Top critical review
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Interesting and useful, but by no means unbiased
on 22 December 2012
Trick or Treatment is a very interesting read about the evidence that exists for the effectiveness (or not) of various complementary and alternative therapies (CAM). The book focuses especially on acupuncture, homeopathy, chiropractic and herbal medicine, with an appendix covering many more treatments in brief. I enjoyed reading the anecdotes on the history of CAM and conventional medicine, and there was a lot of useful information in there, but the authors' tone and approach left me questioning whether they were as unbiased as they claimed to be. Incidentally, I'm a big believer in the principles of evidence-based medicine (EBM), and I'm sceptical about many alternative therapies, so I didn't expect to have a problem with this book.
The main reasons I found myself distrusting Singh and Ernst are as follows:
1. Trick or Treatment claims to be a neutral presentation of the facts, but it is written in a very persuasive tone, with disparaging language used for anything the authors disapprove of. I really felt they were giving me the 'hard sell', which seems at odds with the concept of EBM. Much is made of the fact that Ernst used to be a homeopath, which supposedly makes him less biased, but to me the book seemed to have been written by someone who had become disillusioned by his former profession and therefore had strong feelings about it. On its own, this is not necessarily a problem, but in comparison with the points below it made me wary.
2. Throughout the book, the authors imply that modern conventional medicine is always better than CAM and that it always it has better evidence. They do not acknowledge any of the problems with research in conventional medicine, such as publication bias, or the fact that poor-quality trials exist here too. Anecdotal evidence for the effectiveness of CAM treatments is rightly dismissed as unreliable, but then they present anecdotal evidence in support of conventional medicine or to 'demonstrate' the risks of alternative therapies.
For example, they describe the case of a woman with mental health problems who killed her children after switching from the psychiatric drug Tegretol to St John's wort. This is a devastating tragedy and of course questions should be asked about whether the herb could have been responsible. However, it is wrong of the authors to state unequivocally that being 'deprived' of her usual medication and adverse effects from the St John's wort were the cause. We simply cannot know this, which is why scientific studies are needed. It could equally be that Charlene Dorcy's mental health was already deteriorating and that was what motivated her to change her treatment - it is so hard to tell from one individual case. Similar tragic cases have in fact occurred on conventional antidepressants such as Prozac, but the authors do not mention this.
3. The authors position themselves as experts, rather than presenting the facts and allowing readers to make up their own minds. For me, this contrasted sharply with Ben Goldacre's Bad Science (a book I love). Goldacre frequently provides details of clinical trials and other studies and encourages readers to look at them for themselves; he is also outspoken about the dangers of looking to so-called experts for information rather than examining the evidence. Singh and Ernst tell the reader what to believe, give advice on which type of treatment to seek, and the vast majority of the facts they cite are not referenced, so there is no way of checking them. I was, for example, surprised to read that evidence suggests meditation is dangerous for those with mental illness and therefore should be avoided by this group of patients. Given that one in four of us experience mental ill health, and mental health problems are a very common reason for people to try meditation, I wanted to know more about how the authors define 'mental illness' and what the specific evidence is. But as no details of trials or sources are provided, it will be difficult for me to do that.
If you'd like an overview of the evidence for CAM, peppered with interesting anecdotes, then Trick or Treatment is definitely worth a read. However, if you consider yourself intelligent and capable of drawing your own conclusions, you may find the tone and the amount of repetition a little patronising. It can also be quite difficult to find the information on specific treatments for specific problems, because not only do your have to sift through all the rhetoric, the book's structure is somewhat confusing, with information on the risks of acupuncture and homeopathy in the chiropractic chapter, for example.
This probably reads like a very harsh review. In fairness to the authors, I agree with much of what they're saying (in terms of content) and I don't seriously doubt most of the facts they've presented. But I feel Singh and Ernst failed to show the scrupulous fairness that a book on evidence-based medicine demands. Knowing whether complementary and alternative therapies are safe and effective is such an important issue, and I am disappointed they did not tackle it in a more even-handed way.