CONFUSED AND DISAPPOINTINGLY SHORT
ON DETAILS
Confused and disappointingly
short on details
Sir,
This article by Maizes and Caspi
[1] is thought-provoking, but disappointing. It does not fulfil the stated
aims of its title unveiling very few principles underpinning CAM or
integrative medicine, about which it is solemnly short on detail; nor does
it examine the true challenges integrated medicine represents. By briefly
and wistfully alluding to certain ideas, and raising expectations, it then
fails to deliver, seeming a short and shoddy article on the basis that
this subject requires a longer and more detailed treatment. I would like
to explore what these principles and challenges really are.
As a starting point, the article
quite rightly focuses upon a crucial and often overlooked point when it
states that “central to integrative medicine is the bodys
innate ability to heal,” [1], and when it adds that “healing
is believed to originate within the patient rather than the
physician,” [1]. These two statements very clearly demarcate all
CAM modalities from allopathy, because allopathy, as a pro-active agent,
mostly focuses upon invasively nullifying illness and removing symptoms.
This is what Maizes and Caspi call “the fixing paradigm,”
[1], while CAM modalities mostly behave more passively in enlisting,
encouraging and boosting the bodys innate healing powers. This division
should inspire deeper reflection, which can invoke the realisation that
this is an absolutely fundamental difference in their philosophy and in
the practical application of their respective approaches to patients.
Conventional medicine has a lot
to say about disease and has created very sophisticated knowledge about
it, but, it enjoys only a hazy grasp of the notion of health, where it
comes from and those agents that assist and encourage the bodys innate
healing powers. Allopaths today are probably even more painfully ignorant
of such matters than physicians of the 19th century. Most
clinicians deny the existence of any innate healing powers, or vital
force, what Hippocrates called physis, Paracelsus called alchemy, van
Helmonts Archeus or Stahls anima. The viewpoint Maizes and Caspi
express, implies that greater knowledge of the bodys innate healing
powers could equip conventional physicians with a much clearer
understanding of what the CAM modalities seek to achieve, and how they
work.
Likewise, CAM dwells a lot upon
the notion of healing, but it does not speak so much about disease as an
invading entity. The article could have more sharply emphasised these
pretty basic divisions. In allopathy, sickness is very much seen as a
distinct entity that arrives and takes up residence in the body for a
certain time. Largely ignorant of ANY healing principles, it then seeks
and adopts any measures it can muster to expel this unwanted alien
invader. CAM, by contrast, regards disease as a natural, though
temporary, derangement of the organism, a “dynamic derangement of
the life force,” [2; 37-8, 74], that must be contemplated in its
totality, comprehended in terms of the wider life of the patient, and then
gently corrected according to clear principles by enhancing the innate
healing powers. It is not viewed or treated as an externally invading
entity that must be driven out by force or cut out. Clearly, the
difference in conception between an alien invader and a natural
derangement is huge. It is this difference that most sharply portrays
the major difference between the two medical traditions in practice
and in principles.
When Maizes and Caspi wisely
quote Osler that “it is much more important to know what sort of
patient has a disease than what sort of disease a patient has,”
[1], then they could have probed deeper into the historical basis of this
quote, for it illuminates much that their article has disappointingly left
hidden. While science places similar things together in one category, it
also separates different categories from one another. This is basic and
happens in all sciences:
“The proper aim of the
sciences is to note the number of similarities in the behaviour of objects
and to construct propositions
”
[3; 21]
“
to bring out what is
specific, unique, in a given character or series of events
respects in
which it differs from everything
[and] conveys the unique pattern of
experience.” [3; 22]
However, since the time of
Sydenham [1624-89], medicine has mostly sought to classify and separate
diseases on the basis of defining broadly similar symptom patterns, which
define the disease. The CAM modalities, by contrast, mostly concentrate
upon each patient as an individual. Sydenham formulated a classification
of disease based upon multiple cases, thus giving credence to the view
that a disease was a real entity separate from the patient [4; 230]
and infecting various individuals as circumstance might dictate. This in
turn gave support to the notion that diseases are really external
entities that invade patients, being “independent of the
sufferer,” [4; 230] [5] and causing broadly similar symptoms in
them all.
He thus spawned the idea that
disease is separate from the patient, rather than an aspect of his total
life, and that it should be viewed as an entity in itself, which is a
clear separation of the disease from the patient as “clear
and distinct entities ripe for taxonomy,” [4; 307]. Sydenham also
devoted himself “enthusiastically to the differentiation of
specific disorders,” [6; 12-13]. He was among the first to see an
ongoing similarity between different cases: “Where the ancients
had seen an inseparable connection between the patient and his malady,
Sydenham saw in the patient certain pathological symptoms which he had
observed in others and expected to see again…he distinguished between
the sick man and the illness, and objectified the latter as a thing in
itself. This was a new outlook, an ontological conception of the nature of
disease which was eventually to prove of the utmost significance,”
[6; 13]. This attitude has since become such a pervasive assumption that
most clinicians are even oblivious that it underpins the accepted
allopathic approach.
Thus, we can discern two very
different impulses at work. One looks to large groups or whole populations
to emphasise those similarities that define a disease as a distinct
entity that affects each patient in the same way. The other looks at each
patient and defines their specific problem as a deviation from the
totality of their normal health. One globalises and the other
individualises. How different could this be?
For example, the homeopathic view
of measles [which Sydenham had been the first to differentiate from
Scarlet Fever] is like its view of any other medical condition treat
the patient NOT the disease and all is well. Usually this means remedies
like Pulsatilla and Rhus tox. or maybe Belladonna if there is much fever
and redness. Such drugs correspond to the broad totality of symptoms of
most cases of measles which is then fine-tuned for each case. This
approach is fundamentally different from allopathy instead of doing
what Sydenham set in motion grouping similar cases together into a
grand class of condition and giving it a name and then devising
treatment en masse homeopathy matches a specific drug solely to the
idiosyncrasy of each individual case it looks at differences between
cases that make each case unique the very opposite of allopathy which
does the reverse. It differentiates, rather than globalises; separates
rather than places together. This is a profound difference in approach.
This article therefore opens up
many avenues of ideas, which, for the uninformed reader it then leaves high
and dry as dismally unexplored conceptual cul-de-sacs. For example, it
talks of a “sense of wholeness,” [1], but does not
explain what this might be. It talks of “the principles of
integrative medicine,” [1], but declines to reveal clearly what
they actually are. It alludes to “prevention as a means of
enhancing health and well-being,” [1], but fails to give the
reader more detail. It emphasises the importance of “stress and
coping strategies,” [1] but fails to say why these are so crucial
to the innate healing powers. It claims the “therapeutic
relationship facilitates healing,” [1], but says precious little
on how or why this might be. It alludes to “breathing exercises
and self-hypnosis,” [1], but does not satisfy the readers
curiosity on how these might be employed. It claims “the patients
spiritual life
[is] critical to promoting health,” [1], but,
once again, fails to say why this should be so. It grandiosely claims that
“integrative medicine assists the practitioner
in taking a
holistic approach,” [1], but fails to give us more details. The
article is therefore disappointingly short on details. Indeed, it gives
the impression of merely setting the mouth watering for further juicy
morsels that it cannot or will not supply. It prefers to tease the reader
and keep them guessing.
In fact, the article says
precious little about true healing principles. Though it does mention the
importance of a vital healing principle, yet, it somehow manages to
successfully evade the other two main principles of holistic therapies
that inevitably flow from its own philosophical orientation that, what
evidence it uses must be based on the totality of organism function and
that it always individualises rather than globalises. Once these are
thoroughly understood, then Yameys own question [8] can be answered in
the negative CAM can NEVER be evidence-based in the same sense as
scientific medicine, which, like Sydenham, always globalises rather than
individualises, which is entirely reductionistic in its approach, and
entirely oblivious to the concept of totality. Indeed, so profound is
their ignorance of the organism that most clinicians pour scorn upon the
very ideas of holism or vitalism, frequently deriding both as a trendy
pretence. These two healing traditions are therefore genuinely and
irreconcilably rooted in quite opposing philosophical views of the
organism in health and in disease.
Furthermore, any sober and
even-handed comparison of holistic and reductionistic medical paradigms is
bound to conclude that the latter is always a simplistic, artificial
abstraction superimposed upon complex life phenomena for convenience.
Sydenhams conception of disease is fundamentally flawed, because
diseases do not elicit the same symptoms in all patients, nor do they
confine themselves to the specific time or space limitations in the life
of the organism as would be expected by such definitions. To believe this
is to stubbornly and blindly adhere to the tidy categories imposed upon
reality by disease taxonomists. The global view is thus flawed – some
individualisation of treatment is essential in all medicine. The holistic
view is a superior model precisely because it matches real life phenomena
more closely a disease can genuinely be defined by the totality of the
mind-body symptoms that it manifests. No other definition is as valid and
the globalised definition of broadly based grouped symptoms supplies a
clearly inferior model.
Once you begin to appreciate that
diseases are not distinct entities tightly located in space and time, as
runs the currently unchallenged dogma, and nor is their removal by drugs
and surgery a true cure, then the contention of homeopaths that allopathy
merely suppresses symptoms for a time, which can then re-manifest as a new
disease in other organ systems at a later date becomes truly credible.
Such a contention is perfectly consistent with the holistic view of the
organism. Therefore also, statistically defined global averages and RCT
have only an illusory value for assessing treatment methods and patient
outcomes. Flowing from all these considerations are the real challenges
Maizes and Caspi fail to examine. How do you realistically compare methods
and outcomes where there is little or no agreement on how to define a
disease, as distinct from a patient, and in which one only treats
individuals and the other treats whole populations on the basis of global
averages of pooled data? Common conceptual ground? There is none!
When the acupuncturist says
disease is due to an imbalance in the energies flowing in the meridians,
they are making a certain conception of the disease process, which their
treatment then seeks to adjust. It is not necessarily an incorrect
conception, merely a different one from that of the bacteriologist.
Likewise, when the homeopath calls disease primarily a derangement of
the life force, echoing in this sentiment Stahl’s animism. Or, when the
naturopath conceives disease to be a product of toxins, which fasting and
enemas will eliminate, he comes close to the sentiment that “disease
is not an entity…but is only the organic and functional forces, or
powers of life, modified by perversion of activity
remedies are relative
agents…they only act curatively by a judicious application to the
individual case in hand. Individualism, not universalism, attaches
therefore to all our therapeutic measures.” [7]
Such is still a valid sentiment.
These are all different apprehensions of the disease process due to
different modes of medical conception. All are equally belief-driven or
theory-dominated, but each stems from a very different mode of conception
of what is nevertheless the same disease process. They might well be seen
as different blind men describing the same elephant!
CAM is manifestly not “antiscientific,”
[8] or “grounded in unproven narrative,” [8], as Yamey
contends, nor does it consist of “practices based on anecdote,”
[8]; rather, it is rooted in a long tradition of successfully employing a
fundamentally different view of the organism. Reproducibility is not “the
very antithesis of CAM,” [8], but it is hard to see how CAM will
ever be able to deliver evidence in the precise language and packaging
that science demands. In their apprehension of the organism and disease,
the languages they speak and the corrective measures they devise, they
each spring from wholly different world views. Maizes and Caspi are right
in saying that the future lies in ingeniously integrating the best of both
for the benefit of patients, but it is going to be a long hard road to
travel. But as the Chinese say, we live in interesting times.
Sources
[1] V Maizes and O
Caspi, The principles and challenges of integrative medicine, West J Med
Sept 1999 171: 148-149
http://www.ewjm.com/content/vol171/issue3/
[2] Close, Stuart, The
Genius of Homeopathy, Lectures and Essays on Homeopathic Philosophy, New
York, 1924
[3] Berlin, Isaiah, The
Sense of Reality – Studies in Ideas and Their History, Pimlico, London,
1996
[4] Porter, Roy, For the
Benefit of All Mankind – a medical history of humanity, Norton New York,
1998
[5] Keele, K D, The
Sydenham-Boyle theory of morbific particles, Med Hist,1974 Jul; 18 (3):
240-8
[6] Richard H Shryock,
The Development of Modern Medicine, Philadelphia: Univ. Pennsylvania
Press, 1936
[7] John P Harrison,
Notes on Empiricism, Western Lancet and Hospital Reporter, 8, 1848, 122,
quoted in John H Warner, 1986, The Therapeutic Perspective – Medical
Practice, Knowledge and Identity in America 1820-1885, Harvard Univ.
Press, USA, 63
[8] G Yamey, Can
Complementary Medicine be evidence-based? eWJM 2000; 173: 4-5
http://www.ewjm.com/cgi/content/full/173/1/4