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and 'Traditional Practitioners and Practices' should take precedence
- John P Heptonstall (15 January 2000)
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CAM in a cleft stick
- Peter Morrell (16 January 2000)
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Integrated Medicine should be replaced by Pluralistic Medicine, research being paradigm-sensitive
- Wainwright Churchill (16 January 2000)
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Re: Integration or Pluralism
- Peter Morrell (18 January 2000)
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Re: Re: Integration or Pluralism - Clarification
- John P Heptonstall (19 January 2000)
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Re: Clarification
- Peter Morrell (20 January 2000)
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Re: and 'Traditional Practitioners and Practices' should take precedence
- George T Lewith (20 January 2000)
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Re: CAM in a cleft stick
- George T Lewith (20 January 2000)
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Re: Integrated Medicine should be replaced by Pluralistic Medicine, research being paradigm-sensitiv
- George T Lewith (20 January 2000)
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Re: Re: Integration or Pluralism
- George T Lewith (20 January 2000)
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Re: Re: Clarification
- John P Heptonstall (21 January 2000)
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QUESTIONS FOR FIM
- Wainwright Churchill (21 January 2000)
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John P Heptonstall, Director of Morley Acupuncture Clinic and Complementary Therapy Centre West Yorkshire
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I agree that any medicine meted out to our public must be research led and evidence based, not least Western Medicine (WM). The cry for evidence-base in WM reached a high note in the mid 1990s after it was realised that so much of WM lacks an evidence-base (perhaps as much as 80 to 90%). Steps to redress that balance are now underway and the same steps should apply to all Complementary and Alternatiuve Medicines (CAMs). Lewith et al emphasise the crucial point that 'evidence-base' requires research, and research requires much funding. In the USA the good news is that the government has recognised this by realising funding of $50m through the Office of Alternative and Complementary Medicine within the National Institutes of Health (NIH) to provide structure to sustain a concerted research effort is excellent. The bad news may be that the funding could be spent on research that is performed by people with little knowledge and experience of the CAMs they test, with little interest in the philosophy through which the CAM has been successfully provided to the public (which led to the upsurge in public request for the essentially traditional forms of CAMs), and with little interest in it succeeding. The surge in interest for CAMs was generated by the good works of non -medically qualified CAM professionals, not by biochemical medical practitioners. ( Edzard Ernst, Journal of Medical Ethics 1996;22:197-198, 'The ethics of CM'..."In Europe its prevalence ranges from 49% in France to 24% in Denmark....in most countries, however, its practice is dominated by non- medically qualified practitioners. This popularity of CM..."). (Eisenberg et al JAMA 1998 Nov 11;280(18):1569-75; .... .. "Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians...") ...Yet most traditional CAM practitioners are non-medical and therefore are not part of the establishment (academic, biochemical medical and medical research etc.) that is always prepared for, and quick to, appropriate funds by rapidly 'redesigning' their standard protocols to take advantage of the next handout. If your local 'Complementary Medical Centre', serving the local community handsomely for many years, desires a portion of that funding - either by becoming part of the project carried out by a (knowledgeable about research but not about CAMs) 'academia' or by originating its own project, what chance will it have of attracting funding when competing against a 'medicalised academic' centre calling itself a 'Complementary Medicine Research' facility yet paying lip-service to the CAMs it uses funds for? The latter are already active enough to have generated many, often easily criticised and poor quality, research papers on various CAMs, whilst the traditional CAM Practitioner Centres are too busy to respond being employed providing the impetus, through hard work without funding using traditional formulae on real patients and achieving excellent results, that have made CAMs increasingly popular in the Western world. How does one ensure that the money is well spent such that:- 1. it funds research into CAMs which already have a good track record and, if possible, a good research foundation. 2. the aim of the research is to test CAM treatments as they have served their patients successfully, thus have convinced patients to seek CAMs in large numbers, many of which require INDIVIDUALISED diagnostic and prescriptive intervention unlike that seen in Western Medicine. 3. the funds do not fall into the hands of people whose aim is to produce adverse results in order to denigrate CAMs unreasonably. 4. it avoids medical schools when these are not appropriate places for some CAM research to be based. 'Medical' implies biochemical paradigm which cannot be expected to provide a suitably independent or scientific analytical evaluation of some forms of CAM eg. Traditional Chinese Medicine (certain modalities), perhaps Hypnotherapy, Homeopathy, Ayuvedic medicine and others. For example, Exeter University has a centre for CAM studies within the Social Studies Faculty. 5. ideally the research should be directed and controlled by academics or other capable professionals who are completely independent of 'biochemical medicine' yet who have access to expert opinion from all doctrines required for any particular project. Without this one merely gets a complete bias of biochemical medical opinion for research whose end result will be an inferior biochemicalised interpretation of what could have been a most valuable traditional CAM interpretation (as it served its patients). (Franklin Hope, March 21st, 1994 pp1, The Scientist, www.the- scientist.library.upenn.edu/index.html, "according to David Eisenberg, an internist and instructor in medicine at the Beth Israel Hospital and Harvard Medical School, both in Boston....'It would be senseless and, I think, intellectually arrogant to simply look for an active ingredient without taking into account the diagnostic theory with which that herb has been used for a millennium'...and 10 people with a diagnosis of migraine in Western Medicine might fall into 3 or 4 or more treatment categories using what Eisenberg calls the 'pulse and tongue' diagnostic tefhniques of Chinese Medicine"). It is unlikely that medical practitioners will objectively assess CAM research results. (Ernst, Resch, Garrow 'Does Peer Review favor the Conceptual Framework or Orthodox Medicine? A RCT' Int. Congress of Biomedical Peer Review; www.ama -assn.org/public/peer/dost.htm; "Objective: To test the hypothesis that experts who review papers for publication are prejudiced against complementary medicine....Conclusions: Despite a remarkably large within- group variation in both groups, there seems to be a relevant reviewer bias against papers dealing with unconventional medical concepts"). 6. those who assess for research the modalities favoured by CAMs should not be prejudiced against them if they appear unusual when viewed from a biochemical perspective. (eg. Prof. Edzard Ernst, The Skeptic page 6, 'How to Become a Charlatan. A step-by-step guide to becoming a successful fraud'..."Don't try to diagnose diseases by looking at people's eyes, tongues, ears or hands. Too many fellow charlatans are already earning a good living on these options..." Too many Western Medical establishment characters have voiced a desire to see CAMs taken away from the true CAM professionals and repackaged to fit into their own 'scientific' paradigm without, it would appear, any real concern for the loss of the traditional methodology that brought such doctrines so dramatically into the public arena. They hypocritically condone brief learning curves for medical practitioners in CAMs they recognise to be valuable assets to the public - whilst abhoring the thought of similar learning schedules for their own medical paradigm for non-medical people. Courses for CAM modalities such as 'acupuncture' can be bought from 'medical acupuncturists', of one day's duration, for about £200! The content is so sparse that it must be unable to prepare a medical person even to give advice on whether to see an 'acupuncturist' or not let alone treat a person safely and effectively with the modality. (BMJ 316 6 June 1998 News p 1694 'Double standards exist in judging traditional and alternative medicine' by Hilary Bower, London)...Dr Ian Chalmers, the Director of the UK Cochrane Centre and a vociferous proponent of systematic reviews, told delegates at a London conference on integrated medicine which was organised by the Prince of Wales "that the aim should not be to indulge in 'data free' arguments but to find reliable tools to assess the effectiveness and safety of any healthcare intervention, be it orthodox or complementary". The call was backed by the Prince of Wales who, as President of the Foundation for Integrated Medicine, opened the conference "We need to commit ourselves to a rigorous but open minded evaluation of practice in all aspects of health care, and to finding ways of translating ideas into action in the most effective manner".........'for his part the health secretary Frank Dobson , announced that a further £25,000 had been earmarked to continue developing a regulatory framework for complementary and alternative practitioners'.... £25,000?! Kind regards all John H. |
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Peter Morrell, Hon. Research Associate, History of Medicine Staffordshire University
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Sir, It is clearly implicit, in this letter that CAM finds itself at this time in something of a cleft stick or dilemma. It has thusfar failed to attract greater funding from regular research bodies, presumably because it has little or no 'street credibility' within medicine, and is widely regarded as a marginalised medical minority of dubious worth. Yet, it needs much more research funding simply to conduct the basic research that might establish beyond reasonable doubt that it is not dubious, but therapeutically valid. It is an almost 'Catch 22' situation. This dilemma also reflects the fundamental and ancient division within medicine. How can this dilemma be resolved? The basic interest in CAM in society is not led by physicians, nor by university professors, but by patients. As a movement, it is strongly patient-driven and therefore clinicians are passive bystanders to a social process, and somewhat powerless to influence or deviate its progress. All they can beneficially do, perhaps, is to assist its improved acceptance within medicine and create conditions in which it can thrive and gain more research funding. It is difficult to see what else they can do. This letter also asks who is to fund the research that will validate CAM and hence confer upon it greater kudos within medicine. Drug companies would seem disinclined to do so as they have their own agendas and commercial interests to protect, and many within CAM would resist such offers on moral grounds. Universities also, have only limited interest in this field. Government, perhaps, could earmark special grants and awards for this task, at least to get more basic research off the ground; or, they could choose to share funding with drug companies and CAM charities, which have an interest in this field. Some kind of research corporation, that brings such bodies together, might therefore be required. What is baffling about this particular letter is how we might distinguish within it those who are clearly the friends of CAM - most of the signatories - from those like Professor Ernst, whose basic position appears downright skeptical, to frame it at its politest. This also reinforces the point made so ably by John Heptonstall about the real agendas of those who wish to conduct this type of research, let alone whether they are suitably equipped paradigm-wise to do so. It is to be hoped that it is conducted by the friends of CAM, or by neutral parties who have no vested interest in seeing its demise. Peter Morrell |
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Wainwright Churchill, Traditional acupuncturist and Chinese medical herbalist London
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The concept of Integrated Medicine should be replaced by Pluralistic Medicine, with research being paradigm-sensitive. A notable aspect of CAM modalities is that they are practised according to different paradigms from that of conventional medicine, which I shall refer to as biomedicine. As Thomas Kuhn (1996) made clear, each and every paradigm is a world view, based on various assumptions, with different scopes of action and utility. No paradigm can make a legitimate claim towards revealing absolute truth, as the insights and knowledge it yields reflect its assumptions. Because no paradigm reveals absolute knowledge, none can claim to be the authoritative basis with which to judge another. Furthermore, different paradigms are incommensurable, meaning that one cannot be translated to another, just as statements in one language may not be able to be translated into another. For example, Newton's Laws are not simply a special case of Einstein's theories of relativity; 'the physical referents of these Einsteinian concepts [i.e. space, time, and mass] are by no means identical with those of the Newtonian concepts that bear the same name.' (Kuhn, 1996) Not only are paradigms incommensurable, but scientific observation is theory-laden i.e. what is observed is understood and interpreted with reference to the body of theory forming the basis of the research paradigm. How much is that paradigm implicated in one’s results? Quine observed: 'The unit of empirical significance is the whole of science.' (Sokal and Bricmont, 1999, p63) The fact that CAM modalities have their own paradigms, that paradigms are incommensurable, and that observation is theory laden, mean that research into CAM modalities involves complex paradigm and inter-paradigm issues. Any research cannot claim to have absolute truth value. It will reflect paradigmatic assumptions made. There is a strong pressure for research to conform to the biomedical paradigm. The assumption that the process should involve the following steps is often made: 1) Determine whether a CAM modality works 2) If it doesn’t, don’t use it 3) If it does, determine the mechanisms in biomedical terms, so as to as to develop a biomedical framework for its practice 4) Incorporate it into biomedicine, practised with a biomedical framework. In this agenda, the ‘validated’ CAM modalities is transformed from one practised with its own paradigm to one that isn’t. Most often, proponents of Integrated Medicine (sometimes called Integrative Medicine or One Medicine) have this biomedicalisation agenda in mind. This was strongly implied recently by Stephen E. Straus, MD, Director of the US National Institutes of Health’s National Center for Complementary and Alternative Medicine in the article ‘2020 Vision: NIH Heads Foresee the Future’ JAMA, Vol. 282 No. 24, December 22/29, 1999: ‘As a result of rigorous scientific investigation, several therapeutic and preventive modalities currently deemed elements of complementary and alternative medicine will have proven effective. Therefore, by 2020, these interventions will have been incorporated into conventional medical education and practice, and the term "complementary and alternative medicine" will be superseded by the concept of "integrative medicine." ‘The biological and pharmacological basis for effectiveness of selected herbal and nutritional supplements will be clarified, leading to their standardization and to the rational design of yet more potent congeners. Advances in neurobiology will elucidate mechanisms underlying ancient practices such as acupuncture and meditation, as well as the phenomenon of "the placebo effect." ‘…The field of integrative medicine will be seen as providing novel insights and tools for human health, and not as a source of intellectual and philosophical tension that insinuates itself between and among practitioners of the healing arts and their patients.’ In other words, we’ll have CAM taught to and practised by conventional doctors according to the biomedical paradigm, without the intellectual and philosophical tension associated with CAM being practised according to its own paradigms. This biomedicalising research agenda for CAM has been expressed in different ways many times, and is often associated with the idea that CAM paradigms are superstitious. For example, the EU-associated herbal medicine organisation ESCOP had in its webpage mission statement ‘Activities and goals of ESCOP’ [last modified 25/7/96]: ‘The decision of six national scientific associations for phytotherapy and phytomedicines to co-operate under one umbrella may be considered as the first substantial step towards a European context of perhaps the oldest therapy on earth, already in existence for millennia but now freed from superstition and embedded in a reliable, scientific framework.’ Many biomedical researchers assume that CAM paradigms are mystical, invalid in the light of modern knowledge, etc. The granting a favoured position to biomedicine was expressed, for example, by Prof. Ernst in his article "What's the Point?", The Independent, 20 October, 1998, when he mentioned that the existence of Yin and Yang have not been substantiated convincingly by scientific research. This statement makes several mistakes – because of the nature of paradigms, it is incorrect to assume that the scientific paradigm has a privileged truth-yielding value over the Chinese paradigm. Moreover, it involves lack of understanding of the concepts of the Chinese paradigm. Yin and Yang are not things, therefore no amount of scientific research could ever substantiate their existence. They are comparative qualities, like the relative coolness or warmth of two objects – hardly a shocking or peculiar concept. The lack of understanding the original CAM paradigm is a common aspect of biomedical research into CAM, compounding the inadequacy of the research and reinforcing its tendency to biomedicalise the subject. This inadequacy often involves standardised treatments being used when in the CAM discipline each patient is given individualised treatment, so that research is not representative. Also, very little research attempts to explore whether there is a consistency between CAM concepts and clinical efficacy, for example, in acupuncture whether a point such as Stomach 36 tonifies the Spleen/Stomach function in Chinese terms. If it does, that would profoundly validate the use of traditional Chinese acupuncture beyond its use for treating narrowly defined symptoms of illnesses, meaning that much current research is excessively confined in scope, unfortunately in a manner consistent with the intention to biomedicalise the discipline. As a warning to CAM professionals of the biomedicalisation program implicit in the call for research, consider Filshie and White’s comment in their introduction to Medical Acupuncture (1998, p8): "It is hoped that this textbook celebrates the emergence of acupuncture from its mystical, alternative roots and hastens its complete integration into conventional medicine over the next decade." Responsible CAM professionals welcome research into CAM. It is only reasonable that a sick person should want to know whether a medical treatment, involving time commitment and expense, possibly as a substitute for another form of treatment, will help. However, research should be paradigm sensitive. The goal should not be Integrated Medicine meaning expanded biomedicine and hence biomedical appropriation of the original CAM discipline, it should be Pluralistic Medicine. Organisations like the Foundation for Integrated Health that ostensibly promote the responsible use of CAM should recognise the threat that their call for research makes to CAM disciplines as they are actually practised. The first step should be to abandon the concept of Integrated Medicine, and replace it with Pluralistic Medicine, evolving research strategies and programs that fully respect CAM’s original paradigms. References: E. Ernst. "What's the Point?" The Independent, 20 October, 1998. J. Filshie and Adrian White (eds) (1998). Medical Acupuncture - A Western Scientific Approach. Edinburgh. Churchill Livingstone. Thomas Kuhn (1996): The Structure of Scientific Revolutions (Third Edition). London. The University of Chicago Press. A. Sokal and J. Bricmont (1999). Intellectual Impostures. London. Profile Books Ltd. S. E. Straus. Subsection ‘National Center for Complementary and Alternative Medicine’, in Marsha F. Goldsmith: ‘2020 Vision: NIH Heads Foresee the Future’ JAMA, Vol. 282 No. 24, December 22/29, 1999. |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, I would like to make some comments upon the letters by John Heptonstall and Wainwright Churchill. John states:
I think some evidence to support these statements would be useful. Is it really true that 80-90% of western medicine is not evidence based? It reads like a slight exaggeration. Can we have some examples, please? "The surge in interest for CAMs was generated by the good works of non-medically qualified CAM professionals, not by biochemical medical practitioners. ( Edzard Ernst, Journal of Medical Ethics 1996;22:197-198..." CAM is not dominated solely by the medically unqualified. Predominantly, this may be so, but not exclusively. There are increasing numbers of physicians who practice some form of CAM. Some GPs utilise several, and this is by no means untypical. Therefore this seems like a misleading statement to make. It surely borders on the mythological to also imply that only the medically unqualified can fully comprehend CAM paradigms? "...Yet most traditional CAM practitioners are non-medical and therefore are not part of the establishment (academic, biochemical medical and medical research etc.) that is always prepared for, and quick to, appropriate funds by rapidly 'redesigning' their standard protocols to take advantage of the next handout." People appropriate things from each other all the time, as we all do, somewhat eclectically, so what is the fundamental problem with this? Knowledge surely roams as free as a bird and travels quickly. How therefore, can any form of appropriation be prevented? John seems mainly to object to the POWER of the medical establishment. Does he also fundamentally reject them because of who they are and what they say and do? And, what they stand for? I think this needs considerable further comment, with examples, to make it clearer. John seems to be saying that a medically trained person is uniquely ill-equipped to understand and apply the paradigms of CAM. This argument is an old favourite, which I have many times heard non-medically qualified practitioners make against the medically trained. I think that it is generally untrue, suspect and probably reflects a semi-paranoid view that claims that medics have trained in science ['brainwashed with science' is the usual phrase] and that science is therefore all they can grasp. Well, is that really so? Surely, anyone is at liberty to absorb and accurately apply any paradigm? This also suggests that paradigms are mutually exclusive. Is this correct? Regarding John's comments about appropriation, while I accept the point that applies specifically to the abuse of medical money and power, I am somewhat sceptical of the remarks about the alleged inneutrality of medically qualified people. However, ideally John should supply some evidence in support of these remarks, and which has led him to adopt such a viewpoint, rather than just making such a blanket statement. The viewpoint he expresses appears to be deeply territorial and might be seen as reflecting an 'us and them' attitude. It is an essentially divisive thing to say, as it pushes people in this field further apart, at a time when they could beneficially be brought closer together - which is more what we should be encouraging - yes? In his letter, Wainwright Churchill's quite rightly says: "No paradigm can make a legitimate claim towards revealing absolute truth, as the insights and knowledge it yields reflect its assumptions. Because no paradigm reveals absolute knowledge, none can claim to be the authoritative basis with which to judge another." However, it seems pretty incontestable, that science does claim absolute knowledge, absolute truth and absolute power and it has seemingly been handed this mandate on a silver platter by society to demolish with Inquisitorial zeal anything which is suspected of being ‘unscientific’. That is the nature of the problem. Once medicine sought - and was quickly granted - the support of science, it had the ultimate mandate, which it has not hesitated in using, of wreaking havoc on heterodox medicine. They have certainly "done a hatchet job" throughout medical history, just as Wainwright says - absorbing and simplifying whatever they wish and disrespecting and brutalising the paradigm from which any technique they purloined has been robbed. One of the best examples of this type of appropriation is the speed with which the medical mainstream systematically plundered the homeopathic materia medica and reduced their doses throughout the 19th century. By 1900, the two systems were virtually indistinguishable. Many of the drugs used frequently by homeopaths, such as Aconite, Camphor and Belladonna, were absorbed directly into mainstream medicine. And many that had been first introduced by homeopaths, like Ipecac, Bryonia and Nux vomica, were also robbed right from under their noses, even as the allopaths continued to vilify homeopathy in the press and to each other, whilst also professionally ostracising its practitioners. [More detailed reference to this example can be found in Harris L Coulter, 1972, Homeopathic Influences in 19th Century Allopathic Therapeutics, Washington, and Phillip A Nicholls, 1988, Homeopathy & The Medical Profession, Croom Helm, London]. Regarding the ostracism of homeopaths and other medical sectarians by the mainstream we do well to consider the following examples: 'Orthodox physicians viewed it as their public duty to combat and eliminate these false systems of healing...to expose the dangers and errors of these cults...to employ political leverage and legal muscle. Organised medicine excluded from its ranks those who espoused such systems; denied such practitioners the privilege of consultation; refused to see patients when such healers were assisting in the case; prevented such practitioners from working in or otherwise using public hospitals; went to court to prosecute them for violating existing medical practice acts; and actively opposed legislative protection for them.' [Gevitz, Norman, (Ed.), 1990, Other Healers, Unorthodox Medicine in America, Johns Hopkins Univ. Press, USA, pp.16-17] 'In the late 1840s, regular physicians undertook a series of measures to ostracise homeopaths from the major regular medical institutions...the intention to practice as a homeopath was sufficient reason to deny the application.' [Rothstein, William G, 1972, American Physicians in the 19th Century From Sects to Science, Johns Hopkins Univ. Press USA, p.232] '...homeopaths were banned from regular medical societies, denied hospital privileges at regular hospitals, excluded from boards of health, forbidden to serve on the faculties of regular medical schools and blacklisted from consultations or any professional association with regular physicians. Even their apprentices were denied certification of preceptorship at regular medical schools.' [Rothstein, p.233] On the basis of past behaviour, it therefore seems safe to conclude that some form of integration of CAM into the mainstream is all but inevitable. There might then continue to exist a second strand of practitioners who ‘espouse a purer gospel’, by offering not just the techniques, but the original paradigm too. Nevertheless, this might still constitute a more pluralistic outcome than the present situation. Peter Morrell |
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John P Heptonstall, Director of The Morley Acupuncture Clinic and Complementary Therapy Centre West Yorkshire
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Peter Thanks for your questions which I hope to deal with as they appeared in your last letter:- 1. For evidence in support of 80-90% of WM may not be EB see my letters at www.bmj.com/cgi/eletters/319/7215/975 - Responses to 'The ABC of Complementary Medicine - Acupuncture' by Vickers and Zollman; they are entitled Re:'Only 20% of WM is EB'?Wrong (two letters) both dataed 21st November 1999 and Re:'Clarification'(two letters) dated 2nd December and 8th December 1999. 2. 'The surge in interests of CAMs was generated by the good works of non-medically qualified CAM professionals, not by biochemical medical practitioners' should have had "largely" between the words 'generated' and 'by' as was in my pre-type draft, my typo excluded it (Freudian??), thanks for pointing this out. Although the 'typed' version could technically be construed as misleading as you say, I suspect that the spirit of the overall statement is conveyed, understood and - most probably - accepted by most objective observers. 3. Not sure what mythology you refer to, nor where you derived this point from in my letter. Are you referring to my assertion that 'day-long courses of acupuncture for £200 are inadequate for medics'? If so CAM does not really come into it as 'acupuncture' is not a CAM, it is 'sticking needles into peoples' acupoints'. The 'CAM' should be Traditional Chinese Medicine - Acupuncture and Moxibustion, if one requires to be technical. 'Acupuncture' is a modality of that 'Alternative Medicine'. I suspect sticking an acupuncture needle in someone takes about 2 minutes to learn - one minute to demonstrate and 1 minute for the student to perform; applying the same modality to TCM in an effective and safe way takes upwards of 2 to 3 years training or, in China, typically 5 to 6 years at a national academic institution like The Academy of TCM, Beijing. 4. I have absolutely no problem with academia appropriating funds; I do hope that any funds designated for CAM research will find their way into projects designed by CAM professionals, carried out by them and the results assessed by them - with input as desired from other professionals where necessary, eg. statisticians, (and certainly not 'one-day course' providers whose committment to, and understanding of, TCM would be questionable!). I wouldn't like CAM funds to disappear into some WM 'black hole' for the 'imaginary study' of TCM. It does occur. Some years ago I worked 'voluntarily' as a CAM professional for a Hospital Pain Clinic. I was told by the hypnotherapist (who had secured charitable funds for CAM therapists to be employed therein from a Trust fund) that the Hospital received those charitable funds to be able to employ CAM professionals; the Consultant in charge saw this as a research project (I spent about 2 years there). The amount was said to well over £10,000 per annum. I applied for, and was repeatably turned down by the Hospital, reasonable out of pocket expenses (other than a few pounds for petrol) despite losing the equivalent of almost 2 days of my own private Clinic work treating its patients. I was told that the funds had been used to purchase a computer on which to record any research data (about £6000) and a 'research sister' whose NHS salary was repaid by the fund (about $12,000 p.a.) and none was left for CAM! The medical staff were salaried by the NHS. CAM professionals were expected to work for no remuneration. This probably epitomises what I allude to above, and may also respond to your point about the 'US and THEM' divisive attitude one experiences as a CAM professional which is in the main generated by an unyielding medical establishment. I can assure you most CAMs do not feel it should be Us and Them, indeed many are now trying for 'NHS acceptance', it appears to be the reluctance of THEM, who define all CAMs as generally unscientific from the rather safe biochemical vantage point, who reject outright other paradigms that produces the Us situation. 5. I have no problems with power per se, other than as a corrupting influence. Clearly the 'power' of the hospital mentioned above to allegedly turn charitable donations for CAM employment into capital and salary gains worth tens of thousands of pounds for THEM, whilst distributing a few pounds to US could be construed as a misuse of power by the medical establishment could it not? I don't remember suggesting rejection of medics - I have close family and friends who are medics. "The wrong sort of people are always in power because they would not be in power if they were not the wrong sort of people"....Jon Wynne-Tyson. (paranoid delusionist?) 6. I never referred to medical training as uniquely ill-equipping one to understand and apply the paradigms of CAM. I do believe we are all uniquely ill-equipped to understand and apply certain paradigms. If one is intelligent, interested in the objective and detailed aquisition of knowledge of CAM paradigms one has some of te qualities required. 'Medically trained' often involves the development of a mind-set, particularly biochemicalised, which can preclude interest and objectivity in certain CAM values and concepts. How many chemists do you know who would not reject the concept of 'retained effect despite dilution below Avogadro's Number'? How many medical anatomists can define Meridians, or Qi, or consciousness, soul, spirit, or how our physiology is affected by cosmic activity? Any intelligent person can study and parrot TCM philosophy - but to learn and practise effectively and safely in order to be able to perform TCM interventions at the levels of mind, body, emotion, spirit requires resonance with that paradigm; one cannot accept what one likes, reject tne rest, then blithely continue to treat patients in their best interests. How can one hope to cure particular physical, emotional, mental or spiritual ailmenst if one rejects the concept of cure for those ailments?...absorption of a paradigm does not ensure the ability to apply it as required by that paradigm does it? Some things cannot be learned from books. "There are many truths of which the full meaning cannot be realised until personal experience has brought it home"....John Stuart Mill (1806- 1873). I am sure this is as valid for WM as it is for any CAM. 7. The inneutrality of 'medically qualified' people per se was not mentioned by me was it? I did allude to the results of the study by Ernst, Resch and Garrow which confirmed to them that 'biomedical peer review is prejudiced against CAM'. I also gave an example of a 'medic' who appears to be inneutral to CAMs, particularly TCM, as Professor Edzard Ernst of Exeter University - ' Britain's and the Worlds' First Professor of Complementary Medicine' - who wrote that one becomes a charlatan and defrauds the public by using what are TCM diagnostic techniques. This tells me that some medics (even those paid to analyse CAMs) are clearly biased, and therefore are inneutral, to what they perceive to be 'unconventional medical concepts' - CAMs. Dr. Neville Goodman, Examiner for the Royal College of Anaesthetists, in an article in the Healthwatch Newsletter www.biochem.ucl.ac.uk?~d ab/healthwatch.html ( www.biochem.ucl.ac.uk?~dab/nlett29.html) said "I could not accept a RCT favouring homeopathy...and I hasten to add would decline the opportunity to peer review such research". How can one guarantee that all medics with such strong prejudice against a particular CAM, despite randomised controlled trials favouring the CAM, would avoid partaking in peer review or research that objectively looks at CAMs? Those who cannot display objectivity when reviewing 'unconventional medical concepts' ought to be excluded from that task; according to Prof. Ernst et al this may include virtually all medical practitioners? Those capable of unbiased reviews would be most acceptable. "Truth in science can be defined as the working hypothesis best suited to open the way to the next better one"...Konrad Lorenz. I would conclude with questions for you Peter as answers to these would perhaps clarify to the reader your perspective on the matter:- For two situations 1. Project to assess homeopathy theory that extreme diliution beyond Avogadro's number still has effect 2. Project to assess homeopathy's ability to treat 50 people suffering from myalgic encephalomyelitis (M.E.) who have been selected from the NHS with diagnosis a. who best to direct each project
for each project
where the answers are to be drawn from either C (a traditional CAM practitioner)
Kind regards John |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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John, Many thanks for so patiently answering my questions, and responding to my points in such a friendly and pleasant manner, without even a milligram of anger or irritation at what I said. This creates an environment in which one can think and speak more easily. My apologies for the length of this reply. I think I have answered all your points. You say: "Not sure what mythology you refer to, nor where you derived this point from in my letter." I meant that it is like believing there is a unicorn at the bottom of your garden! If there is one there, then science insists that it must be one we can all see, touch or stroke, not just you alone. The unicorn is a mythological animal. Thus, science always strives to universalise and objectify knowledge. Subjective knowledge, mythologies and unicorns are pretty well disallowed. Much of CAM straddles the border of being subjective/objective, as it often relates to individuals, rather than to groups of people. Which is one reason why double-blind clinical trials are fundamentally flawed in their application to CAM research. My point was that it is mythological to state that only devotees of CAM can comprehend its paradigms. I do not think that is true. It is therefore mythology. I think we are all partially capable of grasping any paradigm, and that under certain circumstances we can grasp several. However, we must be open-minded as a minimum requirement. And that is clearly a problem for folks trained in science, whose minds are far from open. You say: "I have absolutely no problem with academia appropriating funds…" The word 'appropriation' has two meanings in the context it has so far appeared. Firstly, the appropriation of money, or funding for research; and secondly, the appropriation of ideas and techniques from CAM, by orthodox medicine. I used it mostly in the latter sense. Both meanings have been touched on. But, one of the important aspects of this discussion involves the appropriation of medical techniques taken without their paradigms, stripped bare, if you like; like part of the technique is robbed, but the paradigm is thrown aside like an empty husk. This might also be termed ‘expropriation’. You used the example of acupuncture as opposed to the more truly holistic TCM. This is an aspect of what we started out discussing re the 'integration vs plurality' aspect of this topic. You clearly believe, like Wainwright, that ideas and methods taken out of context and used indiscriminately, are wrong, and benefit nobody. In my examples of homeopathy in the last century, the same debate raged. At that time, they believed that to use mixed remedies or to use homeopathic remedies on a non-individualised basis was wrong; it was a mis -use of homeopathy. It is the use of a technique stripped of its natural context, rather like using white sugar [compared with brown sugar] or white flour [compared with wholemeal]. It is in fact, an aspect of scientific reductionism - analysis, purification, simplification and fragmentation: the same impulse led to the removal of 'the active ingredient' and using, for example, vitamin C rather than fresh orange juice. It was this same reductionist impulse that spawned pharmacology. Modern drugs are therefore ‘active ingredients’ robbed from the functional holism of natural medicine. You say: "I have no problems with power per se, other than as a corrupting influence." You clearly do have a problem with the fact that WM has all the power and CAM has virtually none. In addition, that is clearly unfair. You do not trust them. You also gave an example from your own experience, regarding a hospital in which it is quite clear that an unequal power structure seriously demeans the work of CAM practitioners compared to WM practitioners. The power dynamic between CAM and conventional therapeutics [CT], in general, has clearly been a deeply abusive one for many years. CT dominates medicine and has acted as a bully towards CAM for many decades. That still continues today. The psychological reaction of CAM practitioners towards the presence of medics is fundamentally the same as that of a victim when their bully walks into the room. Profound discomfort ensues. There is no trust between them and the one [CAM] is basically paranoid of the motives and behaviour of the other [CT]. Thus, on this basis, integration of CAM into the mainstream would extend even further the territory of ‘the bully’ and further downgrade the paradigm and status of the CAM. Is this what you mean? You say: "I don't remember suggesting rejection of medics - I have close family and friends who are medics." OK, but maybe you reject their mind-set, then. You clearly do not like them, put it that way. I would suggest that you reject everything they say and do, their ideas and their techniques; and their attitude towards the rest of medicine; their whole world view You say: "I never referred to medical training as uniquely ill-equipping one to understand and apply the paradigms of CAM. I do believe we are all uniquely ill-equipped to understand and apply certain paradigms." Though you never mentioned it, you do believe it to be so! Therefore, I was right to raise it. You clearly demonstrate in your letter that you would not trust a medic to take your dog for a walk! Let alone play with your paradigm! As you then say: "'Medically trained' often involves the development of a mind-set, particularly biochemicalised, which can preclude interest and objectivity in certain CAM values and concepts." You say: "How many chemists do you know who would not reject the concept of 'retained effect despite dilution below Avogadro's Number'? How many medical anatomists can define Meridians, or Qi, or consciousness, soul, spirit, or how our physiology is affected by cosmic activity?" Well, to begin with, to the anatomist, meridians are fictional concepts with no agreed upon or observably objective reality. They are intangibles. They cannot be reliably demonstrated to exist, weighed or measured. It may at times be useful or convenient to believe in them, but they are not real. They are unicorns. And to the chemist, a substance diluted beyond the Avogadro limit is a substance no more! It has become a ghost or chimera with no tangible existence and thus incapable of making any impact upon the organism, therapeutic or otherwise. It is another unicorn. However, if an ultra-diluted substance, does have such an impact, what then? Then it opens up a new paradigm, beyond science, which has not thus-far been very thoroughly investigated. Maybe molecules do leave shadows in the solution. Moreover, who is to say? Who is to pontificate on this? The Popes of science? Or the facts of everyday experience? It is useful to briefly tell the story of Galileo and the moons of Jupiter. In order to prove his heliocentric model of the solar system to his friend, the Pope, Galileo invited him to gaze through his telescope at the moons of Jupiter. The Pope declined, saying that scripture had taught him that there were no moons of Jupiter and there was thus no point in him looking. This illustrates the difference between fictional and real objects, and also something about the attitude of science. The Pope’s mind was closed on this matter and somewhat outraged at the presentation of an alternative viewpoint to that of scripture. The Church’s view on cosmology was fixed and dogmatic, unnegotiable. Yet, Galileo’s observations gave birth to the scientific paradigm. The Church was swimming desperately against a cruel new tide. Subsequently, only in the Protestant countries did science forge ahead. In all Catholic lands it was suppressed by the Church, who controlled the beliefs of the masses. Similarly, the observations of Einstein, concerning discrepancies in the too early emergence of Mercury from its occultation with the Sun, suggested that space is bent around a huge mass. Another paradigm shift. With regard to the inneutrality of the medically trained, you did not mention it, but implied it somehow, and now you have handsomely demonstrated that you do believe that they are biased. Regarding the questions you ask me about testing homeopathy, in both of the cases you mention, I would prefer an independent person or a traditional CAM professional to conduct and interpret such a test. Or a statistician. The reason I would choose an independent person, and any non -medic, is that I would believe them to be genuinely non-biased, or less biased, than a person trained in medicine – i.e. science. I believe that science innocently starts out as an impressive set of ideas, but it progressively incorporates a belief system just like a religion. You start to expect certain outcomes and rule out others. That is belief, not knowledge. The belief runs ahead of the observation and sort of smothers it, before it even happens. Then it starts to allow this, but disallow that. How can that possibly be called objective? Thus, it is no longer unbiased and open. Science has become so overburdened by its own theories and models, and its precious rules, that it just cannot see the world of events any more, in spite of claiming to look. Science is the religion of today and its believers are little different in their stubborn prejudices and zealous rantings, from the religious bigots of old. Thus medics, who are very thoroughly steeped in science [try getting into medical school without it], have absorbed a particular way of looking at the world [what you call a 'mind-set'] and are somewhat pre-conditioned in what they are expecting to happen. Pre- conditioned about the way the world really is. They are expecting the world to conform to their beliefs. Just like the Popes of old, who also expected [well, demanded] the world to conform to their beliefs. Anything that does not so conform is branded heretical, fictional, mythological, and those who 'see' such fictions are branded as heretics and enemies of truth. What is the difference between science now and religion in 1600? Answer: very little. Science has become a dictator of truth, just like the Popes of old. Like East German border guards, scientists patrol their self-defined borders of truth armed with epistemological kalashnikovs. Disagree with them at your own peril. In addition, an expectant mind is not an open mind, it is closed. It is closed to all outcomes, bar one. Of course I do not trust such a mind to be unbiased, open and fluid in its apprehension of facts and observations, nor in its interpretation of them. At its worst it is a deliberate deceit on their part, but at it best it is a distortion of mind, which comes with that particular mind-set. CAM faces this situation today. It stands in the firing line of those kalashnikovs. Whatever we experience as real is valid for us - it arises from our common experience; this is true in life generally. If I see a ghost, then it is a ghost. There is little point in disputing it. It is no longer a problem. Yet, I have never seen a ghost in spite of many years wanting to, just out of curiosity. This apparently defines William Blake's view of angels. He saw and conversed with angels on a daily basis. However, there is a problem with the universality of knowledge - which is an assumption, not always a fact. Scientific validity demands that we can all see Blake’s angels, or they are deemed unreal. He alone seeing them is a huge problem for science - it cannot be. It is a forbidden experience, a disallowed phenomenon: therefore, they do not exist, but must be projections of his mind or hallucinations. For science, one person is denied the valid reality of any subjective experience that others cannot also share. This is plainly ludicrous. Science is incapable of acknowledging the reality of personal and individual experience. Think over what that means. Thus the whole of art, music, all literature, creativity, vision, all forms of true genius are disallowed. Leonardo, Shakespeare, Bach, Mozart – must all be rubbish. Nevertheless, of course, in science this assumption is generally valid. Copper sulphate is copper sulphate to the end of the world and cannot be anything else. That is certain knowledge, which we can all agree upon and share. It is fixed and universal. Angels, apparently, are not. Scientific knowledge cannot be destroyed and applies in all times and conditions, as far as we know. It is unnegotiable. As were Galileo's moons of Jupiter. However, if you experience something as well as disbelieving it, then it must have a form of validity that transcends your own subjective experience - as I have when using homeopathic remedies on animals, very young children, on sceptical adults and on myself in the first instance. How can a non-believer experience placebo? How can a baby or animal react to the right remedy knowingly? Yet, not respond to the wrong one? It is a nonsense to say it does not work. They have tied themselves up with all these rules. Each CAM works within the confines of its own parameters. The problem with CAM is that it often appears less certain, more nebulous and more subjective than science is prepared to tolerate. Working within your own parameters is a big problem for science, as it stands outside of their jurisdiction; it stands outside the range of their thought police, beyond their borders. They have a huge problem with that. It is like art or music, they detest it, cannot quantify or measure it. It is beyond their comprehension. What they fail to see is that the problem is in their head, not in the real world. They have chosen to wear a certain type of spectacles, and then they complain that they cannot see straight. Thus, you inevitably come to accept something, not because you believe it per se, but because you see it so frequently, that it is pointless, tiresome and absurd to question or deny it. Blake would have laughed heartily if you had said there are no angels. He saw them daily. His total certainty on this matter was derived from his continuous direct experience. How could you convince him that they were delusions? In the case of acupuncture needles improving health, then you, John, see it daily and it is beyond question. I don’t mean to suggest that acupuncture is a delusion! Merely that some effects within our experience are subjective and cannot necessarily be shared with others in a manner which science demands. They are still real. Perhaps the angels analogy is a bad one? For me, in my experience, I have seen virtually every CAM modality work, either on myself, my children or on many others. This includes herbalism, reflexology, aromatherapy, nature cure, homeopathy, acupuncture, counselling, and hypnotherapy. In addition, like Blake with his angels, I have seen homeopathy work countless times on a daily basis. There is thus no longer an issue over its validity. For me it is a settled matter. What then is the point of questioning efficacy? Or trying to prove it? Well, I have also seen numerous times the wrong remedy do nothing and then the right one work in seconds. Therefore, talk of ‘placebo effect’ is also a nonsense. However, translating the certainty of one's experience into the kind of proof to satisfy science is a very tall order, especially when in hostile territory and you can see their kalashnikovs pointing straight at you. Thus, the question about ultradiluted substances is something of a side-issue. If the therapeutic effect of a microdose is observable and repeatable [for you, on an individual basis], then it is fact and a mechanism can ultimately be found to explain it. If you want a mechanism. Science is perhaps too obsessed with mechanism too. I would say the same applies for acupuncture. The observation comes first in a truly objective science, not the theory. The real world is king, and is the ultimate judge and jury. Truth is subordinate to observation. As with Galileo’s moons of Jupiter. However, many within medicine, or science, or both, disbelieve the observation purely because there is no known explanation to fit it into. That is broadly similar to the Pope, who disbelieved that Jupiter had any moons and declined the possibly cataclysmic challenge to his own beliefs, by refusing to even peer into Galileo's telescope. His beliefs dictated that there were no such moons. Similarly, today, the anti-CAM scientist says the microdoses of homeopathy and the meridians of acupuncture are delusions - because they must be. They have become the popes of knowledge, dictating to us just as forcefully as thundering clerics, what to believe and what not to believe. Thus, they become similarly outraged at the idea of using any alternative modalities. They refuse to change their spectacles. However, we can say, with some conviction, that the charlatans and the heretics have always been the pioneers, the midwives attending the birth of new paradigms: Bruno, Galileo, Luther, Paracelsus, Newton, Einstein, Hahnemann. CAM today is a new paradigm. No amount of ranting and bluster from the popes of science can change that fact. People are demanding change and so change will inevitably ensue; a revolution is banging at the door, demanding entry. Or are we deaf? There is also left from the first letter the matter of the relative merits and drawbacks of integration and pluralism. This has not been fully discussed yet. I can see why CAM professionals prefer pluralism and loathe integration, but can you now say more about his theme? Why is pluralism a fundamentally better outcome? Peter |
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George T Lewith, Honorary Senior Research Fellow University of Southampton
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Dear Mr Heptonstall Thank you very much for your response to our letter. Necessarily letters in the BMJ are fairly short. We refer heavily to the FIM Report on Research Strategy in relation to Complementary Medicine, and this makes it very plain that any research agenda within CAM must involve CAM practitioners, must involve good quality CAM (be it acupuncture or homoeopathy) and must be run in an appropriate research institution with a team-based approach both to the research itself and to the protocol development. As a consequence, I feel that your criticisms of undue bias on non-individualised therapeutic interventions would not be appropriate if we followed the guidelines that FIM has laid down. The Research Committee which produced the Prince of Wales's Report was constituted more or less equally from medical and non-medical practitioners. It was a consensus document that involved a great deal of discussion and research; as a consequence if this strategy is followed (and we hope it will be), you need have no fear of undue bias or discrimination in relation to the fundamental principles of good quality CAM practice. I hope this will reassure you. Best wishes George Lewith |
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George T Lewith, Honorary Senior Research Fellow University of Southampton
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I'm afraid it's not a question of the friends or adversaries of CAM: it's a question of doing good quality research with an agreed national agenda that is adequately funded. You would be misguided to think that just because you were a "friend of CAM" you are better able to produce either good quality research or a positive result for any particular CAM therapy. |
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George T Lewith, Honorary Senior Research Fellow University of Southampton
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Thank you very much for your very long and thoughtful letter. Just because a particular CAM therapy may have a different paradigm doesn't mean that it can't be evaluated in a proper manner through appropriate clinical research. You are also quite right; effective medicine should be incorporated into the body of medicine. Many of the medical interventions currently used by conventional medicine have poorly understood basic mechanisms. Therefore, a failure to understand the biological mechanism of homoeopathy does not and should not suggest that homoeopathy is ineffective. What we need are good clinical trials so that effectivity can be appropriately evaluated. Clearly, if homoeopathy or acupuncture were to be integrated into conventional medicine, then it would have to be done on the basis of "best possible practice". If best possible practice involves adherence to the philosophical paradigms governing these particular therapies, then conventional doctors will clearly have to learn about these ideas and put them into clinical practice in a relevant evidence-based manner. Your concept about the idea of pluralistic medicine seems relevant; pluralistic implies that a competent practitioner will have an understanding of several different medical models including conventional medicine, traditional Chinese medicine and the concepts and philosophy that underlie homoeopathy. My personal view is that in an ideal world, truly integrated medicine would involve such levels of understanding, although it may be very difficult to achieve in one doctor's lifetime. Nevertheless, whether we call it pluralistic or integrated, what we need to do is evaluate best practice to see if it works and then either decide to work as an individual with a capacity to move between different medical models, or as a team with individuals who can work together to provide different medical models for our patients. Certainly within the context of our letter and the research strategy defined by the FIM document, these approaches would be entirely consistent with good practice. |
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George T Lewith, Honorary Senior Research Fellow University of Southampton
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I must admit, the reality of the situation (again expressing my own personal view entirely) is that inevitably CAM will be integrated into conventional medicine on the basis of the available evidence and unfortunately I suspect some of the philosophical tenents within CAM may well be diluted. Ultimately,therefore, we may see purist CAM practitioners. Hopefully, however, we can use a team-based approach which will allow for good quality CAM to be practiced in a properly integrated environment. I am personally, though, only too aware of the elephant traps that may be awaiting us and hope that we can guide this process in a way that does not involve throwing the baby out with the bath water. |
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John P Heptonstall, Director of Morley Acupuncture Clinic and Complementary Therapy Centre West Yorkshire
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Peter's eloquent response conveyed for myself, and probably many other CAM professionals, the essence of why we need to ensure that the paradigms that encompass 'best practise' in our medicines are not lost in the surge to biomedicalise all CAMs, or the modalities developed for those CAMs, deemed worthy of plagiarism. Dr. Lewith's points are also valid, and I appreciate the reality of which he speaks; however, as one who daily sees the effects of TCM-based interventions on many people with so-called 'incurables' it seems necessary that those of us who have seen, and can recognise, the immense value of retaining the doctrine with the modality must try to persuade those who cannot (and may never) see our patients' reality not to destroy that good. Anyone who works with 'classically prescribed' CAMs such as TCM, Ayuveda, Homeopathy - whether medically qualified or not, will not fail to recognise the powerful effects they engender. People are losing patience with WM, it's enormous appetite for money with limited gains against chronic diseases, tremendous surgical advances which leave many disabled later in life to seek our services, and recently well-published tragedies. When 60% of a patient population (USA), and around 30-40% (Europe), seek CAM intervention governments should remove the monopolistic attitude of WM and open the field fairly to funded patient choice. In terms of pluralism, there is no reason why every hospital should not, at this moment, have a ward dedicated to TCM, another to homeopathy, another to ayuveda manned by traditional practitioners; WM practitioners would also have their own ward facilities. People should then be allowed to choose their medicine from the specialities, and if requested, a combination which is prescribed without fear or favour by the specialists from each field. WM can no more claim 'scientific validity' than TCM or Homeopathy - and as I have already shown, WM may have an evidence-base of less than 10% (once the EB intervention has been designed) by the time it reaches the patient where it requires to have been identified by a busy GP, then prescribed properly following an accurate diagnosis. The savings to the NHS would be substantial; for example chronic diseases are cured and dramatically improved using TCM techniques like 'acupuncture & moxibustion'; we do this daily, and have seen it acknowledged in Chinese research. We cannot make savings when 'ring-fenced drug budgets' preclude cheaper options such as herbs and needles; removing this non-essential ring-fencing will allow practitioners to prescribe the best modality for each patient - true patient CARE. Why must the public have to wait for 'scientific validation' by the NHS system, presently controlled by vested interests in the main, before their CAMs are funded and provided by traditional practitioners? They have already selected certain CAM interventions for multifarious disorders, many chronic intractable as far as WM is concerned, and the lack of EB should not preclude these facilities continuing to be used by the masses just as it doesn't preclude non-EB WM interventions. Are the public of no consequence, do others know what's best for them and how to spend their money? Have they been asked properly? Or are certain factions afraid that an open market may eventually see GP surgeries poorly attended, hospital waiting lists reduce dramatically, and public health improve in a short space of time - or is that not what Health Service is about? If the fine minds of those who have shown dedication, from both polarities of CAM debate, through education, practise, research, publications etc. were to reach concensus that people should be provided what they want (they pay for it and have a democratic right to choose) and they were prepared to ask them - that would be a good start to improving our Health service. Regards all John |
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Wainwright Churchill, Traditional acupuncturist and Chinese medical herbalist London
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Dr. Strauss, head of the US National Institutes of Health’s National Center for Complementary and Alternative Medicine, has strongly implied that his organisation’s agenda is to thoroughly biomedicalise CAM. [Please see the quotation in my previous letter.] I believe that Dr. Lewith underestimates the pressure for CAM disciplines to conform, in like fashion, to the biomedical paradigm in the research led and evidence based integrated medicine project he endorsees. Even so, he states ‘the reality of the situation … is that inevitably CAM will be integrated into conventional medicine on the basis of the available evidence and unfortunately I suspect some of the philosophical tenets within CAM may well be diluted.’ A report by the Center for the Study of Drug Development at Tufts University in 1990 estimated the average price for the development of a new drug to be $231 million, and the time required 12 years. (Quoted in J. E. Robbers and V. E. Tyler, 1999, p29.) Much of such cost is for clinical research. Compare this to the $50 million allocated to the NIH NCCAM. Research is often inconclusive. With smaller studies, subjective factors come into interpretations. As Morton Lindbaek wrote in relation to meta- analyses: ‘Meta-analyses based on small studies are not easy to interpret, and conclusions should be drawn with caution. … [In] meta-analyses too there is an element of subjectivity in the research question posed, the choice of outcome measures, and the evaluation of whether significant differences also are clinically important.’ (M. Lindbaek, 1999.) Resch, Ernst, and Garrow concluded in their study 'Does Peer Review Favor the Conceptual Framework of Orthodox Medicine?', European Journal of Clinical Nutrition: "Despite a remarkably large within-group variation in both groups, there seems to be a relevant reviewer bias against papers dealing with unconventional medical concepts". Given the expense of research and biomedical bias against unconventional medical concepts, it is extremely unlikely that a substantial amount of high quality paradigm-sensitive research into CAM modalities will be done. Just to research TCM acupuncture according to its own paradigms would be a mammoth task. The realistic outcome is that research into CAM will be patchy, non authoritative, and adhere to biomedical assumptions, including that CAM’s own paradigms are invalid in the light of modern knowledge. This will be the ‘available evidence’ used to integrate CAM into biomedical practice. CAM as it is currently practised will be supplanted by thoroughly biomedicalised CAM, just as Strauss anticipates. The ‘purists’ left behind will have their disciplines castigated as scientifically unvalidated, however unsatisfactory the process of validation. Most CAM professionals would reject such an agenda, and it is important for institutions that purport to promote CAM via integrated medicine, and who at present rely on the goodwill and co-operation of CAM professionals, to acknowledge and respond to these issues. They should specifically answer all the following questions: 1) What do they mean by ‘integration’ and ‘integrated medicine’, specifically with regard to CAM disciplines being practised in their totality, including according to their own paradigms? 2) Do they think that anything less than authoritative research should be utilised in this project? 3) Do they accept that paradigms are incommensurable and that no paradigm can make a legitimate claim towards revealing absolute truth, as the insights and knowledge it yields reflect its assumptions, so that no paradigm can claim to be the authoritative basis with which to judge another? 4) Do they accord the biomedical paradigm a privileged position over CAM paradigms? 5) Do they envisage CAM being exclusively or primarily being practised by medical doctors in the integrated medicine context? 6) If not, what will be the relative standing of CAM and biomedical practitioners hierarchically? 7) Are they committed to CAM disciplines being practised according to their own paradigms in integrated medicine? 8) If not, are they committed to CAM disciplines being practised according to their own paradigms outside the context of integrated medicine? 9) If they are committed to CAM disciplines being practised according to their own paradigms in either case, what explicit steps will be taken to prevent CAM modalities being biomedicalised and appropriated into biomedicine, as is the very likely practical consequence of the agenda that maintains that complementary medicine MUST be research led and evidence based? I request that the Foundation for Integrated Medicine, the most influential integrated medicine organisation in the UK, answers these questions clearly and fully on this webpage. If the agenda FIM is pursuing is likely to biomedicalise CAM disciplines, and to interfere with or invalidate their practice according to their own paradigms, it is only fair to CAM professionals that this be acknowledged and discussed openly now. References M. Lindbaek, 1999: ‘How do two meta-analyses of similar data reach opposite conclusions?’, BMJ 1999;318:873. Resch, Ernst, and Garrow. 'Does Peer Review Favor the Conceptual Framework of Orthodox Medicine?', European Journal of Clinical Nutrition [Date not given on abstract]. J. E. Robbers and V. E. Tyler (1999). Herbs of Choice – the Therapeutic Use of Phytomedicinals. New York and London. Haworth Herbal Press. S. E. Straus. Subsection ‘National Center for Complementary and Alternative Medicine’, in Marsha F. Goldsmith: ‘2020 Vision: NIH Heads Foresee the Future’ JAMA, Vol. 282 No. 24, December 22/29, 1999. |
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