Annals of Internal Medicine 1998; 129: Dec 15 1061-1065 for the use of this article!
Ted J. Kaptchuk, OMD, and David M. Eisenberg, MD
Alternative medicine has a major presence and persuasive
attraction in the industrialized western world. The extent to which
these practices have clinical efficacy according to biomedical
criteria is a matter of ongoing research and debate. It may be that
independent of any such efficacy, the attraction of alternative
medicine is related to the power of its underlying shared beliefs
and cultural assumptions. The fundamental premises are an advocacy
of nature, vitalism, "science," and spirituality. These themes
offer patients a participatory experience of empowerment,
authenticity, and enlarged self-identity when illness threatens
their sense of intactness and connection to the world. A discussion
of these themes may enable conventionally trained clinicians to
better understand their patients' attraction to and acceptance of
alternative medical therapies.
Ann Intern Med. 1998;129:1061-1065. Annals of Internal Medicine is published twice monthly and copyrighted
© 1998 by the American College of Physicians-American Society
of Internal Medicine.
|From Beth Israel Deaconess Medical Center, Boston,
Massachusetts. For current author addresses, see end
The major presence of alternative medicine in western culture
has been well documented (1, 2). Discussion
has focused on whether these practices have any biomedical efficacy
and on potential adverse consequences. We examined the possibility
that the cultural beliefs and contextual practices of alternative
medicine frame a pathway of words, behaviors, and experiences that
people find persuasive, compelling, and, ultimately, restorative.
Shared cultural assumptions may provide a vehicle for an enlarged
sense of self and a renewed sense of morality and purpose. This
inquiry is not meant to advocate or debunk alternative medicine;
rather, it describes cultural and epistemologic dimensions of
alternative medicine, which are too often overlooked.
Any generic discussion of alternative medicine is problematic.
In the industrialized western world, many unorthodox medical
therapies are readily available. Together, they "represent a
heterogeneous population promoting disparate beliefs and practices
that vary considerably from one movement or tradition to another
and form no consistent . . . body of knowledge"
(3). Despite this diversity, much of alternative medicine
shares important underlying assumptions and themes that have
allowed these movements to form a significant coalition in their
historical tug of war with conventional medicine
(4-7). Although disagreement exists, the depth and consistency
of common intellectual, emotional, political, and health care
preconceptions have contributed to the strength of the alternative
medicine alliance. The fundamental premises uniting the alternative
community involve nature, vitalism, "science," and spirituality.
Taken together, these principles expand behavioral options,
identity, experience, and meaning when illness (or its possibility)
threatens a person's intactness and sense of connection to the
world. We examined these four basic assumptions of alternative
medicine in the hope of facilitating understanding and
communication among physicians, patients, and providers of
Alternative medical therapies provide patients with the generous
rhetorical embrace of a benevolent "nature." In alternative
medicine, nature is innocent and wholesome and is the iconographic
symbol of virtue (8). Oliver Wendell Holmes (1809-1894) called this romantic view "the
nature-trusting heresy" (9). The belief
encodes an unambiguous set of moral polarities: natural versus
artificial, pure versus toxic, organic versus synthetic,
low-technology versus high-technology, and coarse versus processed.
Biomedicine automatically suffers in this bifurcation because of
its association with sophistication and technology as opposed to
the perceived simplicity of undeveloped nature. In this optimistic
and hopeful view, any adverse aspects of nature (ranging from
anthrax bacillus to deadly nightshade and snakebite) tend to be
Nature is the defining metaphor for many alternative medicines.
The preference for botanical medicine is rooted in this idea (11, 12). The health food movement articulates
the superiority of "natural food" (13, 14).
Even if it is not the central image, a belief in nature pervades
other complementary medicines. The metaphor is pliable, relative,
and honorific; anything in the alternative alliance is allowed this
approbation. Thus, acupuncture needles, megavitamins, and
meditation are all "natural."
By using "natural" treatment or changing one's life habits to
conform to "nature's" norms, a person connects to what is perceived
to be a less artificial version of personhood. Authenticity is
immediately enhanced by "purifying" oneself of the toxic dimensions
of civilization and their consequent diseases. Natural healing also
implies ipso facto participation, even without conscious intention,
in a wider reform movement for the regeneration of an overly
developed technological society. Natural health takes on dual
dimensions: personal healing and perfecting of the social order.
The debility of disease (or the work of health maintenance) becomes
an opportunity to save both the self and the world.
Alternative medicine offers a person threatened by illness or
disease a connection with fundamentally benign, lawful, coherent,
potent, and even meaningful powers (15). When
illness isolates, alternative health care allows a rescuing
connection to life-supporting cosmic forces. This vital energy
takes myriad forms: homeopathy speaks of a "spiritual vital
essence" (16), chiropractic refers to the
"innate" (17), and acupuncture is said to
involve the flow of "qi" (18). Ayurvedic
medicine is based on the power called "prana"
(19), and new age healing practices work with "psychic" or
"astral" energies (20, 21). The alternative
alliance routinely claims that its methods rely on enhancing "life
forces" as opposed to "destroying" them with artificial drugs and
Much of alternative medicine is also pervaded with a mental form
of vitalism in which the force is not physical but is considered to
stem from the mind or deeply held emotions
(23-25). In this belief system, consciousness or affective
states are considered to be the primary arbitrators of health. Such
best-selling books as Bernie Siegel's Love, Medicine and
Miracles and Deepak Chopra's Ageless Body, Timeless Mind:
The Quantum Alternative to Growing Old testify to the appeal of
this form of vitalism. The threat of disease is greatly diminished
as a person's imagination, will, and belief are empowered with
healing consequences. Again, an optimistic perspective
paradoxically manages to overlook any sense of fault or guilt
generated from this enhanced autonomy and self-determinism (26, 27).
When people use alternative medicine, "the scientific
enterprise" does not have to be abandoned. In fact, the label
"science" in alternative medicine, as in biomedicine, is an
important source of legitimating power, moral authority, and
self-definition. Alternative medicine includes chiropractic science
(28), homeopathic science
(29), psychic science (30, 31), and even
occult science (32, 33). Academic science
would undoubtedly call these approaches "scientism" and discuss the
boundaries between science and pseudoscience
(34-36). However, for practitioners and their patients, these
sciences are absolutely credible. Indeed, many of these disciplines
have a long intellectual tradition and sophisticated philosophy (37-39), as does the broad notion of nature's
healing power (40) and vitalism (41, 42). Adding to the genuineness of the scientific
label is the fact that training in alternative disciplines may
involve years of study of complex knowledge bases and relations,
intricate determinations of causality, and empirical testing of
practice (43). When debunkers or neutral
scientists attack the "nonscience" of alternative medicine,
participants are mostly perplexed or annoyed.
Biomedicine has a set of epistemologic assumptions that differ
radically from those of alternative medicine
(44). Alternative medicine's version of science lacks the
recently adopted biomedical notion of clinical experiments carried
out under artificially and deliberately controlled conditions,
exemplified by the double-blind, randomized trial (45, 46). Its version of science is observational and
more closely resembles the modern sciences of paleontology and
The science of alternative medicine is ultimately "person
friendly." Its language is one of solidarity, unity, and holism
instead of the distant, statistical, and neutral conventions of
normative science (48). The person-centered
experience is the ultimate verification and reigns supreme in
alternative science. Because self-knowledge and simple observation
are not depricated, no placebo effect haunts and casts doubt on the
validity of therapeutic outcomes (49, 50).
Alternative medicine makes no rigid separation between objective
phenomena and subjective experience. Truth is experiential and is
ultimately accessible to human perceptions. Nature is not separate
from human consciousness. Instruments that extend the senses or
objective diagnostic or laboratory tests that discern what cannot
be felt never replace human awareness. A patient never has to fear
that an illness will be branded as existing "only in their head." A
"real" cause will be found for any sensation. The science of
alternative medicine, unlike the science component of biomedicine,
does not marginalize or deny human experience; rather, it affirms
patients' real-life worlds. When illness (and, sometimes,
biomedicine) threatens a patient's capacity for self-knowledge and
interpretation, alternative medicine reaffirms the reliability of
his or her experience (51).
Alternative medicine science has no radical skepticism. In fact,
alternative medicine science sometimes takes on the appearance of
proving deeply held beliefs by selectively appropriating normative
scientific studies. For example, consumer infatuation with and hope
in self-prescribed vitamins is unshakable and is sustained by
skewed attention to scientific knowledge; contrary evidence is
often overlooked (52).
Alternative medicine offers more than physical and mental health
care. In the words of one observer, it comprises "medical systems
that dispense heavy doses of unconventional religion" (53). Through the patient's participation in nature,
vital forces, and a "human" science, the quest for health takes on
sacred proportions, allowing the patient to discern ultimate
meaning and make profound connections with the universe.
Conventional medicine more or less acknowledges a Kantian
philosophical demarcation between science and religion. Science is
exhaustively competent in the realm of causality in time and space,
whereas religion is the domain of moral freedom and self-chosen
values (54). For many people, this dichotomy
can be confusing and sterile. Many people want their truth with
more unity and seamlessness. In alternative medicine, the spiritual
and physical domains provide different voices of the same cosmic
anthem. Nature and vitalist forces are the "technology" for
regulating the secular-divine dispensation connecting the
metaphysical and physical.
This spiritual materialism can work for both practitioner and
patient. One can see the importance of spirituality in one of the
few rigorous sociologic studies of alternative medicine
practitioners, in which a cohort of 340 members of the American
Holistic Medical Association was compared with 142 California
family practice physicians with similar demographic profiles. The
most statistically significant variable that distinguished holistic
providers from conventional providers was the importance of
"religion or spiritual experiences" in their views of health,
illness, and healing (55).
Participants in alternative healing create a form of religiosity
in their quest for health, although sometimes with less
self-awareness. Vitamins, dietary supplements, and exercise
regimens become daily activities of affirmation, assurance, and
commitment (56, 57). Dietary regimens, which
can seemingly rely on brown rice or raw fruit juices, become
liturgical acts of recognition with deeper implications for social,
moral, and spiritual redemption (58, 59).
Such religious disciplines as meditation or vegetarianism,
originally meant to foster transcendence and a triumph of spirit
over body, are adopted with the aim of somatic perfection (60, 61).
Spirit and body commingle and create what William James (1842-1910)
once called "the religion of healthy mindedness"
The Persuasive Power of Alternative Medicine
The extent to which the use of alternative medicine relates to
biological or measurable health outcomes continues to be
investigated (63). Both positive (64-66) and negative (67-69)
evidence has accumulated, and further investigation will
undoubtedly provide a clearer picture. Whatever the outcome of this
research, alternative medicine will probably continue to exist and
thrive. As claims are disproven (such as treatment with Laetrile
 and iridology ), other therapies will certainly take their
place (72). The enduring attractiveness of
alternative medicine may, at least in part, be largely related to
the experience encoded in its four basic cultural premises.
The possibility of the efficacy of alternative medicine does not
mean that a participant must be a true believer or require
confirmation by critical examination. To use the description that
Laurence Kirmayer gives for metaphor in any medical system, these
shared assumptions are taken in "not in the sense that their truth
value is certified by logic or argument but in the sense that they
are taken into the imagination and lived with, if only for a time"
(73). The assumptions of alternative medicine
can be an especially powerful vehicle for what Arthur Kleinman
called the "pathways of words, feelings, values, expectations [and]
beliefs" that reorder and organize the disease experience involved
in all healing methods (74). These persuasive
themes may be largely responsible for the many unimpeachable
testimonials of empowerment and the concrete perceptions of
transformation that sustain this powerful parallel medical option
This essay has portrayed the distinction between orthodox and
unorthodox medicine rather starkly. We attempted to bring to the
foreground the discordant beliefs of alternative medicine. Even
when patients and practitioners hold such discrepant viewpoints,
physicians still need to negotiate relationships and provide
biomedical care. We hope that this inquiry provides some background
so that physicians may more easily understand why patients are
attracted to and accepting of alternative models of health. Given
the widespread use of alternative medicine, the absence of a
respectful and sensitive attempt to communicate across cultural
medical barriers may subvert the possibility of
relationship-centered care (76, 77).
From another perspective, the chasm between orthodox and
unorthodox can be seen as less absolute and a matter of degree. All
medical systems have their persuasive appeal
(78-80). Biomedicine is also imbued with a "sacred" dimension,
and the white coat still retains elements of the numinous (81-83). Medicine acknowledges a deep sense of core
values, such as respecting patients, giving service, and seeking
truth, which can provide an ultimate sense of meaning. Physicians
often rely on the power of nature (for example, in wound healing
and recovery from the common cold). Vitalist forces also inhabit
the biomedical world in the form of the placebo effect and the
patient-physician relationship. Biomedicine can even wave a
"scientism" banner when it flaunts the authority of science if
evidence is scarce or nonexistent (84).
Given these overlaps, what is the critical distinction between
conventional and unconventional medicine? One fundamental
difference is that biomedicine has a more rigorous and
self-critical scientific method. But there may be an even more
subtle discrimination, equally important, that concerns a basic
ethos and sensibility. It may be that biomedicine, when it is
honest, is less optimistic and more realistically accepts the
limitations and finitude of the human condition.
Acknowledgments: The authors thank Robert Scholten and
Maria Van Rompay for research assistance and Marcia Rich, Janet
Walzer, and Debora Lane for editorial suggestions.
Grant Support: In part by the National Institutes of
Health (U24 AR43441), the John E. Fetzer Institute, the Waletzky
Charitable Trust, the Friends of Beth Israel Hospital, the J.E. and
Z.B. Butler Foundation, and the Kenneth J. Germeshausen
Requests for Reprints: Ted J. Kaptchuk, OMD, Center for
Alternative Medicine Research, Beth Israel Deaconess Medical
Center, Harvard Medical School, 330 Brookline Avenue, LW-600,
Boston, MA 02215.
Current Author Addresses: Drs. Kaptchuk
and Eisenberg: Center for Alternative Medicine Research, Beth
Israel Deaconess Medical Center, Harvard Medical School, 330
Brookline Avenue, LW-600, Boston, MA 02215.
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