Molassiotis is the author of about 40 reviews, all of which are prone to the shortcomings he highlights. His statement, “I urge researchers in the field not to proliferate publications of ‘systematic’ reviews of a very small number and of admittedly poor/low quality level trials”, is thus surprising to say the least. The main point of his response seems to be that “systematic reviews of few and low-quality studies do not help anybody”. We feel that such articles can still be useful, for instance, for disclosing important deficits in our current knowledge.
In making this point, Molassiotis seems to display a lack of understanding of science in general and systematic reviews in particular. Here are a few of his most obvious errors:
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He asks “didn’t we know this [the result of a systematic review] before the review”? It seems obvious to us that the findings of a review can never be known before the research has been conducted.
He refers to “systematic reviews on the same topic by several different authors”. Yet a closer look at the actual articles he quotes informs us that they are, in fact, on subtly different subjects.
He claims that we believe that “anything that does not have a sham arm is not a good trial”. Yet we never stated anything like this. We would, however, argue that, for determining whether an intervention has therapeutic effects beyond placebo, a placebo/sham control is helpful.
He argues that controlling for placebo effects in acupuncture trials is done “to give some ‘science’ credentials to such trials and mimic drug trial placebo-controlled designs”. We would counter that the sole reason for doing this is to be able to differentiate between specific and non-specific therapeutic effects; in our view, this is important for determining the value of any treatment.
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He states, “I am questioning the ethics” [of such sham-controlled studies]. We would insist that differentiating between placebo and specific effects is a crucial ethical task of clinical research.
He claims that “bringing all acupuncture trials together as one treatment is like mixing apples and oranges”. We would like to remind him that, by definition, systematic reviews are about summary judgements of this nature and that most of his own reviews have followed exactly the same principles.
Finally, we agree with him that “we should not deny patients the possibility of experiencing symptom relief and health improvements because of sterile and incapacitating arguments about how to carry out ‘proper’ acupuncture trials”. But we need to point out that, before we can be sure that patients do benefit from our interventions, we need to determine whether they generate more good than harm. In our opinion, this requires rigorous research, and any attempt to bypass this process is likely to be counterproductive and unethical.
Conflict of interest
Both authors declare no competing interests.
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