely popular subject: hardly a day goes by thatthe press does not report about one aspect of CAM or another, and there arecurrently approximately 41 millionWeb sites inundating the public with infor-mation on this topic. Numerous studies have shown how unreliable—indeed,dangerously misleading—this information can be (Schmidt and Ernst 2004;

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Weeks,Verhoef, and Scott 2007). Patients cannot rely on conventional health-care professionals, who tend to be ill-informed about this subject, or on CAMpractitioners, who often overestimate the value of their treatments (Brown et al.2007; Schmidt and Ernst 2003).They cannot even trust the U.K.’s “official” pa-tient guide to CAM sponsored by the Department of Health (Prince of Wales’sFoundation for Integrated Health 2005), which is promotional, uninformative,and inaccurate (Ernst 2005). It is hardly surprising, therefore, that despite theplethora of information, many patients feel “insufficiently informed aboutCAM” (Joos et al. 2006, p. 19).In the first section of this article, I outline how the public is being misled

about CAM. I then discuss evidence in CAM and the obstacles that exist inestablishing an evidence base for it. Finally, I evaluate the notion of “integrated”medicine,which is being promoted as an alternative to EBM. I conclude that theprinciples of EBM can and should be applied to those forms of CAM that arenot overtly absurd.

Misleading “Evidence”

A plethora of information on CAM is available fromWeb sites, newspapers,mag-azines, and books. Unfortunately, much of this information is distorted and mis-leading. Several themes seem to exist which tend to mislead the public:“natural”equals safe; CAM defies scientific investigation; there is no evidence for CAM;CAM saves money; the medical establishment wants to suppress CAM; and anec-dotes are considered top evidence in CAM.

“Natural” Equals Safe

The notion that “natural” is the same as safe is widespread. But there is noth-ing natural about sticking needles into patients’ bodies (as in acupuncture) or indiluting substances to such a degree that the medicines contain nothing but dilu-tant (as in homeopathy). In the United Kingdom, “The Complementary andNatural Healthcare Council” (emphasis added) now regulates many CAM prac-titioners (Hawkes 2008). The term natural in the name of the new regulatorybody perpetuates the dangerous myth that CAM is natural and therefore safe.Even natural treatments may entail risks: many herbal remedies have the poten-tial to interact with prescribed drugs, and some are toxic (Cassileth and Lucarelli2003; Ernst et al. 2006).The risks of CAM might be less serious than those ofsynthetic drugs, but they are by no means negligible (Ernst et al. 2006).

CAM Defies Scientific Investigation

Enthusiasts of CAM often claim that the scientific method is not applicableto their field: the effects of CAM are too subtle to be quantified; treatments needto be tailored to each individual and therefore cannot be submitted to testing inclinical trials; or the therapeutic approach is holistic, which means it cannot be

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evaluated with reductionistic science (Winterson 2007). These arguments aremisleading and are based on profound misunderstandings of what science canand cannot do.Moreover, despite their skepticism about science, even CAM en-thusiasts accept scientific investigations of their intervention—as long as theirresults are positive (Mathie 2003).

There Is No Evidence

Some skeptics negate the existence of any sound evidence in support of anytype of CAM (Toynbee 2008).This is clearly wrong.Thousands of clinical trialsand more than 500 systematic reviews exist, many of which suggest that someCAM interventions do generate more good than harm (Ernst et al. 2006).Proponents of the more exotic forms of CAM (such as Bach Flower Remedies,or iridology), on the other hand, tend to claim that their treatment has not beenscientifically evaluated; they argue that therefore nobody can say with any degreeof certainty that it is ineffective.This notion is wrong too. If we look systemati-cally, we do usually find at least some scientific evidence (Ernst et al. 2006).

CAM Saves Money

Should decision makers become convinced today that CAM reduces totalhealth-care costs, we would probably adapt CAM in routine primary caretomorrow. Many CAM enthusiasts thus try to persuade us that integration ofCAM would be financially attractive (Smallwood 2005).The reliable evidence,however, demonstrates that this belief is wrong. In fact, the scarce data availableto date suggest that CAM constitutes an extra expense that must be added on toall other costs (Canter,Thompson Coon, and Ernst 2005; Ernst et al. 2006).

The “Establishment” Wants to Suppress CAM

Practitioners of CAM tend to claim that their treatments are victims of a well-coordinated undercover attack by “big pharma” or the “scientific establishment”(Ernst 2006c). They believe that these interest groups are plotting to preventpatients from benefiting from effective treatments.There is no evidence to indi-cate that this is true; indeed, there is reasonably good evidence that doctors arewilling to use any treatment that helps their patients, and that “big pharma” takeslittle notice of CAM (Thompson Coon, Pittler, and Ernst 2003).The pharma-ceutical industry is, of course, unlikely to put its profits into CAM research.Thus,the hugely profitable CAM sectors should channel some of their own revenueinto research, similar to what the pharmaceutical sector does to support researchon drug treatments.

Anecdotes as Top Evidence

Anecdotal evidence is frequently cited with regard to CAM, as a Guardianpiece on homeopathy illustrates: “Above all, we should be careful of dismissingthe testimony of millions who say the [homeopathic] remedies have worked for

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them” (Winterson 2007). It is, of course, tempting to assume causality whereonly a temporal link exists.Throughout history, medical progress has been hin-dered by this misapprehension. But medicine has moved on, and we now know(or should know) that millions of people can be entirely wrong when assumingthat this or that treatment “has worked for them.” Clinical improvement can bedue to many factors other than the specific effect of a treatment (Ernst 2007).Anecdotes are no longer considered reliable indicators of therapeutic effective-ness, but despite this well-known and undisputed fact, the anecdote remains oneof the most effective ways by which the press and others mislead the public.

The Importance of Reliable Evidence

Patients are frequently desperate and are therefore susceptible to misinformationof the types just outlined. In order to avoid wrong therapeutic decisions,we needfactually correct information on all forms of health care, including CAM.Evidence-based medicine (EBM) provides the tools to achieve this aim: EBM isthe systematic, explicit, conscientious, and judicious use of evidence when mak-ing decisions, and it is applicable to all areas of medicine—and that, of course,includes CAM.Those who might doubt this statement are referred to key pub-lications that support it by presenting evidence-based summaries of our currentknowledge on CAM (Ernst et al. 2006, 2008;Natural Medicines ComprehensiveDatabase 2004; Ulbricht and Basch 2005).The issues tend to get more complexif we address the vexed question of what is evidence. In EBM, there is a clearfocus on randomized clinical trials (RCTs) and systematic reviews of such stud-ies. In contrast, many CAM enthusiasts argue that observational data are at leastas important for informing us how useful their interventions are (Swayne 2008).

Observational Data

Doctors regularly see patients who suffer from condition X and improve afterreceiving treatment Y. Such observations are similar to uncontrolled studies inwhich a group of patients with condition X receive treatment Y. If the outcomeis positive, clinicians tend to attribute this result to the efficacy of the treatment.But numerous additional factors can, of course, significantly contribute to theobserved clinical improvement (Table 1). Some of these factors are well knownand hardly need an explanation: natural history of the disease, regression to themean, therapeutic relationship, placebo-effect. Other factors can be far less obvi-ous contributors to the observed therapeutic response.For instance, some patients may have used other treatments without inform-

ing their clinician. If effective, these concomitant interventions can cause theobserved clinical outcome.Additionally,many patients try to please their doctorsor therapists, particularly if they were kind and did their best to help.Thus pa-tients may say they feel better while, in fact, there is no improvement, a phe-nomenon often called “social desirability.” In uncontrolled observations, a ther-


apeutic response can thus be determined by the specific effects of the adminis-tered therapy or by a wide range of other factors.These factors are not exclusiveto CAM, but they are likely to be of particular importance in this environment,where the specific effects of interventions are often small, while the nonspecificeffects are large, the treatment periods long, and expectations high. Observa-tional data, which currently seem to dominate CAM, are fraught with problems.For responsible clinical decision making, we clearly need more reliable evidence.

Clinical Trials

In some controlled clinical trials of CAM, one group of patients receivingtreatmentY is compared with another receiving no treatment at all; alternatively,we might compare treatment Y plus usual care to usual care alone. Differencesin outcome between the two groups then tend to be attributed to the specificeffects of treatment Y. However, such a conclusion fails to account for the manyother factors that can contribute to this intergroup difference (Table 1). In CAMthe importance of this multitude of factors is often neglected, and invalid con-clusions are almost inevitable (Ernst and Lee 2008).The gold standard to control for nonspecific factors is the placebo-controlled,

double-blind RCT. But even with such a trial design, we should always considerpossible caveats. For instance, experimental treatments can generate characteris-tic adverse or specific effects, which can lead to a degree of “de-blinding,” orpatients guessing correctly which treatment they are receiving. In turn, this caninfluence expectations and thus the size of the placebo response, an inequality



table 1 CONTRIBUTORS TO OBSERVED THERAPEUTIC EFFECTS IN VARIOUS

STUDY TYPES

SITUATION

CCT RCT RCTexperimental experimental double-blind

Uncontrolled vs. no vs. no placebo-Contributing factor observations treatment treatment controlled

Specific therapeutic effect + + + +

Natural history of the condition + – – –

Regression towards the mean + – – –

Therapeutic relationship + + + –

Placebo-effect + + + –

Concomitant treatments + –* –* –*

Social desirability + + + –

Nocebo-effect of nontreatment n.a. + + –

Hawthorne effect n.a. or + + + –

Patient preference + + + –

Notes: + = factor may contribute to the observed therapeutic response; – = factor is the same in both groups andso should not affect between-group comparisons; n.a. = not applicable; CCT = (nonrandomized) controlled clinicaltrial; RCT = randomized clinical trial; * = provided they are similar in both groups.


that would tend to exaggerate the observed therapeutic response. For severalforms of therapy (in CAM, as in conventional medicine), it may be difficult oreven impossible to identify an adequate placebo intervention. Examples wherethis is true include surgery, psychotherapy, massage, acupuncture, and exercisetherapy.The point here is simple: even apparently rigorous trials can be seriously

flawed.We therefore must scrutinize each study carefully to define its strengthsand weaknesses, rather than accepting results simply because the trial designticked some of the most obvious boxes.

Systematic Reviews

Even the most rigorous studies of the same intervention can generate differ-ent, sometimes contradictory results—not just in CAM, but in any type of med-icine. In such instances, it is advisable not to rely on the results of a single studynor to cherry-pick those trials that one happens to like. The most robust ap-proach for arriving at reliable evidence is to access the totality of the availabletrial data. Systematic reviews attempt to do just that. Essentially they are projectsin which all the data of a predefined methodology are identified in a repro-ducible fashion and subsequently analyzed such that various forms of bias areminimized. If this involves statistical pooling of primary data,we are dealing witha meta-analysis that can generate new quantitative results based on more thanone data set. In this way, systematic reviews and meta-analyses minimize randomand selection biases. This renders them the most reliable type of evidence wecurrently know.

Evidence-Based CAM

The concepts of EBM are applicable to any type of health care, including CAM.Currently CAM is still too strongly dominated by observational data, but manyclinical trials and systematic reviews have emerged during the last decades. Adetailed example of how the principles of EBM are applicable to CAM follows.Based on the principles of EBM, we can summarize the current state of evi-

dence on the various forms of CAM (Ernst et al. 2006, 2008). Essentially thiscreates three categories: (1) interventions that are probably effective—in otherwords, tested extensively with consistently positive results; (2) interventions thatare probably ineffective—in other words, tested repeatedly but the findings failedto generate positive outcomes; and (3) interventions for which effectiveness isuncertain because of a lack of well-designed tests. Examples for these three cat-egories are provided in Table 2. In CAM, the last category is by far the largest.Uncertainty can exist for several reasons, including conflicting, poor-quality, orinsufficient data.As primary research into CAM continues, one could expect thiscategory to diminish in size.

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Acupuncture

To illustrate these points, I will discuss an example of a popular CAM treat-ment in more detail. I aim to demonstrate that the principles of EBM are appli-cable even to a treatment as challenging to research as acupuncture.While acupuncture is a long-standing part of the Chinese medical tradition,

its most recent (Western) renaissance began in 1971, when a journalist in Pres-ident Nixon’s press corps experienced symptomatic relief after being treated forpostoperative abdominal distension (Skrabanek 1984).His report in the NewYorkTimes triggered a flurry of interest and research.These investigations, in turn, ledto the discovery that needling might release endorphins in the brain or act viathe gate-control mechanism. Plausible explanations as to how acupuncturemight affect clinical outcomes in patients seemed thus to have been found (Ernst2006a). In the plethora of clinical trials that followed, results usually suggestedthat acupuncture was effective for a wide range of conditions.Most of these early trials, however, lacked scientific rigor. Some investigators

began to suspect that the results were largely due to patient expectation (Bausellet al. 2005).Others showed that the Chinese literature, a rich source of acupunc-ture trials, does not contain a single negative study of acupuncture, thus ques-tioning the reliability of this body of evidence (Vickers et al. 2007).A major methodological challenge for acupuncture trials had always been the

adequate control for placebo effects. Shallow needling or needling at non-acu-puncture points has been tried, but whenever the results of such trials were notwhat acupuncture enthusiasts had hoped, they have tended to claim that thesetypes of placebo also generated significant therapeutic effects and that a negativeresult was therefore not conclusive.The development of non-penetrating nee-dles was aimed at avoiding such problems.These stage dagger–like devices arephysiologically inert, and patients cannot tell them from real acupuncture.Thusthey fulfill the criteria for a reasonably good placebo (Ernst 2006a).The question of whether acupuncture works has become more complex—

what type of acupuncture, for what condition, compared to no treatment, stan-dard therapy or placebo, and what type of placebo? Meanwhile,many more con-trolled clinical trials have become available, and their results are contradictory.



table 2 THREE CATEGORIES OF CAM

Probably effective Uncertain effectiveness Probably ineffective

Acupuncture for nausea Acupuncture for cancer pain Acupuncture for smokingcessation

Music therapy for anxiety Chiropractic for back pain Chelation therapy for circula-tory diseases

St. John’s wort for depression Hop (herbal remedy) for Shark cartilage for cancerinsomnia

Sources: Ernst et al. 2006, 2008.


Systematic reviews might be helpful in establishing the truth, particularlyCochrane reviews, which tend to be the most rigorous. However, if Cochranereviews based on three or fewer primary studies are discarded, only two evi-dence-based indications for acupuncture remain: nausea/vomiting and head-ache. But even this evidence has to be interpreted with caution: recent trialsusing the above-mentioned stage-dagger devices as placebos suggest thatacupuncture has no specific effects in either of these conditions (Ernst 2006a).A series of eight large RCTs initiated by German health insurers further sup-

ports this hypothesis (Baecker, Tao, and Dobos 2007). These trials involvedpatients with chronic back pain, migraine, tension headache, and osteoarthritisof the knee (two trials for each indication).The studies had a similar, three par-allel group design: patients were randomized to receive real acupuncture, shal-low needling as a placebo control, or no acupuncture.These studies tended todemonstrate no or only small differences in terms of analgesic effects betweenreal and placebo acupuncture. Nonetheless, considerable differences were ob-served between the groups receiving either type of acupuncture and the groupthat had no acupuncture at all. (See Figure 1.)Thus, the principles of EBM are applicable to CAM, even to acupuncture,

where the challenges— no obvious funding sources and a variety of method-ological problems—are formidable. This application has advanced our knowl-edge significantly.

What About Safety?

The value of any therapy is determined not by its effectiveness in isolation,but by the balance between the benefit it may generate and the risks associated

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Figure 1

Schematic representation of the recent acupuncture trials, all following a similar three-group design.


with it. Most CAM interventions carry some risks. Contrary to common belief,these are not always negligible. Table 3 summarizes examples of serious, life-threatening risks of several popular forms of CAM (Ernst et al. 2006, 2008).It follows that therapeutic decisions in CAM (as in any other area of health

care) cannot be based on evidence of effectiveness alone.They must always con-sider risks as well. If we conduct a risk/benefit analysis of CAMs, we find thatthere is often little or no evidence of effectiveness and some evidence of risk(Ernst et al. 2006). In such a situation, the risk-benefit balance is unlikely to bepositive. In turn, this means that it would be unwise to recommend the therapyin question for routine use.

Obstacles

Many experts are convinced that EBM offers significant opportunities for CAM:if applied properly, it should sort out the wheat from the chaff.This is, I think,true, but numerous obstacles on the way to establishing a solid evidence base forCAM cannot be ignored. There are logistical obstacles, for instance the CAMcommunity is often not sympathetic to rigorous scientific investigations. Muchof CAM originates from a counterculture that is deeply opposed to “the estab-lishment.” Unfortunately, science and research are often viewed as being part ofthat establishment. In most areas of CAM, there are not enough research fundsto conduct even the most essential research (an exception might be the neutra-ceutical industry). Money is, of course, scarce in any field of research, but nopotent, big commercial players exist in CAM to support research, and govern-ment funding has been notoriously insufficient for decades.Therefore researchfunds for CAM are even scarcer than in other fields.Furthermore, little research expertise exists in CAM. Research units (mine

included) find it difficult to recruit expert researchers. Most practitioners ofCAM have no understanding of research at all. And CAM research is not gen-erally considered to be a wise career move: trained researchers from other fieldshave little impetus to go into CAM research, as it is neither well funded nor aca-demically rewarding. The political will (at least in the United Kingdom) tochange all this is not strong at present.



table 3 SERIOUS, WELL-DOCUMENTED RISKS OF CAM

Treatment Risk

Acupuncture Perforation of vital organ (e.g., heart or lung)

Chiropractic Dissection of vertebral artery, stroke

Herbal medicine Contamination with toxic substances, liver damage

Homeopathy Use as an alternative for serious conditions

Sources: Ernst et al. 2006, 2008.


Absurdity as an Obstacle

In additional to these logistical problems, there are also problems in principlewith applying the concepts of EBM to CAM. EBM does not address the ques-tion of biological plausibility. It puts little emphasis on the question of whetherthe proposed working mechanism for the treatment in question is based on ourunderstanding of the medical sciences. Usually, it merely asks “Does it work?”This means that even the most absurd claims can (and some would argue, must)be submitted to the rigor of clinical testing. Only after extensive study mightone be sure that this or that irrational claim is not supported by evidence. How-ever, this strategy is not really an option; it would be hugely wasteful and, due tothe extremely limited resources, highly impractical.In CAM, we are regularly bombarded with claims that lack plausibility. Some

examples may suffice to illustrate: the higher the dilution of a remedy the morepowerful are its effects (homeopathy); all human illness originates from“malalignments” of the spine and can be treated with spinal adjustments (chiro-practic); abnormalities of the color pattern of the iris provide diagnostic cluesfor internal diseases (iridology); and all human disease is due to an imbalance ofthe two life forces, yin and yang (acupuncture). Proponents of EBM can findthemselves somewhat defenseless against such irrational claims. Often they relyon Popper’s principle that a hypothesis must be falsifiable, yet all of the aboveclaims are. Falsifiability thus turns out to be an insufficient screening method forthe identification of absurdity.This is, of course, true for any type of medicine. In CAM, however, the prob-

lem is more prevalent than in conventional health care. Proponents of absurdnotions often claim that their theories are untested. According to the logic ofEBM, it is not possible to conclude that untested claims are wrong. But absenceof evidence is not the same as evidence of absence.

Pseudoscience: A Hallmark of Absurd Claims

In this situation, it may be helpful to use the characteristics of pseudoscienceto identify and, in turn, discard absurd health claims. Pseudoscience has severalhallmarks, and different authors have suggested different sets of criteria. Becausenone of these qualities are unique to proponents of absurd claims, a list of char-acteristics may be more useful than a single criterion. In the realm of CAM, sixcharacteristics normally suffice to differentiate between science and pseudo-science.

Biological implausibility. In CAM,we are confronted with many claims that arebiologically implausible, a selection of which was presented above. Biologicalimplausibility is an important characteristic of pseudoscience. In health care,things may, however, be complex. For instance, chiropractic could be useful forsome conditions—in fact, it probably is, despite the fact that its fundamentalclaim of spinal “malalignments” as the cause of all ills is mistaken.

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Intolerance. Many CAM proponents are not able to respond appropriately toreasoned criticism. They tend to believe that criticism is invariably a negativething and deny that it generates progress.Thus, they often do not consider crit-icism but react defensively, aggressively, or with litigation. For instance,when sci-ence writer Simon Singh and I recently published a critical analysis of CAM(Singh and Ernst 2008), the level of unreasonable accusations against us reachedfever pitch.We were accused of professional incompetence, of deliberately mis-representing the evidence, of having closed minds, and of being the lackeys of“big pharma.”

Selectivity.Many CAM proponents will dismiss facts that contradict their ownpreconceived ideas in favor of anomalous data or anecdotal findings. Clinical tri-als, for instance, are designed to overcome the biases associated with simple clin-ical observations.Whenever their results fail to confirm their belief, these peo-ple insist that, for this or that reason, case reports or years of experience orobservational data are more reliable. A typical example are homeopaths who,confronted with disappointing evidence from rigorous clinical trials, argue thatobservational studies (studies that lack a control group) are more illuminatingand important than the results of clinical trials (Swayne 2008).

Paranoia. Proponents of absurd claims believe in conspiracy theories suggest-ing that “the establishment” is determined to suppress their findings.TheWorldWideWeb, for instance, is full of suggestions that “big pharma” is behind a prop-aganda campaign against “alternative cancer cures” such as laetrile or shark car-tilage. Anyone who points out what the evidence really shows is likely to be ac-cused of being in the pocket of the industry.

Inversion of logic. In arguing their case, proponents of absurd claims often seemto formulate their conclusions first, then select those bits of information thatseem to confirm them. Subsequently, they are at pains to make the total body ofthis “evidence” look greater than the sum of its parts.An apt example is the factthat in many clinical trials of CAM, we find the statement that “the aim of thisstudy was to prove the efficacy of treatment X.”Another example would be theregrettable circumstance that studies that generate a negative result are frequentlydata-dredged until a “positive” finding emerges.This in turn would be presentedas a main outcome. For instance, a recent RCT compared homeopathic Arnicawith diclofenac in postoperative pain control (Karow et al. 2008). Patients in theArnica group suffered more postoperative pain, but as there was no differencebetween the two treatments in terms of other variables, such as wound irrita-tion, the authors nevertheless concluded that Arnica can be used “instead ofdiclofenac.”

Misuse. Proponenets of absurd claims frequently misuse science, for instance,by using terminology like paradigm energy, chaos theory, nano, quantum, or entangle-ment in inappropriate contexts devoid of their actual meanings (Ernst 2004).Accepted standards are dismissed and double standards proposed.As an example,




I might simply quote from the abstract of a recent article on “bioresonance”:“The bioresonance treatment is based on cell communication on a biophysicallevel. Disease causing frequency patterns of cell communication should be con-verted into therapeutically effective frequency patterns” (Rahlfs and Rozehnal2008).This may look impressive to nonscientists, but it does not in fact make anysense. Other forms of misuse of science include selective citation and even fraud(Ernst 2006b).

What follows from this discussion is, I think, clear. Evidence-based CAM is bothfeasible and desirable. It is, however, vulnerable to absurd claims. Of course, notall of CAM is absurd, but in many instances a preliminary reality check on theclaims that are being made may be helpful. If they are absurd, research funds aremost likely better spent in other areas. Some might argue that any widely usedtherapy, however absurd, must be tested. I would respond that we should merelydisclose the absurdity of that therapy and avoid wasting money and time. Inother words, overt absurdities, regardless whether they originate from the realmof CAM or from conventional medicine, should be excluded from the assess-ments of EBM if we aim to spend limited research funds wisely.

Evidence-Based or Integrated Medicine?

In recent years, a new term has emerged:“integrated medicine.” One of its pro-moters, Prince Charles, views it as the “best of both worlds” (HRH PrinceCharles 2001). Most definitions of integrated medicine combine two distinctlyseparate concepts (Rees andWeil 2001).The first is the parallel use of the “best”interventions from both mainstream and complementary medicine.This soundsentirely reasonable, but is it? The answer depends on how we choose to define“best.” In health care,“best” can only mean one thing: supported by sound evi-dence to demonstrate that more good than harm is being done.The first con-cept of integrated medicine is therefore synonymous with EBM. If that is so,integrated medicine could turn out to be a superfluous distraction from the aimsof EBM.The second concept behind the idea of integrated medicine is that of a whole-

person approach. Again, this seems desirable, reasonable, and important: patientswant and have a right to be understood as whole individuals with unique physi-cal, mental, emotional, and spiritual dimensions.Holism has been (and always willbe) a core principle of any good medicine. The recent National Institute forHealth and Clinical Excellence (NICE) guidelines for the treatment of osteo-arthritis, for instance, stress the importance of a holistic assessment of patients(National Collaborating Centre 2008). But those who promote integrated med-icine want to persuade us that holism is unique to their type of health care. Forexample, on the Web site of the Prince of Wales’s Foundation for IntegratedHealth, we find the following revealing statement: “holistic and patient-centred

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care might be incorporated into conventional medicine” (Bishop 2008).To pre-tend that holism is a characteristic feature of integrated medicine is not merelymisleading, it sends out the message that the rest of health care no longer caresabout whole individuals.One could argue that real life is rarely black or white. In fact, much of con-

ventional medicine has become regrettably neglectful of holism.The undeniabletruth also is that many complementary treatments used in everyday integratedpractice are unproven and that several have even been disproven (Ernst 2008). Itfollows that the integration of these two worlds could result not in the best butin the worst for our patients. Introducing unproven CAM treatments as a re-placement for evidence-based interventions in routine health care would be farfrom desirable. And applying the constraints and pressures of the primary andsecondary health care of today to the holism, empathy, and time of CAM prac-titioners would most likely destroy those qualities of CAM that render it attrac-tive to many.

Conclusion

The principles of EBM are applicable to CAM, and in the name of progress theyshould be applied to this field. It is essential, however, that the reliability of theevidence is scrutinized carefully. If that is done, EBM is an opportunity for deter-mining which CAM interventions generate more good than harm and whichfail to do so. Nonetheless, important challenges for EBM remain: dealing withthe many biologically implausible claims in CAM; the intolerance of some pro-ponents of CAM to reasoned criticism; and selection bias, paranoia, inversion oflogic, and misuse of science. Not every absurdity should be submitted to testingin clinical trials. A reliable method for the identification of absurdity wouldtherefore be an important first step in applying the principles of EBM to CAM.The notion that integrated medicine provides a way forward seems ill conceived.On the contrary, it might turn out to be an unwelcome distraction from EBMthat opens the door to admitting unproven or disproven treatments into routinehealth care.

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