BMJ  2004;329:118 (10 July), doi:10.1136/bmj.329.7457.118

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PERSONAL VIEW

An open letter to the Prince of Wales: with respect, your highness, you've got it wrong

Twenty years ago, on the 150th anniversary of the BMA, you were appointed its president and used your position to admonish my profession for its complacency. You also used this platform to promote "alternative" medicine. Shortly after that I had the privilege of meeting you at a series of colloquia organised to debate the role of complementary and alternative medicine (CAM). Of course, you won't remember me but the event is indelible in my memory. I was the only one of my colleagues unequivocally to register dissent.

A few days later you had a four page supplement in the London Evening Standard, promoting unproven cures for cancer, and the paper invited me to respond. I requested the same space but was only allowed one page, which at the last minute was cut by a quarter to make space for an advert for a new release by Frankie Goes to Hollywood. Furthermore, the subeditors embarrassed me with the banner headline, "With respect your Highness, you've got it wrong" (13 August 1984). As I have nothing more to lose I'm happy for that headline to grace the BMJ today.

Over the past 20 years I have treated thousands of patients with cancer and lost some dear friends and relatives along the way to this dreaded disease. I guess that for most of my patients their first meeting with me was as momentous and memorable as mine was with you.

The power of my authority comes with a knowledge built on 40 years of study and 25 years of active involvement in cancer research. I'm sensitive to the danger of abusing this power and, as a last resort, I know that the General Medical Council (GMC) is watching over my shoulder to ensure I respect a code of conduct with a duty of care that respects patients' dignity and privacy and reminds me that my personal beliefs should not prejudice my advice.

Your power and authority rest on an accident of birth. Furthermore, your public utterances are worthy of four pages, whereas, if lucky, I might warrant one. I don't begrudge you that authority and we probably share many opinions about art and architecture, but I do beg you to exercise your power with extreme caution when advising patients with life threatening diseases to embrace unproven therapies. There is no equivalent of the GMC for the monarchy, so it is left either to sensational journalism or, more rarely, to the quiet voice of loyal subjects such as myself to warn you that you may have overstepped the mark. It is in the nature of your world to be surrounded by sycophants (including members of the medical establishment hungry for their mention in the Queen's birthday honours list) who constantly reinforce what they assume are your prejudices. Sir, they patronise you! Allow me this chastisement.

Last week I had a sense of déjà vu, when the Observer (27 June) and Daily Express (28 June) newspapers reported you promoting coffee enemas and carrot juice for cancer. However, much has changed since you shocked us out of our complacency 20 years ago. The GMC is reformed and, as part of this revolution, so has our undergraduate teaching. Students are taught the importance of the spiritual domain but also study the epistemology of medicine or, in simpler words, the nature of proof.

Many lay people have an impressionistic notion of science as a cloak for bigotry. Nothing could be further from the truth. The scientific method is based on the deductive process that starts with the humble assumption that your hypothesis might be wrong and is then subjected to experiments that carry the risk of falsification. This approach works. For example in my own specialism, breast cancer, we have witnessed a 30% fall in mortality since 1984, resulting from a worldwide collaboration in clinical trials, accompanied by improvements in quality of life as measured by psychometric instruments.

You promote the Gerson diet whose only support comes from inductive logic—that is, anecdote. What is wrong with anecdote, you may ask? After all, these are real human interest stories. The problems are manifold but start with the assumption that cancer has a predictable natural history. "The patient was only given six months to live, tried the diet, and lived for years." This is an urban myth. With advanced breast cancer the median expectation of life might be 18 months, but many of my patients live for many years longer, with or without treatment.

I have always advocated the scientific evaluation of CAM using controlled trials. If "alternative" therapies pass these rigorous tests of so called "orthodox" medicine, then they will cease to be alternative and join our armamentarium. If their proponents lack the courage of their convictions to have their pet remedies subjected to the hazards of refutation then they are the bigots who will forever be condemned to practise on the fringe.

I have much time for complementary therapy that offers improvements in quality of life or spiritual solace, providing that it is truly integrated with modern medicine, but I have no time at all for "alternative" therapy that places itself above the laws of evidence and practises in a metaphysical domain that harks back to the dark days of Galen.

Many postmodern philosophers would have us believe that all knowledge is relative and that the dominance of one belief system is determined by the power of its proponents. However, perhaps we should all remain cognisant of the words of the Nobel laureate Jacques Monod: "Personal self satisfaction is the death of the scientist. Collective self satisfaction is the death of the research. It is restlessness, anxiety, dissatisfaction, agony of mind that nourish science." Please, your royal highness, help us nourish medical science by sharing our agony.

---

University College London

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