Journal of the Neuromusculoskeletal System 1998 (Oct 23); 6 (3)
Craig F. Nelson, D.C.,
Center for Clinical Studies,
Northwestern College of Chiropractic,
Bloomington, Minnesota
This article is republished exclusively @ Chiro.Org by permission of Data Trace Publishing Co, publishers of JNMS. A special thanks to Sheryl Baum of Data Trace and to Ryan Evans for creating a scanned copy
for our use. Check out their website @ Data Trace Publishing
The increased popularity and acceptance of alternative
health-care (AHC) have been well-documented [1–5]. While there is little
doubt as to the reality of the AHC phenomenon, there is
considerable uncertainty and disagreement over its meaning and
significance. For some, the phenomenon is celebrated as the
dawning of a new era in health care, while skeptics are appalled
by what they perceive to be either a craven effort to cash in on
a credulous public's appetite for New Age bunk, or simply the
abandonment of reason. Within the medical community, the debate
continues whether it is possible or desirable to integrate
alternative practices within mainstream medicine or whether the
only principled action is to oppose, discredit, and eliminate
these practices.
The chiropractic community has tended to view the boom in
alternative health care as an unqualified blessing for the
profession. Chiropractic views the AHC phenomenon as vindication
of its own principles, as evidence of the vulnerability-of
medicine, and as a sure guarantee for the future growth of the
profession. There is the assumption that the current upward
trajectory of AHC will persist and even accelerate in the future.
However, any calculation as to the ultimate status of AHC within
the health care system and how this may affect the chiropractic
profession's role within that system must proceed from an
analysis and understanding of the actual meaning of the AHC
phenomenon. Such analyses have largely been absent. It is also
difficult to study this phenomenon without activating a variety
of professional jealousies and interests. Turf is at stake always
a complicating factor. This article is an attempt to clarify the
issues.
THE NEW AGE IS NOT UPON US
It is first useful to ask in what sense AHC is
alternative. Alternative to what? It is not necessarily
alternative to medicine. Some of the most prominent
advocates/theorists of the alternative health care movement are
medical physicians, and there are many instances of alternative
therapies being used by medical physicians in medical settings.
What does set AHC apart are the metaphysical belief systems upon
which most are predicated. Most systems propose novel physical or
biological laws, or the existence of as yet undiscovered forces:
chiropractic has its innate Intelligence and subluxations,
acupuncture has its meridians and chi, and homeopathy has its
laws of infinitesimals and similars. Alternative status derives
principally from these beliefs and the means by which they are
conceived and examined alternative, therefore, to the
conventions of the scientific method, and to the orthodox
understanding of the nature of health and disease.
For many advocates and patients it is precisely the
metaphysical components of these practices, even beyond any
tangible health benefits, that are the most appealing. There is
an overt anti-science mentality that pervades the phenomenon.
Some believe, in fact, that what we are seeing is the emergence
of a new way of understanding the world a rejection of what is
often called the Western, linear, Newtonian point of view, in
favor of a postmodern relativism that asserts that all points of
view are equally valid. The study by Astin found that it is not
dissatisfaction with medical care that drives utilization of
alternative care; rather, it is what he terms "philosophical
congruence" between patient and practitioner [6]. Specifically,
persons who are categorized as "cultural creatives" are those
most likely to utilize alternative health care. This group is
characterized by, among other things, an affinity for "exotic
forms of spirituality and personal growth psychology . . . and a
love of the foreign and exotic."
This group of cultural creatives, both patients and
practitioners, should not feel vindicated by the apparent
successes of alternative health care. In spite of its popularity
with the public, its growing acceptance by medicine, and the
evidence of effectiveness of some alternative therapies for
certain complaints, there is no reason to believe we have entered
the New Age. This newfound respectability should not be
interpreted as validation of the exotic metaphysics upon which
many AHC systems are predicated, and for which many patients feel
an attraction. Indeed, even as a therapy like spinal manipulation
gains credibility, the original doctrine that once was used to
rationalize its use becomes less plausible than ever.
It is often reported in the popular press that mainstream
scientists themselves have come to accept many of the tenets of
AHC. For example, a recent meta-analysis on homeopathy clinical
trials concluded that the effects seen in these trials could not
be accounted for by chance or placebo effects. This study,
published in the prestigious journal Lancet, is often
cited as an example of the scientific acceptance of AHC
principles. However, in two accompanying editorials, the authors
of the study concluded that publication bias, methodological
errors, and other unknown biases were more likely to account for
the observed effects than was actual homeopathic treatment
effects [7–9]. The authors concluded, "scientists are likely to
remain doubtful [of the validity of positive findings] unless
plausible mechanisms are discovered."
There is no study, observation, set of facts, or emerging
understanding of health and disease associated with AHC that
should cause anyone to question the well-established principles
and methods of scientific inquiry. There is to date no clinical
finding associated with alternative therapies that is
incompatible with conventional scientific beliefs. The scientific
method that eliminated smallpox, controlled diabetes, and
extended our lives by decades remains valid, and is the only
method that is likely to extend those accomplishments in the
future.
It is worth noting that the current zeitgeist that has
given
rise to the AHC phenomenon and the cultural creatives who utilize
its services is not unique in American history. There has always
been a strong appeal for vitalistic and naturalistic healing
methods within American culture and this appeal has waxed and
waned throughout our history. Indeed, it was during one such
cyclic upswing over a century ago that the chiropractic and
osteopathic professions were born [10, 11].
NOT ALL ARE EQUAL
With regard to the belief systems that define many AHC
practices, an important distinction must be made. While most
alternative systems are predicated upon beliefs that are
incompatible with accepted physical and biological laws, some do
not require an acceptance of those beliefs to imagine how
they might have therapeutic effects. For example, the
chiropractic profession was founded on the idea that there are
certain life forces coursing through the body which are impeded
by spinal misalignments, thereby causing disease. This belief is
still held by many in the profession.
However, it is not necessary to believe this in
order
to imagine or understand how spinal manipulation might be an
effective therapy for certain conditions. It is entirely possible
to develop a rationale for the use of spinal manipulation in
terms which are wholly consistent with a conventional
understanding of anatomy and physiology [12, 13]. Similarly,
acupuncture, massage, and herbal medicine all carry with them
belief systems that are at odds with conventional science, but
which are also not necessary to explain their effects.
Acupuncture can be understood as a neurologic phenomenon, massage
as a physical modality like many others, and herbal medicine as
pharmacology.
The same cannot be said of homeopathy, for example.
Homeopathic preparations, after the dilutions that are considered
essential to their effectiveness, may contain zero molecules of
the active agent. These preparations are pure (hopefully) water
and ethanol. It is hypothesized by believers that the missing
agent has somehow passed some of its essence or resonance to the
remaining water. Thus one must believe in some sort of "energized
water" theory to sustain a belief in the effectiveness of
homeopathy. Anyone considering the question might wonder why
every glass of water that is drunk is not homeopathically active
in some way. Surely, serendipitous dilutions are occurring all
the time.
There are many other alternative systems of therapy
(crystal
therapy, energy healing, aura therapy) whose acceptance requires
a similar suspension of one's critical faculties, and there is no
evidence that doing so will result in a greater understanding of
health and disease. Those practices that require the
invocation of new physical laws, or undiscovered forces, may
reasonably and fairly be dismissed until such time as evidence of
these revelations emerges. The principle that extraordinary
claims require extraordinary proof remains valid and relevant
vis-a-vis alternative health care.
THE BIOPSYCHOSOCIAL MODEL
If one accepts that the metaphysical aspects of AHC do not
represent an advance in our understanding of health and disease,
what value could they have? Whether an alternative health care
system is scientifically plausible and whether that system
provides a needed and valuable service to persons with health
problems are not the same questions. Twenty years ago
psychiatrist George Engel, M.D., writing in the journal
Science, proposed a revision to what he called the
"biomedical" model of disease [14]. This model assumes that a
disease state can be fully understood in terms of deviations from
physiologic or anatomic norms. The role of the physician, then,
is to restore these biologic variables to normal values. Engel
argues that while this model has been enormously successful in
numerous and obvious ways, it provides an incomplete
understanding of disease processes. It does not account for, or
recognize the importance of, behavioral, psychologic, or social
factors in how patients experience disease and illness, or how
these factors may be modified to promote patients' recoveries.
Engel concludes that a "biopsychosocial" model more accurately
describes disease processes and provides for potentially more
effective intervention. Both critics and advocates of alternative
health care have failed to take into account this biopsychosocial
model when assessing the role and value of alternative health
care.
A frequent criticism of alternative therapies is that any
improvement that patients may experience is wholly the product of
placebo effects, and thus of no real value. This reflects the
biomedical purists' understanding of disease which equates
placebo effects with a sham treatment. There remains the
conviction among many in medicine that any therapeutic effect
that cannot be defined biologically is the product of a gullible
patient and a deceitful practitioner. But Engel's formulation
implies that it is entirely proper and necessary to provide
therapies that maximize these extrabiologic effects. Others have
also rejected the notion that to administer a placebo is the same
as doing nothing, or worse, committing a fraud [15]. While it
might strike some as an exercise in euphemism and obfuscation,
the use of the term nonspecific treatment effect, rather
than placebo, represents a more nuanced and complete
understanding of this phenomenon.
The limitations of the biomedical model are clearly seen
when
studying low back pain. In the absence of any gross anatomic
lesion, there is not a great deal that can be meaningfully said
about the causes, prevention, and treatment of low back pain that
conforms with the biomedical model [16]. Several decades of
research have failed to identify any important physical factors
(posture, strength, type of injury, degree of degenerative
changes, etc.) that predict the occurrence, affect the prognosis,
or define what treatment regimen will be most effective for low
back pain. A recent study on the effects of a back pain
prevention program based on sound biomechanical principles failed
to show any benefits from such a program [17]. Neither has the
chiropractic profession been able to demonstrate that properties
of vertebral alignment or misalignment are related to the
phenomenon of back pain. To date, the most important variable
identified as a predictor of back disability is not a physical,
but a social variable: job satisfaction [18]. While there may yet
be important undiscovered physical principles that explain back
pain, it is clear that to ignore the psychosocial component is to
limit the potential improvements that can be made in managing
this problem.
It is also evident that even when physical causes are
obvious,
extra-biologic factors remain important. Every disease process,
particularly chronic disease, is accompanied by a functional or
reactive component to that process: fear, loss of control,
anxiety, behavioral changes, and generalized suffering. The
degree of suffering or loss of function a person experiences as
the result of a physical illness is not in direct proportion to
the degree of the physical complaint. These reactions create
patient needs which are independent of the pathologic changes
which initiated the process. Alternative care is sometimes
criticized for doing nothing other than addressing this component
of illness. But these needs are real and legitimate, and in many
clinical circumstances there may be nothing else to do except to
address this component of the patient's illness. To the extent
that medicine fails to value this type of care, and to the extent
that medicine views its role primarily as that of "lesion
management," it will fail to meet many patients' needs and these
patients will inevitably turn to others.
THE AHC FALLACY
Engel's criticism of the biomedical model has been seized
upon by AHC advocates and interpreted as an invitation to reject
the methods and conclusions of biomedical science and to invoke
their own metaphysics as explanations for health and disease.
While critics of AHC-may fail to appreciate the value of
addressing the psychosocial component of disease, its advocates
often fail to recognize that these factors may be responsible for
patient improvement. The failure to recognize the role of
psychosocial factors in their patients' improvement leads
alternative practitioners to the erroneous conclusion that this
improvement is evidence of the validity of their underlying
theoretical constructs.
Thus AHC has turned Engel's analysis upside down. It has
replaced the biomedical model not with the biopsychosocial model,
but with a biochiropractic, bioayurvedic, or biohomeopathic
model, whereby biologic effects are presumed to result via the
hypothesized mechanisms that define these alternative systems. In
this way AElC repeats the same reductionist error as medicine and
in a far less convincing manner.
The alternative care movement also frequently distorts the
meaning and significance of the role of the mind or psyche in
disease. Engel's observation that psychologic factors are
important in understanding disease processes does not imply that
the mind can be used as a therapeutic tool. Many AHC practices
are predicated on the belief that thoughts, feelings, emotions,
and mental imagery can be used to directly influence and correct
aberrant biologic functions. The belief that tumors can be made
to shrink, immune systems made whole, and cardiovascular disease
reversed through cognitive or meditative effort is not a logical
corollary of the biopsychosocial model and these effects remain
undemonstrated.
In a curious way, both ends of the spectrum of belief in
alternative health care converge and stumble over their
understanding and appreciation of the biopsychosocial model.
Neither the skeptics nor the advocates appear comfortable with
the conclusion that patients may experience substantial benefits
from AHC that are not derived from changes in any biologic
variables or that it is a valid end in itself to promote patient
well-being via psychosocial mechanisms.
SAFETY
Much of the anxiety expressed by skeptics regarding
alternative therapies concerns the question of safety. These
therapies, many of them being untested and unregulated, may be
hazardous. There are abundant anecdotes and case reports of
AHC-related mishaps, most of them resulting from vitamin toxicity
or contaminated herbal preparations. There is little doubt,
particularly with respect to the nutritional and herbal
supplements, that these practices are not as safe as they could
be, and that some sort of standardization and regulation could
eliminate most adverse incidents. If herbal or botanical
preparations do have beneficial biologic effects, it is only
because they contain pharmacologically active ingredients (i.e.,
drugs) and the fact that they are in some respect "natural" in no
way ensures that they are safe. A recent series of papers and
editorial comment in the New England Journal of Medicine
has highlighted this problem [19–21].
But even with this shortcoming in mind, the alarm and
apprehension expressed by many concerning the safety of AHC seems
unwarranted. By their very natures, which are largely
conservative, noninvasive, or even inactive, alternative
therapies tend to be intrinsically safe. The evidence regarding
spinal manipulation, the most aggressive and potentially
hazardous of the alternative therapies, indicates a more than
acceptable level of safety, particularly when compared to other
treatment options [22–24].
Critics also raise the safety issue by suggesting that
alternative health care may cause "indirect toxicity" whereby
patients postpone or abandon effective medical care in favor of
ineffective, if innocuous, alternative care [25]. The Eisenberg
study on unconventional medicine does not support this argument
[1]. In this study, only 4% of respondents with a medical
condition who used unconventional therapy did so without also
seeing a medical physician. There were no examples (out of 1,539
respondents) of patients using unconventional therapy, but not a
medical doctor, for the treatment of cancer, diabetes, lung
problems, skin problems, high blood pressure, urinary problems,
or dental problems. The survey found that by far the most common
reasons for utilizing unconventional medicine were for conditions
(back pain, headache, anxiety, sprains or strains) which are very
unlikely to represent a serious underlying condition.
There is no evidence that patients are abandoning safe and
efective medical care for unproven and hazardous alternative
practices. In fact, the inherent benign and safe nature of AHC is
a principal attraction for patients. They correctly perceive
these treatments as being less likely to do harm than medicine.
Suggestions of systematic and pervasive threats to public health
and safety remain undemonstrated.
CONCLUSION
There has always been an active and vocal movement within
medicine and its allied sciences to expose the shortcomings of
alternative health care. The debunking of pseudoscience and the
effort to protect the public from harmful practices are
legitimate and honorable enterprises. However, the impulse to
deplore any health care practice which does not conform to
established scientific principles should be tempered by several
considerations:
The unorthodox theories that characterize many AHC
practices may obscure valuable therapeutic modalities. It is easy
to become distracted by the implausible conjectures of some
alternative systems, but the proper question to ask is not
whether the theories make sense, but whether the practices
themselves make sense. Those practices for which plausible
mechanisms can be hypothesized should be investigated, and
embraced or rejected as the evidence dictates. The scientific
attitude toward those practices should be one of ruthless and
rigid skepticism. There is no rationale for holding AHC to a
different scientific standard or to employ different methodology
in its study than is conventionally used [26]. But if neither
theory nor practice can be made to conform to some reasonable
understanding of physical laws, there is no obligation,
scientific or otherwise, to expend effort or expense in their
study. In such cases, the burden of proof lies with the advocates
of those AHC systems.
Patients' needs may extend beyond the resolution of
specific lesions or pathologies. And these needs are sometimes
effectively met by alternative practitioners. The existence of
extra-biologic factors in the etiology and resolution of the
disease state does not, of course, suggest the inevitable
efficacy of alternative health care practices. AHC practices may
also be ineffective in addressing these factors, but there is
clearly something to be learned from alternative health care
about the psychology of health and disease which all health care
practitioners might profitably adopt for their own use.
The promotion of scientific literacy should not be
confused
with patient care. Promoting scientific literacy is a noble
endeavor, but a physician's office is not the proper place to
pursue this objective. A fierce rationalism is not necessarily a
patient's only proper response to a health crisis. Unless some
harm is likely to result, patients' best interests may be served
by listening attentively and nonjudgmentally as they describe a
belief about their health that is at odds with one's own. If a
patient reported that he felt much better after having his auras
balanced, what would be accomplished by confronting this
perception other than to prove that the physician is smarter than
he? It is not inevitably true that scientifically naive beliefs
about health and disease result in harm to patients.
The standard of comparison should not be perfection.
Critiques of alternative health care should not proceed from the
assumption that in utilizing alternative health care patients are
abandoning a perfectly ordered, intrinsically safe, and
predictably effective medical health care system. It is too easy
to document the uncertainty of medical outcomes, the degree to
which medical decisions are guided by economic self-interest, and
the harm which routinely results from conventional medical care
to make this assumption credible.
At the same time, uncritical acceptance of alternative
health
care should also be tempered:
The recent enthusiasm for AHC is largely a cultural
rather
than a scientific phenomenon. While in the short term this
cultural shift may provide some new opportunities for the
chiropractic profession and others, the public's present
fascination with AHC will have little effect on the long-term
vitality and growth of our profession. The pendulum will likely
swing (and this may already have begun) away from the current
fashionability of AHC.
A far more important and durable trend than the current
cyclic upswing in AHC is the recognition that health care
providers must be held accountable for the safety and
effectiveness of their practices. Orthodox methods of
investigation and research will be the basis by which those
practices are evaluated. The label, "alternative health care,"
will not excuse any profession from the requirement to
demonstrate safety and effectiveness.
The chiropractic profession occupies a position midway
between
mainstream and alternative health care; it is the most orthodox
of the alternative systems. This position can be exploited to the
advantage of both the profession and the public if the strengths
and weaknesses of these two polarities are fully and rationally
assessed.
Received, September
24, 1998
Revised, October 21, 1998
Accepted, October 23, 1998
Reprint requests: Craig F. Nelson, Northwestern College
of Chiropractic, 2501 W. 84th St., Bloomington, MN 55431.
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