The Persuasive Appeal of Alternative Medicine This section is compiled by Frank M. Painter, D.C.
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FROM: Annals of Internal Medicine 1998 (Dec 15); 129: 1061-1065 ~ FULL TEXT
Ted J. Kaptchuk, OMD, and David M. Eisenberg, MD
PERSPECTIVEAlternative 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 of text. 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 therapies.
Nature
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 overlooked (10).
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.
Vitalism
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 surgery (22).
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).
Science
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 geology (47).
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).
Spirituality
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" (62).
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 [70] and iridology [71]), 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 (75).
Conclusions
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 Foundation.
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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