Another week rolls by and another missive from the Advertising Standards Authority drops into my in-box leading me to yet another batch of informally resolved cases in which a variety of alt-med practitioners have had to remove health-related claims from their websites in order to comply with the ASA’s requirement that advertising must be honest, decent, legal and truthful.

What is the CAM industry to do in the face of this unprecedented assault on their ability to market their wares to the general public?

Well, they could lobby the government for an opt-out from the onerous and tyrannical regulatory regime imposed by ther ASA with its insistence that health-related claims must be back up by well-founded and credible scientific evidence and call, instead, for the responsibility for CAM-related advertising to be devolved to a new, industry-led, voluntary regulator called, for the sake of an argument, the Quackvertising Standards Authority.

Under this new voluntary scheme, which would operate in parallel to that of the ASA, the QSA would regulate the health claims made by CAM practitioners not on the basis of scientific evidence but rather on the basis of whether particular health-related claims are generally accepted within the industry sector to which the claims relate. After all, who could possibly know more about what works, and what doesn’t, than the practitioners themselves – they are the acknowledge experts in their own field.

That is, of course, a completely preposterous suggestion. Why, if they wish to make health-related claims about their products and services, should the CAM industry and its practitioners not be held to same rules, and the same standards of evidence, as other industries?

Its a ridiculous proposition – but it is nevertheless the precise situation that exists when one enters the consulting rooms or offices of CAM practitioner or you merely encounter such a practitioner in person. If you find yourself face-to-face with a quack then they can may any health-related claim they like, irrespective of whether there is any credible evidence to support support their claims. And if, after being subjected to a swift walletectomy – the only procedure common to all branches of so-called alternative medicine – you’re at all dissatisfied with the ‘treatment’ you received then your only recourse, if your lucky, lies in a complaint one of the many voluntary trade associations which purport regulate practitioner operating their own specialist field.

I won’t dignify any of these organisations by referring to them as regulators because that’s not what they are. Regulation is a practice that lies far beyond their capabilities even were it the case that they were genuinely inclined to perform such a rile in an effective manner. These organisations may put on the facade of a regulator. They may have their own regulatory code or code of ethics and this may even pay lip service to the idea of evidence-based practice. They may well also maintain a public register of practitioners which can be consulted by members of the general public and publish their own practice guidelines which providers listed on the register are notionally expected to follow, but regulators they most certain are not.

Unlike the General Medical Council, which regulates doctors, or the Law Society, which performs the same function in respect of solicitors, these sham ‘regulators’ possess no regulatory teeth whatsoever. Without a license to practice from the GMC, a doctor cannot legally practice medicine in the UK nor take on employment as a doctor. Without a listing on the practitioners’ ‘register’ of, for example, the Society of Homeopaths, a CAM practitioner may call themselves a homeopath, advertise their services as a homeopath and practice as a homeopath without any restraint whatsoever such that these so-called ‘professional registers’ have no more status, credibility or legitimacy than a listing in the Yellow Pages.

And when it comes to those self-style ‘voluntary regulators’ who do pay lip service to the idea of evidence-based practice, what one finds is that standard of evidence required to support at a particular claim of efficacy is, at best, pitifully low while, at worst, it requires the so-called regulator to engage directly in the disingenuous misrepresentation of the both the quality and strength of the evidence for particular claims. One only has to look at the ‘research’ sections which feature on many of the websites of these trade organisations to realise that the most common standard of evidence they apply to their own claims is simply that of ‘any positive result will do’, irrespective of whether that result is statistically, let alone clinically, significant or the methodological limitations and shortcomings of the research from which that evidence is derived – of which there are usually many.

This entire parallel ‘system’ of non-regulation is a joke, one protected from prosecution for fraud only by virtue of its custodians and practitioners having successfully deluded themselves as to the efficacy of their patent remedies and medicaments before setting out to delude the general public for profit. One only has to read through this recent email exchange between Simon Perry and Maggy Wallace, the Executive Chair of the Complementary and Natural Healthcare Council (CNHC) – aka OfQuack – to appreciate the extent to which these organisation rely entirely on their own delusions to justify their very existence:

Clearly there are things on which we are not going to agree. As a regulator you cannot honestly expect us to support a position as stated by you to the effect that ‘………..Genuine, honest training on reflexology must cover the simple truth that reflexology is not known to be effective for any condition.’

This is your opinion and in our view, is unsupportable as a statement. If we believed what you say to be true, and continued to regulate reflexology, we could be accused of misrepresentation and acting without integrity, both of which would be serious accusations indeed.

Contrary to Wallace’s assertion that Simon was expressing an unsupportable opinion his assertion that reflexology is ‘not known to be effective for any condition’ is fully supported by the outcome of a systematic review of reflexology RCTs conducted by Edzard Ernst and published in the Medical Journal of Australia in 2009 [1]:

Three systematic reviews have previously assessed the value of reflexology. Our previous evaluation is now outdated;[2] this article is an attempt to update it. Hughes and colleagues recently published a review of massage techniques in paediatric cancer care.[3] Even though it included several RCTs of reflexology, its aim was not to summarise the totality of the evidence for or against reflexology. Wang and colleagues recently published a systematic review of the efficacy of reflexology and found that “there is no evidence for any specific effect of reflexology in any conditions”.[4] Unfortunately, this systematic review included less than 50% of the available RCT data.

My systematic review has several limitations. Although efforts were made to find all relevant RCTs, I cannot be sure that this aim was achieved. Publication bias might have led to the disappearance of negative studies. In this case, the (already quite disappointing) overall picture generated here might be too positive. Finally, the paucity and the poor quality of the existing studies prevents definitive judgements about the value of reflexology.

In conclusion, this systematic review failed to demonstrate that reflexology is clinically effective for any of the wide range of conditions for which it has been tested.

Although Wallace is correct in saying that ‘If we believed what you say to be true, and continued to regulate reflexology, we could be accused of misrepresentation and acting without integrity, both of which would be serious accusations indeed’ she is wrong in thinking that belief alone is sufficient to avoid such accusations. As an organisation which professes to ‘regulate’ reflexology, which is nothing more than a foot massage, OfQuack must not not only believe that reflexology is efficacious but have good reason to hold such a belief having taken full account of the scientific evidence. And because of its lofty position in the CAM industry and its pretensions of operating, however ineffectively, as a regulator, the standard by which one must judge whether its beliefs are reasonable must necessarily be higher than those one might otherwise apply to a mere practitioner who, by training, has been well steeped in the Kool-Aid of reflexology.

Where OfQuack, and Wallace, demonstrate a lack of integrity is in their obviously unwillingness to subject their own beliefs to scrutiny in the face of well-founded scientific evidence which flatly contradicts their chosen position.

Earlier in this exchange, Wallace advances the following, utterly preposterous argument:

Reading your proposed activity, I am struck again by the fact that you as an individual and we as an organisation appear to have many of the same objectives, namely that of not wishing the public to be misled with regard to inappropriate claims of efficacy of certain treatments. It is in our methods of achieving those objectives that we differ: CNHC preferring to work with practitioners, for example, with regard to changing their advertising, and you by complaining against them.

It seem ironical to us that those individuals who have chosen to be registered with CNHC – thereby demonstrating that they take a responsible approach to their work and have undertaken relevant education and training and have signed up to a code of conduct – should be targeted. Surely it is those who have not made such a commitment to professional standards who should be the subject of your activity.

There is, of course, nothing ironic (or ‘ironical’) in Simon’s decision to target reflexologists who’ve signed up to OfQuack’s system of pseudo-regulation. From a purely pragmatic standpoint, the existence of a register of quacks makes the whole business of tracking down their websites and checking them for the presence of unsupportable health claims a much easier and less time-consuming exercise that would be the case were Simon, and others, forced to rely entirely on Google. But beyond that, targeting those CAM practitioners who have signed up to one of these sham registers after undertaking ‘relevant education and training’ and signing up to a code of conduct drives how the fundamental point that nonsense is still nonsense, no matter how much time, energy, effort and resources – including public money in the case of OfQuack – you might be inclined to throw at so-called regulation.

OfQuack, in particular, is nothing more than a rather expensive way of demonstrating that Garbage In still results in Garbage Out, however you try to slice it.

References

1. Ernst, E., Is reflexology an effective intervention? A systematic review of randomised controlled trials, Medical Journal of Australia, 7 Sep 2009, vol. 191, no. 5, p. 263-266

2. Ernst E, Köder K. An overview of reflexology. Eur J Gen Pract 1997; 3: 52-57.

3. Hughes D, Ladas E, Rooney D, Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncol Nurs Forum 2008; 35: 431-442.

4. Wang MY, Tsai PS, Lee PH, et al. The efficacy of reflexology: systematic review. J Adv Nurs 2008; 62: 512-520.