The Dilemma with Ethics

Within the health care profession, as practitioners, we find ourselves in a sector that is subject to the most intensive and sensitive regulation. We are entrusted with the highest good of all, the life of human beings. This confidence in our credentials requires sincere monitoring, directing, and legislative and ethical boundaries. We are dealing with a patients´ most vulnerable existence, illness, a state when his vitality is weakened by imbalance.  Whether practicing in general medicine or complementary and alternative fields, we are all dealing with this highest good and have to prove our worthiness and are required to abide to the rules that assure the patients security.

Samuel Hahnemann laid out the initial rules of professional practice in the field of homeopathy, in his first aphorisms of his Organon [1]. Aphorism 1 states that it is a practitioners´ highest good and only profession to retrieve the sick man from illness and render healthy again. Aphorism 2 then tells us that the highest ideal of curing is to do it quickly, gentle and such that the healing is of permanence. We are to remove and abolish in entirety the disease and are to do this most rapidly, reliably and following precise, comprehensive motives. These words can well be translated into our times and are contingent to many professional codes of the health practices, ever since first pledged in the oath of Hippocrates [2]; and today manifest in the declaration of Geneva [3]. These phrases constitute the ethical principle of beneficence.

Beneficence, whether to the allopath or the homeopath, in practice, means the same thing; that it is our duty to our patients, to act in their best interest and to do good [4]. But at the same time of laying out an ethical boundary for the practitioner, it is here perceivable that these boundaries are liable to flexibility. Because, with Beneficence, what is good for the patient is left to be declared by whom? Is the practitioner competent enough to explain to the patient all aspects of a therapy such that he, the patient can make the decision for or against a therapy himself? Is the autonomy, the ability of the patient to actively make his own decisions [5], at all times sustained with the patient? What about non-maleficience, that requires us to do no harm to our patients [4]? With vaccinations, for example, patients are receiving injections of a harmful nature. Is the general practitioner committing non-maleficience?

For a general practitioner abiding to the code of ethics seems slightly more complicated than it is for the homeopath. What if the general practitioner has to treat a patient that is brought into his care unconsciously [6]; who decides on beneficence and where does that leave autonomy? An overall rule that needs to be followed is that whatever a practitioner decides on, the benefits of a treatment have to outweigh the risks.

In homeopathic practice, to fully explain to the patient all aspects of homeopathy and all effects that a remedy reaction may bring forth would exceed the time available for a consultation. So are we practicing unethically? We cannot possibly provide all information that there is. But we are required to provide enough information for our patient to understand and be able to make an autonomous decision [7].This decision the patient then makes has to be respected, even if it should, to our beliefs, be inappropriate to the patients´ positive health development. We are complying with the principle of autonomy. But it is here that beneficence and autonomy may clash. Especially in general medicine, this clash is apparent, so for example where patients need, yet refuse to have a blood transfusion because their religious believes prohibit them to [8]. In order to protect the practitioner it is therefore, important to have the patient sign a consent form where he declares his abstinence from treatment or therapy. Likewise if the patient wishes to proceed with a treatment, in order to protect the practitioner, the former should have to sign a form of contract where he declares his approval and understanding of the procedure and the possible consequences [5].

Where such “contracts”, or consent forms, have not been signed, from a legislative aspect, a practitioner may be exposed to claims of civil liability. This may also occur where tort of negligence of the practitioner towards the patient is claimed. But to be proven guilty of negligence the principles of negligence must have been violated. 1. To owe a duty of care, 2. To breach that duty,3. This breach of duty must have caused the damage complained of [9].

What about ethical justice? Are we able to provide our services to everybody on equal terms [5]? The diverse health systems of many countries have shown us that this is impossible. We already have medical systems today that at the most provide essential medicinal services rather than fulfil the necessary requirements [10]. The discrepancy in the health care system lies in deep confrontation to the ethical principle of justice which states that all patients have to be treated equally and have to be given access to the same resources [5]. Therapies of complementary and alternative practice though are not integrated into the health care systems and have to be disbursed privately by the patient and are therefore not obtainable for every patient. From this point of view justice is not met.

The issue of ethics is not a simple one and it is evident that stretchable boundaries are necessary. To assure that these boundaries are maintained, a health care professional is a member of a board or society monitoring professional practice within the practitioners´ field of competence. Ethics is the code of behavior that guides our actions in our professional environment [11]. To abide by these rules is essential for any practitioner in the health care sector. What is important to remember is that at all times the benefit has to outweigh the risk.

So can we as homeopaths, meet the ethical demands that our professional body codified for us, fully and at all times? We have to attempt to fully comply, but have to accept and be aware of the fact that the ethical principles overlap and their restrictive boundaries are slightly flexible.

[Thanks to Jean Duckworth, University of Central Lancashire, for assistance with this assignment]

References:

[1] Hahnemann, S., 1974. Organon der Heilkunst. 2te Auflage. Heidelberg: Karl F. Haug Verlag.

[2] Bauer, A., Anon. Der Hippocratische Eid [online] last accessed 24 January 2009 at URL http://www.rzuser.uni-heidelberg.de

[3] Jones, D., 2006. The Hippocratic Oath II [online] last accessed 09 February 2009 at URL http://www.catholicdoctors.org.uk

[4] Pantilat, S., 2008. Beneficence vs. Nonmaleficence [online] last accessed 05 February 2009 at URL http://missinglink.ucsf.edu

[5] Swagerty, D. Anon. Ethics: Terms [online] last accessed 10 February 2009 at URL http://classes.kumc.edu

[6] Davenport, J. 1997. Ethical principles in clinical practice [online] last accessed 05 February 2009 at URL http://xnet.kp.org

[7] Ernst, E., Cohen, M., and Stone, J., 2003. Ethical problems arising in evidence based complementary and alternative medicine [online] last accessed 19 January 2009 at URL http://jme.bmj.com

[8] Gardiner, P., 2003. A virtue ethics approach to moral dilemmas in medicine [online] last accessed 07 February 2009 at URL http://jme.bmj.com

[9] Duhaime, L., 2006. Negligence an Introduction [online] last accessed 07 February 2009 at URL http://www.duhaime.org

[10] Schulz-Ehring, F., Weber, C., 2008. Zwei-Klassen-Medizin [online] last accessed 24 January 2009 at URL http://www.pkv.de

[11] Fieser, J., 2006. The Internet Encyclopedia of Philosophy [online] last accessed 10 February 2009 at URL http://www.iep.utm.edu

To swallow or not to swallow…that is the question!

Abstract

A high degree of satisfaction is reported by patients of the homeopathic approach to health care [11]. Hahnemanns [10] postulations in Aphorism 2 of the Organon insist on a treatment that acts “in the shortest, most reliable and least detrimental of ways” (p.35). The routes by which remedies are administered can influence patient satisfaction with a regimen.

Central to this essay lies the question of the efficacy of the oral transmucosal remedy delivery over the oral swallow method. It is a common belief that, in homeopathic practice, an administered remedy needs to be dissolved on or under the tongue, such that absorption of the active properties via the oral mucosa is established. A survey has been conducted amongst practicing homeopaths evaluating their beliefs and experiences. The alternative routes of remedy delivery and the prevalence of the oral route have been identified via a second survey undertaken amongst suppliers of homeopathic remedies in 4 European countries.

The survey results have emphasized that the oral route of remedy administration has predominance over other routes of remedy delivery. Furthermore the outcome has clearly shown that the efficacy of a homeopathic remedy is believed not to be impaired if it is administered via the oral swallow route, without prior contact to the oral mucosa. The research of relevant literature has identified the homeopathic routes of administration as rated high in patient convenience and satisfaction.

In conclusion to the results of the surveys undertaken, it can be said that in future homeopathic practice the custom of supplying instructions of remedy administration to the patient can be facilitated immensely. Consequently, this may lead to increased patient compliance with the regimen. Further research is suggested.

Keywords: oral, swallow, transmucosal, routes of administration, convenience, compliance, satisfaction, homeopathy

Introduction

In the existing market economy that we have in the western world today, health care is increasingly being viewed as any other commodity that is demanded and supplied. With this development consumer satisfaction is augmented in value [18]. A patients´ satisfaction is influenced by aspects surrounding care and treatment, and may be decisive of acceptance and compliance with approaches that consequently may impact on the outcome of a therapeutic intervention [1].

The “empathic interaction with the health provider” [18] (p.377) is equally as important to the patient as are aspects such as the satisfaction with medication. The latter may influence the correct and continued intake of medicines and may ensure compliance with the prescribed regimen [1], [8], [25].

Besides the expected efficacy of medications, patients decisions are influenced by side-effects in relation to their medicine intake, the dosing regimen prescribed, the dietary restrictions associated and the routes of administration by which the medicinal substance is delivered into the patients system [8], [25]. The more convenient a drug delivery is, the better the patient feels in terms of compliance [5].

This paper aims to critically evaluate the routes of administration used in homeopathic prescribing. The deconstruction of the beliefs surrounding the oral-transmucosal route of remedy administration is sought to be refuted via the evaluation of available literature. The results of two surveys that have been undertaken are meant to deliver a re-constructive conclusion of the oral-swallow administration as a viable route for homeopathic remedy delivery.

 De-constructing the oral – mucosal route of administration

In conventional medicine the oral route of administration is the predominant method of drug delivery [24]. It is “the most convenient, inexpensive and safest route” [5] (p.197). The majority of drugs administered, whether in solid or liquid form, are being delivered into the body via the digestive system. What is taken in orally and swallowed is “absorbed into the blood system from the gastro-intestinal tract” [3](p.1398). For this purpose tablets, pills and capsules have to be produced in forms that withstand the exposure to the acidic environment of the stomach [2], the passage through the hepatic metabolism and rapid decomposition in the intestines [2], [3], [7], [24]. If this cannot be overcome, the exposure of the drug to the patients system in the digestive tract is diminished [3] and not enough active ingredient can be retained for the expected medicinal purposes of the drug to take action [5].

In my homeopathic practice, I have primarily made use of the `other´ oral route of drug delivery. I recommend to my patients, to allow dissolving on or under the tongue of the homeopathic tablet, pill, or granule such that the remedy may be absorbed through the mucosal lining of the mouth. The sub-lingual, gingival, buccal and soft-palatal mucosa are, according to research in allopathic medicine, the sites of the mouth where medicinal substances may best be absorbed into a patients’ system [24]. Hereby the above mentioned difficulties of degradation in the digestive tract are avoided, but exposure to drug substance is short and the drug action may be interfered by drink, food and other irritants that are absorbed through the mouth [24], [25]. Carlston [4] and Schütt [23] point this out for homeopathy and recommend that certain foods should be avoided directly before and after a remedy is allowed to dissolve in the mouth.

Although Hahnemann [10] suggests in the Organon (Aph.259 & 260) that obstacles to the cure, dietary and of regimen that could have a medicinal effect, are to be removed from the patient, no evidence could be found of Hahnemann being as precise as Carlston [4] and Schütt [23] above are. Hahnemann also does not suggest the inefficacy of a remedy if it is exposed to the acidic environment of the digestive tract. In fact, Hahnemann in Aphorism 284 describes the stomach as site of absorption, suggesting that he did not expect remedial action to be diminished if a remedy had been swallowed without prior contact to the oral mucosa.

From the Organon [10] it could not be extrapolated that Hahnemann explicitly insisted on the oral-transmucosal remedy delivery. Hahnemann [10] speaks in the Organon of “Gabe”, what is best translated as `administration´ [14]. In the Footnote to Aphorism 247 Hahnemann [10] employs the term “einnehmen” which refers to `ingestion of´ [15]. In Aphorism 272 he describes to the homeopath that a “granule placed dry on the tongue, is one of the smallest administrations for the less severe, only recently developed cases of disease” [10] (p.158). He goes on to point out that as such, only few nerves are touched by the medication. Further he describes that if the granule is dissolved in water and is prior to repeated ingestion succussed; a much stronger medication is created of which even the tiniest dose comes into instant contact with many nerves [10]. Yet, this also does not deliver indications for a definite necessity of transmucosal absorption.

This raises the question if the practice, of keeping the remedy in the oral cavity for transmucosal absorption is at all necessary. Many authors [4], [6], [13], [21], [23] suggest this as an explicit necessity for the remedy to be able to unfold its healing action.

Consequently, more questions have arisen. In what form are remedies most prevalently prescribed? What are the beliefs of practising homeopaths? Is it necessary to allow the remedy to dissolve in the mouth or is it also effective if swallowed? What other routes of administration are being used in practice?

Questions and answers – Survey 1

In a quest to answer those questions, two colleagues and I forwarded a questionnaire to fellow homeopaths on two homeopathic social networking sites, asking them to share their experiences and beliefs of the efficacy of oral-swallow versus oral-transmucosal remedy absorption and other routes of administration they used in their practice. The outcome was interesting.

Table 1

Table 2

As can be extrapolated from table 1 all homeopaths that replied to the questionnaire use the oral route of administration of remedies. 70% also used topical, 20% olfaction and 10% other forms of remedy delivery, namely playing with/holding of the closed vial. In table 2 is shown that 89% of homeopaths believe that if a remedy is swallowed, without prior dissolving in the mouth, it is still effective. 11% oppose this belief and state that swallowing is not effective.

Survey 2

A second questionnaire was formulated that was sent to suppliers of homeopathic remedies in the U.K., Germany, Austria and Switzerland. Here it was of interest to us to identify the greatest demand for and supply of different remedy types. Of 11 companies that were contacted, 10 replies were received in time for inclusion in this paper. The following table shows the companies contacted:

U.K.AustriaGermanySwitzerland
HeliosRemediaWeledaOmida
FreemansSpagyraAlceaSimilisan
Ainsworth Staufen 
  DHU (*) 

(*) the reply from the DHU, came too late for inclusion in this paper.

Chart A: Suppliers contacted

In the U.K. the main remedy forms supplied are tablets and pillules, in Austria and Switzerland it is granules, whilst in Germany granules, liquid, and tablet are greatest in demand. Austria and Switzerland have producers that supply Collyria of homeopathic remedies. Only in Germany are remedies available as injections. Crèmes and Suppositories / Pessaries are in supply in all four countries. The greatest variety of homeopathic remedies forms is available via suppliers in the U.K.. It is interesting that in the U.K., Tablets and Pills are the predominantly purchased forms of remedy, while in continental Europe granules are highest in demand.

What becomes evident is that the oral administration has predominance in homeopathy. The highest demand is for remedy forms that are delivered via the oral route of administration.

There is a demand for homeopathic remedies in the form of injections in Germany, an invasive route, belonging to allopathic medicine that is low in patient compliance [1] and much in opposition to the gentle homeopathic approach postulated by Hahnemann [10]. In survey 1, of homeopaths in practice, this route could not be identified as one common to the field of homeopathy. It requires therefore to be pointed out that Staufen is a producer of homeopathic products and of spagyria, and Weleda a supplier of homeopathic and anthroposophic remedies. It could not be identified whether injections were of a greater quantity in use for spagyric and anthroposophic treatment or classic homeopathic use.

In their response `Staufen´ point out that the increasing demand of granules may be down to self-medication of the public with homeopathic remedies, while the demand for injections reflects a pure practitioner demand [20].

The replies also showed that there are other sites of transmucosal drug passage used in practice. These may be the nose, eyes, rectum, and vagina [3], [24]. The demand for remedies in the form of Collyria, pessaries and suppositories, shows that homeopaths also use these routes of administration.

Below is a table that illustrates the quantitative differences in the demand for certain remedy forms. As not all suppliers have shared numeric data, the graph contains only the data of those that have. I have only included 3 product items for each supplier.

Chart B: Approximate quantities supplied

What becomes visual in this chart is the great prevalence of oral solid remedy forms over oral liquid forms. Chart b also provides an idea of the quantities demanded of other remedy forms that are not visually shown in this graph. They are very low.

Reconstruction – The other routes of administration

The results extrapolated from the surveys, and the lack of evidence insisting on the oral-transmucosal remedy administration, have shown clearly that the efficacy of homeopathic remedies is believed not to be reduced if administered by swallowing.  At the same time the evidence for the requirement of precautions and restrictions ultimately before and after the intake of remedies is absent in the principal homeopathic literature. Hahnemanns [10] exclamations made in the Organon relate to the intake of substances with medicinal effect only (Aph.259 & 260), and he does not make any restrictions as to time, such as before and after remedy intake. This may remove, in future practice, the directions of remedy administration supplied by practitioners to their patients and narrows the general restrictions frequently given by the practitioner; a development Hahnemann [10] much criticized in followers of homeopathy (Aph.260). Thus convenience for the patient is augmented.

Alternative methods of administration are being used by practicing homeopaths, as can be seen in table 1. Taking into consideration the results visualized in chart B, the use of these is relatively small. Within the Aphorisms of the 6th Organon there is little mentioning of other routes by which remedies could be delivered. Only in Aphorism 284 does Hahnemann [10] describe sites of absorption other than tongue, mouth and stomach, mentions olfaction and inhalation and points out that the skin is also appropriate for remedy administration especially if concomitant to the oral intake of the remedy.

Of the alternative routes, topical administration finds greatest mentioning in the 6th Organon and is further described in Aphorism 285, and the footnote of Aphorism 282 in the case of Warts. There is supply of topical applications by 7 of the 10 suppliers of homeopathic remedies interrogated for our survey and table 1 shows that this route is one chosen in practice by 70% of homeopaths. According to Atkinson et al. [1] oral and topical administrations in conventional medicine are rated by patients as of highest satisfaction and convenience.

In Aphorism 272, as mentioned above, Hahnemann [10] describes the single granule dry on the tongue as the smallest dose, and in `The Chronic Diseases´ he also says this of “moderate smelling of an open vial” [16].

According to Little [17] alternative routes of administration may become necessary, where a remedy cannot be given orally, so for example if a patient is unconscious, or as McKay [19] describes, if patients are “in their final stages of life” (n.p.), when the open vial can simply be held under the sleeping patients nose to allow administration via inspiration. Also with children and infants this is an effective alternative form of remedy delivery [19]. Little [17] points out that in the 5th Organon (Aph.288) Hahnemann describes in detail how inspiration via mouth or nose can be used to deliver the remedy and further explains that it may even suffice for the sensitive patient to hold or touch the closed remedy vial. This is being practiced by 10% of homeopaths who replied to our questionnaire (Table 1).

An indirect delivery method Hahnemann [10] goes on to describes in Aph. 284. Here the remedy for the ill baby is to be given to the breast feeding mother. The child will consequently receive the remedy via the breast-milk [10].

Homeopathy is a person-centred approach that values the totality of the patient and respects the patients´ individuality [11]. As such the methods of remedy delivery offer a wide range of routes to be used to the patients convenience and best compliance. Kayne [13] points out that in conventional medicine the therapeutic efficiency is the prime determinant of the form in which a drug is delivered. In homeopathy the choice of form of remedy is one dependant on patient convenience solely [6], [13]. The same applies to the routes by which drugs are delivered [9].

Conclusion

In conclusion it can be said that improvement of methods of administration is not relevant to the practice of homeopathy. Hahnemann propagated different routes of remedy delivery ever since the creation of homeopathy [23]. The results of the above surveys have indicated that the oral route of delivery is by far the most extensively employed route of administration and that homeopaths in practice have a marked preference of using remedies in solid forms. The common belief that remedies need to be kept in the mouth and be allowed to dissolve has not been affirmed in practice as our survey has shown. Efficacy is maintained even if a remedy is swallowed.

The outcomes of the surveys and the preceding literature search have helped to identify the homeopathic method of remedy delivery as one of increased convenience and compliance to the patient. These routes, as postulated by Hahnemann [10], are non-invasive and adaptable to patient request and preference. By Hahnemanns own words in Aphorism 2, a homeopathic treatment should lead to “fast, gentle and durable recovery to health or elimination and annihilation of disease in all its complexity, in the shortest, most reliable and least detrimental of ways” [10] (p.35).

As much as convenience of the homeopathic methods of remedy delivery may receive high ratings of satisfaction and compliance by the patient, one problem may remain. There may be scepticism towards the efficacy of some of the alternative routes of administration of homeopathic remedies. Patients may doubt efficacy when the homeopathic practitioner insists that smelling a remedy may suffice for the expected healing action to take place [12]. Likewise it may be viewed rather sceptically if it is suggested to simply hold the closed vial [17]. Belief in the efficacy of these routes may be frail, despite the trust in homeopathy as an effective therapeutic approach.

It needs to be pointed out that further research to verify the efficacy of the oral swallow administration in homeopathy is relevant. The representativeness of survey 1above, reflecting the experience of practicing homeopaths, is very low as participation was only approximately 4.2 % of all homeopaths to whom the questionnaire was made available. For further research it can therefore be said that a social networking platform appears inadequate for the appraisal of a survey, even if, as in our case, the focus of the sites our questions were posted on was strictly homeopathic.

Acknowledgements

Many thanks to Rehana B. Issat for the assistance with the surveys used for this assignment and the presentation associated.

[Thanks to Hazel Partington and Jean Duckworth, University of Central Lancashire, for assistance with this assignment]

References:

1. Atkinson, M., Sinha, A., Hass, S., Colman, S., Kumar, R., Brod, M. & Rowland, C. (2004) Validation of general measure of treatment satisfaction, the treatment satisfaction questionnaire for medication using a national panel study of chronic disease [online] Health and quality of life outcomes Vol.2, No.2, article from Biomed central, last accessed 17 March 2011 at URL http://www.hqlo.com

2.Beller, K. (no date) Mukodermale Applikation mit dem Adapplikator: Neue pharmazeutische Technologie [online] last accessed 17 March 2011 at URL http://www.adapplicator.de

3. Borchardt, R. (1998) Value of pharmaceutical sciences [online] Journal of pharmaceutical and biomedical analysis Vol.16, pp.1387-1401 article from Elsevier, last accessed 17 March 2011 at URL http://www.sciencedirect.com

4. Carlston, M. (2003) Classical Homeopathy Pennsylvania: Churchill Livingstone

5. Chin, R., & Lee, B. (2008) Principles and practice of clinical trial medicine London: Elsevier Inc

6. Clarke, J. (1992) The Prescriber Ninth Edition (reprint), Somerset: Hillman Printers (Frome) Ltd

7. Constantino, H., Illum, L, Brandt, G., Johnson, P. & Quay, S. (2007) Intranasal delivery: Physicochemical and therapeutic aspects [online] International journal of pharmaceutics Vol.337, pp.1-24 article from Elsevier, last accessed 16 February 2011 at URL http://www.sciencedirect.com

8. Cook, S. (2007) Approved drugs and their problems in patient care: Routes of administration and dosing [online] Journal of the neurological sciences Vol.259, pp.38-41, article from Elsevier, last accessed 18 March 2011 at URL http://www.elsevier.com

9. Fordney, M, French, L. & Follis, J. (2008) Administrative medicinal assisting (6th edition) Delmar Cengage Learning Inc.: New York

10. Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg: Karl F. Haug Verlag

11. Hartog, C. (2009) Elements of effective communication-Rediscoveries from homeopathy [online] Patient education and counselling Vol.77, pp.172-178, article from Elsevier, last accessed 02 October 2010 at URL http://www.elsevier.com

12. Jütte, R. (2008) The doctor-patient relationship as reflected in the case books of Samuel Hahnemann [online] Hpathy last accessed 16 March 2011 at URL http://hpathy.com/homeopathy-papers/the-doctor%E2%80%93patient-relationship-as-reflected-in-the-case-books-of-samuel-hahnemann/

13. Kayne, S. (1997) Homeopathic Pharmacy: An Introduction and Handbook New York: Churchill Livingstone

14. Leo Dictionary (2011a) Gabe [online] last accessed 23 March 2011 at URL http://dict.leo.org/

15. Leo Dictionary (2011b) Einnehmen [online] last accessed 23 March 2011 at URL http://dict.leo.org/

16. Little, D. (2006a) Hpathy: Hahnemann’s Advanced Methods Part 2: The medicinal solution [online] Hpathy last accessed 17 February 2011 at URL http://hpathy.com/homeopathy-philosophy/hahnemanns-advanced-methods-part-2-the-medicinal-solution/

17. Little, D. (2006b) Hpathy: Hahnemann’s Advanced Methods Part 7: Administering the Dose, [online] Hpathy last accessed 17 February 2011 at URL http://hpathy.com/homeopathy-philosophy/hahnemanns-advanced-methods-part-7-administering-the-dose/

18. Lupton, D. (1997) Consumerism, reflexivity and the medical encounter [online] Social Science & Medicine Vol.45, No.3, pp.373-381 article from Elsevier last accessed 18 October 2010 at URL http://www.sciencedirect.com

19. McKay, A. (2009) “Nothing by Mouth”: Olfaction, Friction and other non-oral delivery routes [online] Hpathy last accessed 16 March 2011 at URL http://hpathy.com/homeopathy-papers/%E2%80%9Cnothing-by-mouth%E2%80%9D-olfaction-friction-and-other-non-oral-delivery-routes/

20. Mittelstadt, U. (2011b) Staufen Pharma, Monchique: Personal communication.

21. Pratt, N. (1991) Homeopathic Prescribing (Revised edition), Beaconsfield: Beaconsfield Publishers Ltd

23. Schütt, K. (2009) Application of Homeopathic Remedies [online] Hpathy last accessed 16 February 2011 at URL http://hpathy.com/homeopathy-papers/application-of-homeopathic-remedies/

24. Shakya, P., Madhav, N., Shakya, A. & Singh, K. (2010) Palatal mucosa as a route for systemic drug delivery: A review [online] Journal of controlled release in press, article from Elsevier, last accessed 17 March 2011 at URL http://www.sciencedirect.com

25. Shikiar, R. & Rentz, A. (2004) Satisfaction with medication: An overview of conceptual, methodologic and regulatory issues [online] Value in health Vol.7, No.2, pp.204-215, article from Wiley, last accessed 17 March 2011 at URL http://www.onlinelibrary.wiley.com

In a nutshell…..Posology and Dosology

Dosology refers to the quantity of a remedy that is given and posology to the actual frequency of administration of this dose [3]. In Aphorism 2 of the Organon Hahnemann specified that the highest ideal is to restore a patient to health rapidly, gently and durably. To do this, a careful selection of the appropriate remedy is a prerequisite, followed by the administration of the adjusted dose as not to overstress the vital force, and a cautious selection of remedy repetition [5].

In terms of dosage of a remedy, this must be large enough to overcome the opposition of the vital force and be sufficient to induce a curative action [2] and is dependant, as is the potency of a remedy, on factors such as sensitiveness of the patient, nature of the disease and remedy prescribed [5].  Bhatia [1] in his Guidelines to the 6th Organon points out that in an acute case a single dose may be sufficient to resolve the case, but in a chronic case a repeated split dose may be more effective (Aphorism 246). The dosage should be altered with each administration of the prescribed remedy; which is best done by increasing the number of succussions and does not necessarily request an alteration of potency (Aphorism 280).

The prescription should only be repeated if the patient shows little and slow improvement. Should the patient experience evident and obvious amelioration, a repeated intake of the remedy could aggravate and slow down the healing process [5] and should thus be avoided. A repetition of dose becomes necessary if the symptom picture returns or has not fully improved. If a new picture arises a layer has been removed and a second latent miasmatic condition is revealed, in this case a different picture has presented that will require a new and altered prescription [2]. Hahnemann [4] points out in aphorism 276 of the Organon that great disaster is caused if dosage is too great or repetition is too extensive; not seldom is the patient rendered in danger of life or his ailment is rendered incurable.

Therefore, following remedy administration, interference by dose repetition should be avoided, until signs of improvement relapse [2]. A single dose is appropriate unless a strong initial aggravation is expected and a split dose is required for minimization of such [5];[6]. The split dose is administered in a first dose that is effective in delivering the remedy information and a second dose that cuts off the full expression of the remedy in the patient; thus preventing a possible aggravation from occurring [7]. Roy [7] points out, that it is important to control the aggravation of a repetitive dose in that the healing movement is to be enhanced and not the disease.

In aphorism 275 Hahnemann [4] stated that the adequacy of a prescription is not only dependant on the matching remedy but equally as much on the requirement of the appropriate dosage and the minuteness of the posology.

[Many thanks to Ian Townsend, University of Central Lancashire, U.K., for his assistance with this assignment]

References:

1. Bhatia (Anon) Guidelines in 6th Edition of Organon of Medicine (1842) [online] last accessed 06.04.09 at URL http://www.hpathy.com/software/posology/help/Organon6.htm

2. Close, S. (2000) The Genius of Homeopathy Lectures and Essays on Homeopathic Philosophy Chapter 13 [online] last accessed 07.04.09 at URL http://homeoint.org/books4/close/chapter13.htm

3. De Vries, A. (2004) Homeopathic dose [online] last accessed 06.04.09 at URL http://www.hompath.net/homeopathy/homeopathic-dose.php

4. Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg:Karl F. Haug Verlag.

5. Little, D. (2006) Hahnemann´s advanced methods [online] Homeopathic ezine, last accessed 06.04.09 at URL  http://www.hpathy.com/philosophy/little-medicinal-solution.asp

6. Little, D. (2007) Dose and Potency according to the Organon [online] last accessed 06.04.09 at URL http://www.simillimum.com/education/little-library/case-management/dpato/article.php

7. Roy, M. (2006) Homeopathic case analysis  Kilmarnock, Ritchie UK Ltd.

In a nutshell…..Primary and secondary reactions

In the Organon [1], Hahnemann states that each potency that is imposed onto an organism affects the vital force and creates an alteration in the patients´ state of being for some time (Aphorism 63). This is known as a primary reaction. The vital force though seeks to oppose this influence and induces a force encouraging rehabilitation to the initial healthy state of the patient (Aphorism 64). This is the curative action and is called the secondary reaction.  It echoes Newtons´ third law that states that to every action there has to be an equal but opposite reaction [2]. Cure should take place according to the law of Hering, which means from inside out, top to bottom and in reversed order of symptom appearance [3].   Roy [4] describes primary and secondary reaction in more detail: The primary reaction of an appropriate homeopathic medication creates within the diseased individual a pseudo-ailment that mirrors in its expression that the patient is actually presenting with; pointed out also in the Organon in Aphorism 157 [1]. This first reaction is an impulse to the vital force that triggers it to start opposing this alien disease agent. This oppositional stimulation, that seeks to resolve the diseased state, is the secondary reaction, the curative process that shall restore the patient to good health. This secondary action, the amelioration, should be widely symptom free.

Minor initial aggravations in the primary reaction, are considered a sign demonstrating that the remedy choice was indeed a closely matching one, but in highly sensitive patients there may be major homeopathic aggravations that suggest that the potency or the dosage had been inappropriately chosen [3]. Secondary reaction aggravations occur if the selected remedy is only partially matching the case [3] or the dose is too high for the patient prone to susceptibility, this may lead to enduring ailments of this artificially induced disease [5].  The appearance of new symptoms that stand in no relation to the presented ailment may be of the underlying condition surfacing as the prior layer has been removed, or symptoms of the remedy itself may be expressed [3]. Little [5] (n.p.), calls this a “dissimilar aggravation” meaning that the patient has received a remedy that is not relevant for his cure. This may mean the patient is proving the remedy [6]. Here an antidote should be administered prior to in-take of a more accurately matching prescription [5].

The remedy, if appropriately chosen should mirror the ailment the patient is presenting with. The action of the vital force to this stimulus, the secondary reaction, should be in opposition to the primary reaction, thus be able to remove the presented ailment once the artificial infection of the administered remedy has ceased [4]. It is not always possible to find the exact matching remedy that will relieve the patient of all symptoms at once. This well chosen remedy may remove one layer of the patients presented state and may reveal another that will require a new remedy.

[Many thanks to Ian Townsend, University of Central Lancashire, U.K., for his assistance with this assignment]

[1] Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg:Karl F. Haug Verlag.

[2] Close, S. (2000) The Genius of Homeopathy
Lectures and Essays on Homeopathic Philosophy Chapter 13 [online] last accessed 07.04.09 at URL http://homeoint.org/books4/close/chapter13.htm

[3] Koehler, G. (1989) The Handbook of Homeopathy  Vermont, Healing arts press.

[4] Roy, M. (2006) Homeopathic case analysis  Kilmarnock, Ritchie UK Ltd.

[5] Little, D. (2006) Hahnemann´s advanced methods [online] Homeopathic ezine, last accessed 06.04.09 at URL  http://www.hpathy.com/philosophy/little-medicinal-solution.asp

[6] Sherr, J. (1994) The dynamics of proving  Malvern, Dynamis Books

A quest for consensus of speech – Say what you mean!

An exploration and critical analysis of the terminology used to describe ultra high dilution, the position of homeopathy in medicine and its relation to science – a demand for agreement on inter- and cross- disciplinary definition and vocabulary.

Abstract

In homeopathy there is a lack of consensus on the terminology used to describe it. The meaning of nomenclature is frequently not what we are expressing in words, because the terms we are using are not universal to the discipline of homeopathy. This fosters criticism, misinterpretation and confusion. The words describing `ultra high dilution´, serve as an example to illustrate this requirement for agreement on semantics.

Even outside the realms of homeopathy there is no agreement on a joint language. Medicine as a generic term, repositions homeopathy, and raises questions of the place of homeopathy as a science.

The dominant paradigm of science is ignorant of immaterial notions; therefore the question of a shift of paradigm to match the development of knowledge and science over time is discussed. Consequently it becomes evident that with a consensus of speech and an amendment to the existent paradigm, the position of homeopathy in medicine and science could be clarified. A universal language, will unite the knowledge, and avoid the misunderstanding of homeopathy.

Keywords: terminology, semantics, homeopathy, ultra high dilution, criticism, science, paradigm, medicine.

Introduction

With Homeopathy we have at our disposal a health care system that meets the demand for a scientific methodology strictly researched on human subjects. Homeopathy has been objectively and subjectively documented in sensitive detail for over 200 years. No other medical system is subject to such intense investigative, case-descriptive and experiential verification as is homeopathy [14]. Despite such extensive clinical evidence, the foundational pillars of this alternative medical approach are stumbling blocks to acceptance and acknowledgement of the efficacy of this treatment approach. The prime criticism against homeopathy relates to the law of Similars, the law of Infinitesimal and the law of Chronic Disease [10].

In my practice as a homeopath I have had the most queries concerning homeopathy, questioning the plausibility of the law of infinitesimal. A lot of controversy, criticism and misunderstanding surrounds this homeopathic principle. But not alone due to the persistent doubt of its efficacy, the inexplicability of the underlying mechanism, or its  position in the realms of medicine and science are practicing homeopaths constantly in need to defend their therapeutic approach. The terminology too, is often causing confusion.  I have therefore chosen to critically evaluate and analyze the fundamental concept of ultra high dilution from the point of view of its terminology. By way of terminology, I have also sought to identify the position homeopathy holds in medicine and science and am aiming at deconstructing conjectural beliefs and fundamental claims.

Relevant literature for this essay comes from books, and articles and studies that were taken from electronic databases such as Sciencedirect and Elsevier available via the UCLan subscription.

I have chosen to take definitions from “the pocket oxford dictionary” [19], a `house-hold´ dictionary, devoid of having a specialty focus in the contained vocabulary.  This is relevant for the argumentation concerning the confusion surrounding the semantics of homeopathy.

Personal experience from the patient-practitioner interaction and discussions with opponents to this treatment methodology, founds the basis for argumentation and investigation undertaken in this essay.

The importance of semantics

In my practice with patients it has not gone unnoticed that, although homeopathy is understood as an ‘other, gentle´ treatment approach, the comprehension of principles and specialized vocabulary is cause of confusion and misunderstanding. This is not surprising, considering the falsified semantics we homeopaths have been employing. When addressing ultra high dilution for example, by use of the wording, we are describing a solution that in reality is far from what we actually utilize as a homeopathic remedy.

Ultra molecular dilutions, ultra high dilutions, infinitesimal dilutions, are names given to the medicinal substances of homeopathic prescribing. Yet, they are false as they do not describe what is actually meant and are not precise in the dimensions they are sought to be descriptive of.

By the definition of the prefix ´ultra` as “extremely, excessively, beyond” [19] (p.817), one decisive explanatory factor is omitted. The use of the word `high´, is equally controversial. The most matching definition, for the description of the term ` high´, is “extreme, intense, above the normal” [19] (p. 346).

These quantitative terms that we utilize in the description of homeopathy, are relative and stand widely in connection to individual parameters. What is `ultra´ or `high´ is therefore dependent on who uses the term and in what context. `Infinitesimal´ likewise is best understood within context, but comes closer to what we mean it to describe in homeopathic terms. It is descriptive of something that is “infinitely or very small”, with `infinite´ meaning “boundless, endless; very great or many” [19] (p. 377).

Molecular has the meaning “of or relating to or consisting of molecules” [19] (p. 473). `Dilution´ is derived from the stem verb `to dilute´ which is to “reduce strength of (fluid) by adding water or other solvent; weaken or reduce forcefulness of” [19] (p.204).

When using the term `ultra molecular´ for a dilution, we describe a solution `beyond´ the consistence of molecules, if we employ the above definitions. But in relation to `dilution´, this lacks the correct description of the element that makes the remedial substance homeopathic. An ultra molecular substance as we comprehend it in homeopathy is not one that has merely been reduced in concentration [12], but one that has been serially diluted and rendered dynamic. Hahnemann [15] described this in Aphorism 269 of the Organon. This process is known as dynamization or potentization. Crude substances lose their toxicity or their respective state of `being without healing´, by dilution, and increase their medicinal power by succussion or trituration [6]. Therefore a homeopathic remedy has to be serially diluted and vigorously shaken at each stage of potentization, in order to attain its healing modalities [7], [30]. A more correct term descriptive of a homeopathic remedy, is therefore an `ultra molecular potentization´.

To be descriptive of what we mean when we speak our homeopathic language, the definition of the wording we use has to be known and understood.

Complemented by a definition given according to www.britannica.com, `infinitesimal´ is of a “quantity less than any finite quantity, yet not zero.” This description of the word could meet the demand for a more precise definition, when used in a homeopathic context, as it incorporates a descriptive component of the dimension of the infinitesimal potentization. But this requirement for extension to the meaning may be unclear to the lay person or to potential patients as it makes use of a definition that is taken from another source. This raises the question of which definition comes closest to the correct meaning of the term and underlies an expression, or which dictionary or lexicon carries the most precise definition. We homeopaths need to utilize the same definitions and words if we and our therapeutic approach are to be clearly and correctly understood.

This is essential! Different sources produce different meanings to one and the same term and there from, at the very root, foster differentiation in meaning and consequently fallacy and disagreement in speech.

In my discussion with my patients, it has become evident that the difficulty of acceptance of and the criticism towards homeopathy lies mainly within the realms of the principle of `ultra high dilution´, or actually within the false terminology that describes it. A mere dilution is not what patients can see as an effective agent for the treatment of ailing symptoms. How controversial the mechanism of potentization is, the application of a mechanic motion to the remedial substance receives more acceptance of plausibility than just dilution. In practice therefore, this is not subject to quite as much scrutiny as is experienced from the realms of science or other medicinal methodologies. Patients frequently believe in `things between heaven and earth that cannot be explained´ and if these are able to make them feel improved, the `how´ this happens is not that relevant [16].

Alternative or discipline of medicine

Having no clear one language and precision in what we, within the discipline, mean causes confusion in the dialogue with lay persons and as previously illustrated, with our own patients. The above example of a re-definition, may have little implication on the overall comprehension of homeopathy, but does in the discourse with persons who only engage with homeopathy in the broadest sense, foster misunderstanding and consequently uninformed criticism. We are postulating in our practice an ethical treatment approach where patients are able to make an informed choice for their treatment [25] and therefore require provision of enough information for them to found their decisions. With an inappropriate terminology this is difficult. Consequently what can be identified as homeopathic terminology may, require slight correction [12].

Semantics also plays a crucial role when it comes to the communication amongst us practicing or engaged with homeopathy, and with those outside the homeopathic field of practice, with science and other medical disciplines [11], [12].

Our unorthodox use of the term `homeopathy´, already bares proof of the need to speak with one voice when representing a homeopathic stance. `Homeopathy´ in its usage, even amongst homeopaths, has different meanings [22]. In discourse with practitioners and lay persons alike, I have heard this terminology in use for the description of the consultation, the remedy, the philosophy and the principles; much like is mentioned in Relton et al. [20]. And I follow with Relton et al. for `homeopathy´ to describe a “system of therapeutics” (p.153) and all other terms to provide a distinguishable prefix, suffix or additional term highlighting their difference.

As much as the term `homeopathy´ is unclear in its application, the position of this treatment approach is not certain in its comparison and relation to what we normally describe as general medicine.

Homeopathy is described as a discipline unconventional or alternative; as opposed to what? To allopathy or allopathic medicine? Is homeopathy really that `other´? Is it not a therapeutic approach aimed at treating illness, just as is what we know as general medicine? Guajardo, Searcy, and Reyes, [13] have aimed at specifying semantics that may permit a better understanding of the position that homeopathy holds in the realms of medicine.

They point out that `allopathic medicine´ as such is not existent, but that `allopathy´ itself is descriptive of a treatment approach and not of medicine in general. The word `medicine´ is not equivalent to allopathy, although in practice it is frequently used interchangeably. From this it already becomes evident that outside homeopathy there is also little consensus of terminology or definition.

With respect to homeopathy, Guajardo et al. [13] state that we, homeopaths, “maintain the habit of labeling ourselves as a dissident medicine” (p.35), so to speak as `alternative´ or `unconventional´, “when in truth homeopathy is but a method” (p.35). Why is homeopathy described as a ‘other´ medicine, when in reality homeopathy just like many other therapeutic methods, is but a treatment approach to illness [12], a discipline, a methodology or a specialty? Homeopathy is not alternative or unconventional compared to medicine, but complementary to the different treatment disciplines that make up health care and make up what is described as `medicine´. The term `medicine´, is therefore the generic expression for many different treatment approaches aimed at treating disease.

Science or paradigm

Homeopathy, being one treatment approach of many that are together comprised in the term `medicine´, raises fundamental questions. If homeopathy belongs to the group `medicine´, and medicine is described as scientific, then homeopathy as a medicinal discipline should also be scientific. Yet critics find it hard to permit homeopathy this sort of labeling [4]. The argumentation is that the principles underlying homeopathic practice are “not explainable on the basis of established science” [10](np). Bellavite [3], states that “the homeopathic and scientific medical worlds have developed separately” (p.203). But this again places homeopathy aside of medicine when semantics above has shown that it is in fact a therapeutic discipline of medicine. So where does homeopathy stand?

Campbell [4] argues that what is described as conventional medicine frequently does not live up to the attempt to be scientific, and homeopathy, on the other hand, is the “only true scientific form of medicine” (p.79). Science, according to a dictionary definition is a: “branch of knowledge involving systematized observation of and experimentation with phenomena; systematic and formulated knowledge” [19] (p. 667). Does this not apply to both the generic term `medicine´ and specifically to homeopathy? With its underlying principles that are fundamental to homeopathy, and the confirmation of its efficacy in practice [4] homeopathy should be acknowledged the requirements defined for a science. Why then is it viewed with criticism and not acknowledged as scientific?

The question of the efficacy of ultra molecular potentization is one that critics describe as obstacle to homeopathy’s acknowledgement as a science. The efficacy of a homeopathic remedy potentized beyond Avogadro´s number, that is, beyond the stage where an molecular entity is traceable in the attenuation [28], [32], is in its mechanism not explainable by the laws of the mechanistic [1] or materialism [23] paradigm of science that scientists generally apply to the realms of medicine [1], [23]. What a paradigm represents is according to a dictionary definition, simply an “example or pattern” [19] (p.531). A better description is given by Swayne [27]: “a mindset that determines, and restricts, the direction in which scientific thinking and investigation are allowed to progress” (p. 90).

And again, here it becomes evident that there are differing terminologies in use. Is there the mechanistic paradigm as Bastide [1] calls it, or the materialism paradigm, so named by Scholten [23] in his article, in application of mainstream science? Are they the same or different? Why do we use different terminologies? `Mechanistic´ relates to `mechanism´, “structure or parts of machine or other set of mutually adapted parts” [19] (p.456), and `materialism´ means “nothing exists but matter and its movements and modifications” [19] (p.453). Both definitions have in common what Scholten [23] points out for the materialism paradigm that denies “the existence of emotions and thought” (np), and claims that “only the material world can be object of scientific research” [23] (np). Consequently homeopathy is declared as incompatible with the dominant scientific paradigm, and is denied recognition as a science.

In homeopathy, we speak of vitality and potentization and include criteria that are immaterial such as emotions and consciousness [23]. Therefore, does this not call for a new framework or paradigm as the, to date, dominating one “is in contradiction with the experience of all people” [23]?

We are in need of a shift in paradigm! A shift that permits the comprehension of “living structures” as Bastide [1] put it.

The paradigm of signifiers identified by Bastide and Lagache in 1992 is one that could be used to understand the impact of ultra molecular potentization [2] (nd). It states that “life forms communicate with their world in a non-verbal way, both on a somatic and a psychological level” [1] (p.129). In terms of ultra high potentization, this implies that homeopathy is related to a form of information transference. This implies that the remedy incites a transference of information from the remedy into the patients system, that is there recognized as a potential source of harm and consequently the immune system reacts by fighting this and the similar, existent disease information [1]. The result is a return to health of the patient.

Potentization can therefore be seen as the process that extracts information from the solvent [2] and thus a homeopathic remedy “contains only information but no molecules” [29] (p.109).

The problem that remains is that “as long as the materialism paradigm prevails, proof in favor of homeopathy will be denied, ridiculed or put away as irrelevant or unreliable” [23]. And this explains why recent research that undeniably provides evidence for the efficacy of ultra molecular potentization is rejected, although “information specific to the original dissolved substance remains and can be detected” [29] (p.109).

Experience or research

The recent research conducted by Montagnier et al. [17] has been revolutionary in that it demonstrated that there exists the “capacity of some bacterial DNA sequences to induce electromagnetic waves at high aqueous dilutions” (p.81). Chikramane et al. [8] have been successful in providing evidence for the retention of “starting materials and their aggregates even at extremely high dilutions” (p.242). The latter is, like the former, for homeopathy, of radical and outstanding value. This has major implications for future research, focusing on the comprehension of the processes underlying potentization and remedy activity [8], and consequently, may, at the scientific foundations, foster the necessity to re-consider the paradigmatic orientation.

Scientific research is necessary where the results reduce insecurity and deliver a better basis for decision making [31]. But according to Rubik [21] “major changes in science have never been brought about by isolated experimental findings but by collective evidence” (p.165). This gives rise to the question of why the numerous homeopathic provings that have been undertaken, with ultra molecular potentized remedies, leaving healthy individuals experiencing symptoms that have distinct parallels to the symptoms created in the testing of crude substances [18], are given little notice. Likewise the many successful treatments reported by patients, providing proof of efficacy of homeopathic remedies, are consistently ignored by those external to the discipline.

Experience in practice has justified our treatment approach and yet not all rules of homeopathy behave strictly as Hahnemann had described it. The circumstances out of which Hahnemanns´ postulations developed, have to be viewed critically and comparatively to the development of us and our environment in the time since Hahnemann wrote the Organon [22]. For example, we have to acknowledge that in ultra molecular potency prescribing “the old axiom of high potency for mentals and low for physicals is irrelevant” (p.83) as Sherr [24] put it. This shows that our practice in over 200 years is constantly put to the test in order to improve and prove our claims.

Likewise I believe that Science and its´ paradigm should be re-viewed critically and comparatively to its development through time and should experience a re-evaluation.

We humans are undeniably emotional and have a conscious functioning. Therefore, the dominant paradigm excluding the immaterial is outdated and should undergo a shift.

Conclusion

In the over 200 years of its existence, homeopathy has experienced highs and lows, great acceptance and large opposition. It is undisputable for those convinced by its efficacy that ultra molecular potentization contains an active property. Critics undoubtedly will oppose even the above mentioned study results.

What happens during the process of dynamization of an ultra molecular potentization, is still without comprehension even for us homeopaths, and is, for those from outside homeopathic prescribing, an even greater prohibition to acceptance of homeopathy as a rational healing discipline [26]. Yet research has provided us with the proof that something remains in our potentized remedies.

Therefore, in my communication with patients and in discussions with interested persons, when asked to theorize on a possible mechanism of action of the ultra molecular potentization, I describe a model quite similar to that fundamental to the paradigm of signifiers. The terminology of `ultra molecular potentization´ allows, for me, little other speculation of a possible mechanism of action. The transfer of information and a subsequent immune response against the intruder that carries a very similar imprint of information to that of the disease, present in the patient, cannot be denied plausibility. Given this explanation, the criticism against homeopathy is not silenced, but its plausibility thoughtfully weighed as possibly inherent of a mechanism following this explanation [16].

Future research will hopefully bring us closer to knowing how exactly this mechanism works.

It cannot be renounced that we have to be more careful with the choice of our wording. We homeopaths, have to reach an agreement on our language, such that this will be copied and borrowed correctly by others engaged with homeopathy, and by those external to our discipline, scientists and lay persons alike.

It is false to postulate `ultra high dilution´ as a fundamental concept of homeopathy. The definition of terminology used, requires specification and consensus of meaning. What we seek to express, needs to be just.

A universal consensus will globally inform and subsequently reduce criticism that is founded on wrong semantics.

Guajardo et al. [13] state that, “we should nurture the dignity of our specialty” (p.36). We can do this by assuring a high level of education of future practitioners [5], [13], by committing to unbiased research and by sharing a joint terminology, globally, of those practising the homeopathic healing art.

[Many thanks to Hazel Partington and Jean Duckworth, University of Central Lancashire, U.K., for their assistance with this assignment]

© U.M. at Clever Homeopathy

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