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HEALTH ETHICS TODAY
Alternative
Knowledges, Alternative Healing: What Justifies the Label "Standard"? Laura Shanner, Ph.D. The words 'standard' and 'alternative' are funny things. We might expect 'standard' to provide a solid reference point, but "standard treatments" vary widely over time and across different cultures. Meanwhile, the words 'complementary' and 'alternative' are meaningless except in reference to something taken as standard. In common North American usage, "standard" often implies that the treatment has been scientifically validated, despite many obvious exceptions. Can science and theories of knowledge shed any light on these categories? I deeply value the scientific method, and I seek the best possible evidence of safety and effectiveness. However, science has its limits both theoretically as a source of knowledge, and also practically as the result of human choice and fallibility. SCIENCE AS A SOURCE OF KNOWLEDGE There are two very different approaches to learning about the scientific method. In science classes, students learn how to employ the scientific method to solve problems. In philosophy classes, students reflect upon the scientific method as one of several mechanisms of gaining knowledge; others include deductive proof, intuition and sensory perception. In science classes, the validity of the scientific method is without doubt; while some limitations in technique are noted, confidence reigns that the method will eventually, systematically, uncover all that is true. The philosopher observes that the only indubitable method of gaining knowledge is to apply deductive logic to true assumptions; this is the process followed in mathematics, but not experimental science. Although one of our better forms of gaining knowledge, the scientific method contains a significant flaw: it is inductive rather than deductive. That is, the hypothesis testing method intuits conclusions after observing several cases rather than deducing specific conclusions from known truths. These inductive conclusions then become assumptions that ground future hypotheses and study designs. Accordingly, the scientific method can make mistakes by failing to observe enough cases of sufficient diversity before drawing conclusions; by hypothesizing from assumptions that turn out not to be true, or simply by choosing the wrong conclusion from several that might explain the data. The limitations of the scientific method open the door to frequent revision of what we claim to know: "butter is bad for you, eat margarine"; "no, margarine is worse for you than butter"; "no, butter is bad, eat olive oil." Sometimes the revisions to our scientific knowledge base are massive, overturning not just a few details but the entire framework within which we comprehend a phenomenon. Most scientific activity is conducted within an established set of assumptions, data sets and methods, with the goal of adding incremental bits of information to the accepted overall picture. Thomas Kuhn called this framework a paradigm1. Sometimes, however, new data are so incongruous with the existing paradigm that they throw the entire field of inquiry into question; such data might emerge when new technology allows observation of previously inaccessible phenomena, or creative new methods or assumptions might refocus attention to unnoticed data that existed all along. At other times, a new theory may unseat long-held paradigms; Einstein's theory of relativity had this effect on classical physics. These paradigm shifts, as Kuhn called them, enable genuine progress within science; they allow us to abandon incomplete or misguided paradigms, while the standard model of incremental discoveries merely builds upon frameworks that may be insufficient. SHIFTING PARADIGMS Central to most distinctions of "standard" and "alternative" therapies are assumptions about how the body works, what causes diseases or symptoms, and how interventions might work upon the body. Changing any of these assumptions, or perhaps adding to or deleting from the list of possible explanations, changes the treatment landscape quickly. Once again, I do not endorse any specific treatment approach; I am simply asking why certain possibilities are so often rejected out of hand by various practitioners. Standard western medicine focuses on physics and chemistry, but only of certain types. For example, anything swallowed, inhaled or absorbed dermally involves chemistry, regardless of whether the chemical is a pharmaceutical, an herbal, an environmental toxin, an aromatherapy oil, a nutritional supplement or a component of food. Extensive medical training focuses on pharmaceuticals and, to a limited extent, the role of toxic exposures in conditions such as cancer, birth defects and acute poisoning. Very little attention is paid to nutrition and non-pharmaceutical herbals, while chronic, low-level exposures to chemicals are rarely considered possible culprits for illness. Allergies are recognized, but "chemical sensitivities" are suspect. Why are some examples of chemistry apparently more important than others? Options in physics are even more controversial. "Standard" medicine focuses on the classical physics of blunt trauma and surgical repair, and on molecular physics as revealed in chemistry. Homeopathic preparations are rejected in the "standard" model because they are so diluted that, theoretically, no molecules of the active substance remain in the recommended dose. However, the claimed effect of homeopathy rests on an assumption that water molecules themselves have been changed at an atomic level, not the molecular level, and thus retain a "memory" of contact with the active substance. Since several homeopathic preparations have demonstrated a higher level of effectiveness than a placebo (but not all have tested positively) why is an "atomic memory" effect considered impossible? "Standard" medicine identifies the existence of electromagnetic energy in the body, most notably in muscle twitches and nerve impulses. Diagnostic devices such as EEG's, ECG's, MRI's and others work by tapping electrical and/or magnetic properties of the body, and energy is used therapeutically to start a stopped heart or relax muscles (e.g., with a TENS machine). Oddly, though, "standard" medicine rejects claims that magnets might have therapeutic effects; that energy might flow through acupuncture meridians, or that something like an "aura" might exist, be sensed, or be manipulated. Interestingly, PET scans have recently detected altered brain activity when acupuncture points (but not points off the meridians, mere millimeters away) are stimulated. Why is energy obvious in some forms and unthinkable in others? Perhaps the greatest challenge to science is the realm of metaphysics, which is by definition "beyond physics". Most Canadians (including most scientists and physicians) believe in the existence of a non-material soul that is typically believed to leave the body at the moment of death. Indeed, the claimed existence of a soul -- despite the lack of scientific evidence for its existence -- is central to many clinical decisions not to perform abortions or euthanasia. If there is such a thing as a non-material soul, might the soul's interaction with the body result in illness or healing? Might it be a soul that accounts for the electromagnetic energy identified in the body? If it isn't unreasonable to believe that the soul departs the body at death, then might illness be a partial separation or misalignment of body and soul? The role of the caregiver in creating the effect is also a common point of difference. Most "standard" treatments are considered validated regardless of which reasonably capable practitioner performs them. In several alternative approaches, however, the role of intuition is much greater. The ability to perform acupuncture, for example, may be as much about sensing the patient's energy flow or "feeling" the right acupuncture point as it is memorizing the location of meridian maps and tapping the needle a specified distance. The categories sometimes differ in outcome measures. As physician Howard Brody observed, "sometimes the measurable drives out the important."2 How important is the patient's perception of feeling better, worse, or "not quite right", especially if no objective data confirms the state of affairs? To an "alternative" practitioner, the self-report often opens avenues for relief, even if a more specific cause is not further understood. The patient's perception of feeling better, even if without objectively measured improvement of metabolism or function, is also typically deemed more important in "alternative" approaches. Finally, "standard" approaches focus on a range of normal indicators, but often have a hard time accounting for a specific individual's range of normal. For example, someone whose normal body temperature is at the low end of "normal" may genuinely have a fever despite having a temperature at the high end of "normal". "Alternative" approaches are typically more attuned to "normal for this person" than "normal" across populations. Some of the grounds for a potential paradigm shift in healing approaches thus include the following:
Even without major paradigm shifts, the incremental scientific method faces some important limitations that challenge the common distinction between "standard" science-based treatments and "complementary" non-scientific approaches. Science can only answer the question that is asked. An absence of scientific information thus does not constitute proof or disproof, but merely a gap in inquiry. These limits and gaps take many forms, creating openings for "non-standard" approaches to fill. Several limitations of study design deserve attention to clarify what works and what doesn't.
Women's health (except for reproduction) has traditionally been under-studied, leading to a lack of information about alcohol metabolism, cardiovascular disease, and a host of other processes that were assumed to be identical to those in male bodies3. Genetics and ethnicity sometimes matter, too: for example, the standard dose of lithium for bipolar depression is toxic to some with African ancestry. Pediatrics, adult internal medicine and geriatrics are established medical specialties because so much in our bodies changes with age. What other factors might create differences among individuals that are less well studied?
Randomized clinical trials (RCTs) are considered the gold standard of research. However, most RCTs to establish the safety and efficacy of medications (or the safety of chemical exposures) test fairly high doses for a short period of time. Very little is known about the effects of chronic exposure to medications or small doses of environmental chemicals. Little is known about drug interactions and "chemical soups" rather than exposure to a single chemical. Little is known about the effects of nutrients on drug and chemical metabolism. Most procedures, as well as devices and medications on the market prior to the introduction of drug testing laws, have not been subjected to RCTs at all. How much information does the RCT "gold standard" really offer in the clinical setting?
The selection of the subjects and conditions within a study can influence the results in many different ways. In particular, the isolation of variables creates problems for using the intervention in a messy, complex, less controlled environment. People selected as study subjects typically receive excellent diagnosis and present with few complications beyond the condition being studied. In the general population, multiple and undiagnosed conditions may confound the use of an intervention. Study subjects are also more carefully monitored and tend to have greater contact with care providers. This might result in overly positive outcomes that cannot be expected in regular practice with less contact, or intrusive monitoring might create additional stress that undermines an otherwise effective treatment. Some effects might be easier to achieve if common barriers and confounding factors are removed, while other effects may be harder to achieve without certain reinforcing factors. Do results obtained with limited variables accurately reflect the phenomenon in a complex reality? CONCLUSIONS All healing approaches seek similar goods: to relieve suffering, to improve function and, when possible, to cure illness or disability. No matter which techniques we employ, patients and society at large have consistent interests in safe, effective and cost-effective interventions. Practitioners should therefore be monitored, and techniques subject to continuing research, across all disciplines and therapeutic approaches. I end this reflection with as many questions as ever. I think we are on the brink of a revolution in our understandings of bodies and healing, in which the lines between "standard" and "alternative" approaches will shift. The possibility of a paradigm shift that will make us reconsider many taken-for-granted "truths" in the search for greater genuine knowledge. REFERENCES
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Updated September 10, 2010
Health Ethics Today
