“The mind–body dualism has long overstayed its visit. Western science needs to advance beyond the current reductionist model to some blending of the subjective and social aspects of healing.”—John S. Haller Jr.
We conclude our week-long feature on Shadow Medicine: The Placebo in Conventional and Alternative Therapies with an excerpt, fittingly enough, from the concluding chapter. In “Reassessment,” Haller examines some of the challenges confronting alternative medicine as it tries to gain greater legitimacy as well as the need to integrate our understanding of what both alternative and conventional medicine offer:
With approximately 80 percent of the world’s population, including half the US population, using some form of [contemporary and alternative medicine] (CAM), the scientific community can no longer view these therapies as simply a fringe interest among consumers. However, because CAM therapies diverge sharply from reductionist science, the nature of their evidence and the subjective manner of their production create substantive problems for evidence-based medical knowledge. This suggests a remarkable similarity between CAM therapies and numerous nonspecific theories and practices such as psychotherapy that, although difficult to explain in terms of their modus operandi, have proven beneficial to patients. The current tension between conventional therapies and unconventional therapies represents a collision of epistemologies. For the former, disease causation constitutes the ideal form of evidence; for the latter, outcomes are of equal or greater importance. In our postmodern world, multifactorial causation has become more accepted as doctors and medical researchers adopt a more integrative role for unconventional therapies—a road that neither is straight nor accompanied by clear markers.
As the usage of homeopathy, acupuncture, herbals, chiropractic, and other CAM modalities amply demonstrate, their poor performance in clinical trials have caused little or no diminution in their popularity. They remain robust in their claims and ever anxious to expand their therapeutic applications. Even with increased consumer interest, however, only a small number of CAM therapies are expected to achieve legitimacy alongside conventional medicine. Unlike biomedicine, which is constantly justifying its existence through replication and evidence-based research, most CAM modalities have yet to prove their efficacy or replicability, standing firmly on a static set of principles and practices that appear to “work,” albeit only marginally better than the placebo. To date, only a few have been able to build a scientific explanation for their efficacy. And for those that have achieved this status, the outcome has not always been to their benefit. The fact that the management of chronic disease constitutes 78 percent of medical expenditures in the United States explains why conventional medicine has been so aggressive in fighting CAM and, where possible, co-opting its more effective therapies.
To the extent that CAM therapies choose to seek third-party approval, they can be expected to institute some degree of standardized training and professionalization. This translates into a need to demonstrate not only a sense of stability, but one of replication—the ultimate test of their working truths. But the issues don’t end there. How is it, ask skeptics, that millions of Americans can still believe in meridians, crystals, auras, chakras, and water memory to cure disease? Worse still, how can those same individuals demand that the federal government spend taxpayer dollars to investigate modalities that defy the normative laws of science? Should there be a clear dividing line between biomedical and nonreductionist systems, or is this distinction determined by time, place, and attitude? How do CAM modalities use and abuse science? When is enough known to conclude that a practice is worthless? Do individuals have the right to demand that their health-care plans supply them with the therapy they desire? Should society be burdened with paying for treatments that are neither safe nor proven effective? Should druggists advise or caution purchasers concerning their choice of alternative medications? Is it really medicine if it has not been tested by the RCT? Will integration of EBM with alternative medicine enhance health care or simply appease patients or both? Should an evidence-based approval process be required for all CAM systems? Is there any substitute for science-based evaluation?
Overall, most CAM therapies have failed to meet the standards demanded of the evidence-based pyramid. Those few that have succeeded in achieving some degree of efficacy have done so with results that beg the question of whether they are equal to or more than what might be expected from the placebo effect alone. Most high-quality RCTs and meta-analyses of CAM therapies use such operative phrases as “safe but without clear evidence of benefit,” “not enough evidence,” “inadequate to allow any conclusion,” “insufficient evidence,” “the data do not allow firm conclusions,” “further studies are recommended,” “there is some evidence . . . but the results are not consistent,” “can make no definitive statement,” “currently no reliable evidence of benefit,” and “more trials are required.” In an environment where expense is no object, further research would perhaps be justified. In today’s world, that luxury is less of an option.
Given that poor evidence is often worse than no evidence at all, CAM continues to fight a perennial uphill battle due to weak methodologies, small trials, and the lack of predetermined criteria for evaluating claims. It counters criticism by claiming to be a holistic, consumer-driven phenomenon whose therapeutic benefits occur at levels not always quantitatively measurable, setting it directly opposite EBM with its quantifiable, reproducible outcomes. Nevertheless, only those CAM therapies that reach beyond their rhetorical defenses are likely to achieve the same degree of legitimacy as conventional practice. Aside from issues with the evidence-based pyramid, the challenge remains for systems such as homeopathy, naturopathy, therapeutic touch, anthroposophy, and other unconventional therapies to show that their outcomes for patients are more than the result of words, symbols, ritual, tradition, insight, or transference.
CAM’s general failure to conform to the biomedical model does not necessitate its retreat from the field. The mind–body dualism has long overstayed its visit. Western science needs to advance beyond the current reductionist model to some blending of the subjective and social aspects of healing that includes the placebo. This will require conventional medicine to end its either–or reliance on the RCT. Equally important, both CAM and conventional medicine must spend less time generating arguments of mutual disparagement and look for new and different tools with which to understand the causal links to explain and treat disease and illness. Such a task is not easy, and getting there will probably be fraught with considerable error before it can provide a better approach for medical research….
From the many contributors to this discussion, one learns to appreciate—as did William James, from whom we still have much to learn—that epistemologies that seem illogical and irreconcilable with normative science may nonetheless work. The question at hand is not only whether conventional and unconventional therapies can stand on their own self-authenticating authority, but whether it is possible to modify the context of these two opposing camps into something both can benefit from sharing. To date, there is no hard-wired connection, but the bridge between them is nowhere as long nor the chasm beneath them as deep as they once appeared.