The Singh libel case and ‘alternative medicine’ Free

The Singh case

Simon Singh, a physicist and a leading science writer, authored bestsellers on Fermat's last theorem, the Big Bang and code breaking. Recently he co-authored with Edzard Ernst, Professor of Complementary Medicine, a book on alternative therapies entitled Trick or Treatment?. When published in April 2008, Singh wrote an article for The Guardian which coincided with chiropractic awareness week, ‘Beware the spinal trap’. The article has been retracted by The Guardian but is easily googled, republished widely on the web by a band of bloggers, publishers and sceptical organizations.

Chiropractic therapy was invented by faith healer Daniel David Palmer in 1890s America. Inspired by the miraculous recovery of a deaf man whom he treated by ‘racking’ his back, Palmer thought that 99% of all diseases are caused by nerves trapped by misaligned vertebrae, causing blockages in the flow of energy from the spinal column. While modern chiropractors focus on treating back problems, traditional chiropractors still believe Palmer's mythology. Singh discussed the risks of chiropractic treatment, which he noted have been associated with dislocations and fractures, potentially leading to stroke and death.¹ He challenged the evidence base for these treatments in various childhood conditions. The British Chiropractic Association (BCA) claimed Singh had defamed their reputation and threatened to sue him in libel. Singh decided not to back down. He wrote: ‘The article was about an issue of public interest, namely childhood health and the effectiveness of particular treatments for some serious conditions. Hence, I was not prepared to apologize for an article that I still believed was important for parents to read, and which I believed was accurate and legally defensible. (http://www.senseaboutscience.org.uk/index.php/site/project/340, accessed 21 August 2009)’ Most of those commenting on the case argue that the BCA, by suing Singh personally instead of The Guardian newspaper, sought to send a warning to critics of chiropractic treatment.^2,3

Fair trials

Can the statement that spinal manipulation help treat children with colic, frequent ear infections or asthma be supported by evidence? Richard Brown, the Vice-President of the BCA offered 18 references in support of the efficacy of chiropractic treatment in childhood diseases.⁴ Edzard Ernst, Professor in Complementary Medicine, discussed the evidence presented by Brown.⁵ According to Ernst, four references were not about chiropractic but osteopathy, eight were not trials and not properly designed to address the question, one was only available as an abstract, one did not present new data and one compared two treatments of unknown effectiveness without proper control group. One was a part of larger Cochrane review, describing two trials as of low quality judged to present ‘weak evidence’, two described non-specific effects in small trials of low quality, and one offered weak and statistically insignificant evidence. What Brown omitted was as eloquent as what he presented. Brown omitted at least three randomized controlled trials and two reviews, all in high-impact journals or the Cochrane library. All failed to show that chiropractic is effective in childhood conditions. Fiona Godlee of the BMJ concluded that ‘[Edzard Ernst's] demolition of [Brown's] 18 references is, to my mind, complete’.² Reading the evidence presented by Brown and Ernst, few would disagree with Singh's criticism's of chiropractic treatment and the BCA.

British libel laws

At the heart of the Singh case is the British law on libel, which reverses the burden of proof in allegations of unjustified defamation.^3,6 While in most countries, claimants who believe their reputation damaged have to prove to the court that the allegations are false, in Britain those accused of defamation have to prove they are true. Further, the exact meaning of the allegations is decided by the court. Singh appeared before Mr Justice Eady, the country's most senior libel judge, who has given a series of controversial rulings. Eady decided that the meaning of Singh's comment was that the BCA was deliberately using unfounded claims. In Singh's own words ‘Although I feel that chiropractors are deluded and reckless, I was not suggesting that they are dishonest’. It is close to impossible to ascertain the motives of the BCA and the meaning placed on Singh's words are not what he intended. The judgement makes his case indefensible.

Readers of this Journal may think that this is only relevant to those people living in that island of the Western European coast, reputed for their opinionated habits. They are mistaken. British law affects any content that can be read in the UK, including online content.^3,6 Many books have been censored in the UK, including number one bestsellers in the USA, because the publishers do not wish to risk a libel suit. The costs involved are huge and the reversed burden of proof scares all. Write an editorial claiming that McDonalds misrepresents the health contents of its food and you may find yourself in a British court, having to prove that McDonalds is deliberately poisoning children. Write a critical comment on a paper and you may need to prove that the authors are frauds. Peter Wilmshurst, a cardiologist, is having to defend exactly such an action.⁷ Wilmshurst was an investigator who withdrew from authorship of a medical paper. When a website in the USA publicized Wilmshurst's criticisms, the industrial sponsor, NMT, instituted libel proceedings against Wilmshurst. Industries use increasingly British libel laws to silence critics: ‘libel tourism’ to England and Wales is a booming business (http://en.wikipedia.org/wiki/Libel_tourism, accessed 21 august 2009). The US Congress is debating a bill that would protect its citizens from British libel rulings (http://www.govtrack.us/congress/bill.xpd?bill=s111-449&tab=summary, accessed 25 September 2009). If British law is not changed soon, EU countries must follow the US example. For every case that reaches the media, many critics swallow their pride and retract their criticism, although they are sincerely convinced this criticism is true and well founded.

Alternative medicine, conventional health problem

Chiropractors have tried to use legal muscle to silence critics not only in the UK.⁸ So-called ‘alternative’ medical practices sit uncomfortably with evidence-based medicine and increasingly fight back using intimidatory tactics. Richard Dawkins defined alternative medicine as a ‘set of practices which cannot be tested, refuse to be tested, or consistently fail tests’.⁹ That is too harsh. Ernst estimated that of 685 treatment/condition pairings evaluated in the ‘Desktop Guide to Complementary and Alternative Medicine’, 7.5% were supported by sound data.¹⁰ Therapies are evidence based, experimental or questionable. Evidence-based therapies rely on scientific methods that properly estimate effectiveness and safety. Experimental techniques are unproven but have a plausible rationale and should undergo further investigation. Questionable therapies lack a scientifically plausible rationale and can show no evidence of effectiveness. Conventional medicine does include many questionable practices that ought to be weeded out. ‘Alternative medicine’ that is evidence-based ought to be included in conventional medicine. Chiropractic for low back pain is an example, although side effects occur and cost-effectiveness has not yet been demonstrated.¹¹ Where chiropractic therapy consistently failed tests of evidence for any other medical condition, it belongs to Dawkins’ definition of alternative medicine.

In the Journal, any policy on questionable therapies and pseudoscientific medicine is missing. Articles are few and far between. While we increasingly learn about errors in conventional medicine, we know next to nothing about the statistics of diseases and deaths caused by questionable therapies, aggregated under the umbrella of ‘alternative medicine’. We have no idea how many people could have been saved by proper information, by timely diagnosis or by improved regulation of useless but dangerous therapies. We have little idea how much money is wasted on questionable therapies with unreasonable claims. We do not know why people become quacks and why medical education failed to instil a sound scientific attitude. We have scant knowledge of why people do or do not turn to alternative therapies, which cultural aspects favour the modern proliferation of quackery, and why. In short, we need descriptive epidemiology to quantify the problem, aetiological epidemiology to research its causes and action research to identify effective policies to respond to it.

Use of questionable therapies is a European public health problem, by wasted money and by wasted health. It is time for proper public health action. Define the problem, identify its causes and test promising therapies curing and preventing irrational and harmful beliefs.

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