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Volume 8, Number 2, 1992


The editors of Humane Medicine, perturbed by the sometimes unreasoning challenges to "orthodox" medical practice by "alternative" claims have asked me to comment, which I do more in the spirit of meditation than review, more as prologue than critique. If I have made the issues too either/or, I am sorry, because I believe in the words of a popular song, "It don't matter if you're black or white." For the term, orthodox, which implies only one straight path, I prefer, mainstream, in which we all move in the same direction but at different speeds.

Alternative medicine may be characterized as any therapeutic program that defines itself as outside the mainstream of medical practice. Usually, its practitioners aim, in some unconventional manner, at relieving symptoms. Of course what is conventional in one culture, such as acupuncture, may be unconventional in another. Indeed, as anthropologic studies remind us, much of our therapy is influenced by cultural definitions of what it means to be sick. "Post-traumatic stress syndrome," "chronic fatigue syndrome," or even "silent ischemia" show how labels turn a complex of symptoms into a "disease" that for a time may have a great following among lay people and doctors. Diseases are whatever doctors apply to that label; they are not to be found in Plato's sky, however real their ravages.

Alternative medicine is nothing new. In Grecian times Hippocratic medicine was mainstream practice, which depended upon a logical set of reasons about the cause and effect of disease. Set off against this Hippocratic tradition, to which Western physicians like to trace their origins, was a priestly Aesculapian medicine, which relied on dreams, oracles and the unreasonable whims of the gods in their sky.1 The sick, who were not cured by the practitioners from Cos, could try the temples of a favourite god, take potions and pour libations and find healing in dreams, just as patients today, dissatisfied with standard and sometimes sterile approaches, turn to other kinds of healers seeking alternative therapies.

Anthropologists tell us that usually cultures explain disease as the result of a personalistic agent, human or supernatural, whose malign action causes disease or pain, or a naturalistic one, more congenial to physicians, in which natural forces, germs, geography or something more, are deemed responsible for disease.2 However odd a form the practice may take, scientific medicine is about the second agent, whereas the first encompasses a variety of alternative approaches. Faith healing and Christian Science represent current personalistic approaches, but homeopathy, however we may cavil, falls under the naturalistic rubric. In some alternative approaches, the practitioner holds that the locus of healing resides in the person afflicted rather than in a supernatural spirit. However, even the self-help movement has an antique origin. Once William James derided the "mind-cure" system as "moonstruck with optimism," but later on his way to Paris to consult a quack, confessed to Osler, "Nevertheless, I don't wish to leave that stone unturned. 3

There are, doctors should remember, many different ways of dealing with the world. Sadly, in the waning years of the second millennium, physicians are trained to look only at disease, which we define as whatever we can detect by our machinery, image, endoscope or analyser. Few modern doctors pay enough attention to illness - the patient's experience; because illness cannot be quantitated, let alone visualized, symptoms often are denigrated as "soft data." Implicit in the current wave of algorithms for medical practice is a mathematical analogy: everything has a set and logical answer if only we make the right measurements.

The spirit of the Enlightenment rules modern medicine, as it should, but the Counterenlightenment, that Romantic reaction to the rule of reason and the methods of natural science based on materialism, has passed by most British and American medical practice. The triumphs of science, which it is never my purpose to decry, has lost the mind in the brain and transformed love or hope into neural impulses. No wonder alternative practitioners are so busy, for they try to touch that romantic strain of the mystical, the irrational and the spiritual component of human life.

Alternative medical practitioners know that men and women live in two worlds; we have a body and we have a mind. The mind may arise out of the brain, but it is too early yet to reduce all thought or feeling to neurobiologic impulses. A sick person is part of his or her culture; embedded in pathophysiology lie personal reactions to specific situations. Fifty years ago that concept was enshrined as "psychosomatic medicine"; today some of its heirs follow the "holistic" tradition, however much they might want to disavow the inheritance.

The major differences between mainstream practice and alternative medicine lie in the claims that are made and the criteria that are applied to test those claims. Mainstream physicians ground their practices and claims in accepted science and technology; alternative practitioners often do not and offer their assertions of disagreement as equivalent to proof. For example, I believe that placebos have their uses, but their benefits must be judged by the criteria of science rather than by the witness of testimony.4 Too often alternative and "holistic" practitioners seem to accept the claim, "I feel better" as equal to "I am cured." Here, assertion is allowed to take the place of evidence, and to that all should object. However, holistic practitioners know that not all symptoms have an "organic" basis, and often they attempt to enhance their patients' spiritual life. This effort provides an antidote to the current emphasis on the scientific algorithmic approach of modern medicine that a century ago William James called "medico-materialist" and we might label "reductionism." Isaiah Berlin has called "scientific fallacy" the belief that everything can be solved by measurement and science.5 Alternative practitioners who stand in the Romantic tradition are wiser than that.

Once, on one of the wonderful islands of Hawaii, where East and West unite, I listened to a Methodist-Buddhist preacher talk of his healing ministry. I listened sympathetically until I realized that all his "healed" patients had ended up in the proverbial pine box. For him, I think, "healed" meant "happy." He was using the term in a way mainstream practitioners could never do, and so it was not easy for me to talk with him.

Claimants need to define their terms before any meaningful conversation can take place. Also, it seems reasonable to ask that the claims of alternative or holistic medicine meet the same criteria mainstream physicians apply to their own studies. Still, when there is so much to do and so little money to do it with, I do not believe that all the claims made by alternative medicine require mainstream confirmation or refutation. There is not world enough nor time.

Physicians need a loving heart; that we can learn from "holistic" doctors. But all doctors need science-based competence, and that they can learn from us.

Castiglione A: A History of Medicine, Knoph, New York, 1947: 148-178
Foster GM: Disease etiologies in non-western medical systems. Am Anthropol 1976; 78: 773-782
James W: Edelstein: letters from William James to William Osier. Bull Hist Med 1946; 20: 292-293
Spiro HM: Doctors, Patients, and Placebos, Yale U Pr, New Haven, Conn, 1986
Berlin I: Against the Current, Penguin, New York, 1982: 80-110
Division of Digestive Diseases, Department of Internal Medicine, School of Medicine, New Haven, Conn.
Correspondence to: Dr. Howard M. Spiro, Division of Digestive Diseases, Department of Internal Medicine, School of Medicine, 333 Cedar St., New Haven, CT 06510-8056, USA