Understanding Alternative Health Care
 
   

Understanding Alternative Health Care

This section is compiled by Frank M. Painter, D.C.
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   Frankp@chiro.org

 
   

Journal of the Neuromusculoskeletal System 19998; 6 (3)

Craig F. Nelson, D.C.,

Center for Clinical Studies,
Northwestern College of Chiropractic,
Bloomington, Minnesota


This article is republished exclusively @ Chiro.Org by permission of Data Trace Publishing Co, publishers of JNMS. A special thanks to Sheryl Baum of Data Trace and to Ryan Evans for creating a scanned copy for our use.   Check out their website @   Data Trace Publishing


The increased popularity and acceptance of alternative health-care (AHC) have been well-documented [15]. While there is little doubt as to the reality of the AHC phenomenon, there is considerable uncertainty and disagreement over its meaning and significance. For some, the phenomenon is celebrated as the dawning of a new era in health care, while skeptics are appalled by what they perceive to be either a craven effort to cash in on a credulous public's appetite for New Age bunk, or simply the abandonment of reason. Within the medical community, the debate continues whether it is possible or desirable to integrate alternative practices within mainstream medicine or whether the only principled action is to oppose, discredit, and eliminate these practices.

The chiropractic community has tended to view the boom in alternative health care as an unqualified blessing for the profession. Chiropractic views the AHC phenomenon as vindication of its own principles, as evidence of the vulnerability-of medicine, and as a sure guarantee for the future growth of the profession. There is the assumption that the current upward trajectory of AHC will persist and even accelerate in the future. However, any calculation as to the ultimate status of AHC within the health care system and how this may affect the chiropractic profession's role within that system must proceed from an analysis and understanding of the actual meaning of the AHC phenomenon. Such analyses have largely been absent. It is also difficult to study this phenomenon without activating a variety of professional jealousies and interests. Turf is at stake always a complicating factor. This article is an attempt to clarify the issues.



THE NEW AGE IS NOT UPON US

It is first useful to ask in what sense AHC is alternative. Alternative to what? It is not necessarily alternative to medicine. Some of the most prominent advocates/theorists of the alternative health care movement are medical physicians, and there are many instances of alternative therapies being used by medical physicians in medical settings. What does set AHC apart are the metaphysical belief systems upon which most are predicated. Most systems propose novel physical or biological laws, or the existence of as yet undiscovered forces: chiropractic has its innate Intelligence and subluxations, acupuncture has its meridians and chi, and homeopathy has its laws of infinitesimals and similars. Alternative status derives principally from these beliefs and the means by which they are conceived and examined alternative, therefore, to the conventions of the scientific method, and to the orthodox understanding of the nature of health and disease.

For many advocates and patients it is precisely the metaphysical components of these practices, even beyond any tangible health benefits, that are the most appealing. There is an overt anti-science mentality that pervades the phenomenon. Some believe, in fact, that what we are seeing is the emergence of a new way of understanding the world a rejection of what is often called the Western, linear, Newtonian point of view, in favor of a postmodern relativism that asserts that all points of view are equally valid. The study by Astin found that it is not dissatisfaction with medical care that drives utilization of alternative care; rather, it is what he terms "philosophical congruence" between patient and practitioner [6]. Specifically, persons who are categorized as "cultural creatives" are those most likely to utilize alternative health care. This group is characterized by, among other things, an affinity for "exotic forms of spirituality and personal growth psychology . . . and a love of the foreign and exotic."

This group of cultural creatives, both patients and practitioners, should not feel vindicated by the apparent successes of alternative health care. In spite of its popularity with the public, its growing acceptance by medicine, and the evidence of effectiveness of some alternative therapies for certain complaints, there is no reason to believe we have entered the New Age. This newfound respectability should not be interpreted as validation of the exotic metaphysics upon which many AHC systems are predicated, and for which many patients feel an attraction. Indeed, even as a therapy like spinal manipulation gains credibility, the original doctrine that once was used to rationalize its use becomes less plausible than ever.

It is often reported in the popular press that mainstream scientists themselves have come to accept many of the tenets of AHC. For example, a recent meta-analysis on homeopathy clinical trials concluded that the effects seen in these trials could not be accounted for by chance or placebo effects. This study, published in the prestigious journal Lancet, is often cited as an example of the scientific acceptance of AHC principles. However, in two accompanying editorials, the authors of the study concluded that publication bias, methodological errors, and other unknown biases were more likely to account for the observed effects than was actual homeopathic treatment effects [79]. The authors concluded, "scientists are likely to remain doubtful [of the validity of positive findings] unless plausible mechanisms are discovered."

There is no study, observation, set of facts, or emerging understanding of health and disease associated with AHC that should cause anyone to question the well-established principles and methods of scientific inquiry. There is to date no clinical finding associated with alternative therapies that is incompatible with conventional scientific beliefs. The scientific method that eliminated smallpox, controlled diabetes, and extended our lives by decades remains valid, and is the only method that is likely to extend those accomplishments in the future.

It is worth noting that the current zeitgeist that has given rise to the AHC phenomenon and the cultural creatives who utilize its services is not unique in American history. There has always been a strong appeal for vitalistic and naturalistic healing methods within American culture and this appeal has waxed and waned throughout our history. Indeed, it was during one such cyclic upswing over a century ago that the chiropractic and osteopathic professions were born [10, 11].



NOT ALL ARE EQUAL

With regard to the belief systems that define many AHC practices, an important distinction must be made. While most alternative systems are predicated upon beliefs that are incompatible with accepted physical and biological laws, some do not require an acceptance of those beliefs to imagine how they might have therapeutic effects. For example, the chiropractic profession was founded on the idea that there are certain life forces coursing through the body which are impeded by spinal misalignments, thereby causing disease. This belief is still held by many in the profession.

However, it is not necessary to believe this in order to imagine or understand how spinal manipulation might be an effective therapy for certain conditions. It is entirely possible to develop a rationale for the use of spinal manipulation in terms which are wholly consistent with a conventional understanding of anatomy and physiology [12,13]. Similarly, acupuncture, massage, and herbal medicine all carry with them belief systems that are at odds with conventional science, but which are also not necessary to explain their effects. Acupuncture can be understood as a neurologic phenomenon, massage as a physical modality like many others, and herbal medicine as pharmacology.

The same cannot be said of homeopathy, for example. Homeopathic preparations, after the dilutions that are considered essential to their effectiveness, may contain zero molecules of the active agent. These preparations are pure (hopefully) water and ethanol. It is hypothesized by believers that the missing agent has somehow passed some of its essence or resonance to the remaining water. Thus one must believe in some sort of "energized water" theory to sustain a belief in the effectiveness of homeopathy. Anyone considering the question might wonder why every glass of water that is drunk is not homeopathically active in some way. Surely, serendipitous dilutions are occurring all the time.

There are many other alternative systems of therapy (crystal therapy, energy healing, aura therapy) whose acceptance requires a similar suspension of one's critical faculties, and there is no evidence that doing so will result in a greater understanding of health and disease. Those practices that require the invocation of new physical laws, or undiscovered forces, may reasonably and fairly be dismissed until such time as evidence of these revelations emerges. The principle that extraordinary claims require extraordinary proof remains valid and relevant vis-a-vis alternative health care.



THE BIOPSYCHOSOCIAL MODEL

If one accepts that the metaphysical aspects of AHC do not represent an advance in our understanding of health and disease, what value could they have? Whether an alternative health care system is scientifically plausible and whether that system provides a needed and valuable service to persons with health problems are not the same questions. Twenty years ago psychiatrist George Engel, M.D., writing in the journal Science, proposed a revision to what he called the "biomedical" model of disease [14]. This model assumes that a disease state can be fully understood in terms of deviations from physiologic or anatomic norms. The role of the physician, then, is to restore these biologic variables to normal values. Engel argues that while this model has been enormously successful in numerous and obvious ways, it provides an incomplete understanding of disease processes. It does not account for, or recognize the importance of, behavioral, psychologic, or social factors in how patients experience disease and illness, or how these factors may be modified to promote patients' recoveries. Engel concludes that a "biopsychosocial" model more accurately describes disease processes and provides for potentially more effective intervention. Both critics and advocates of alternative health care have failed to take into account this biopsychosocial model when assessing the role and value of alternative health care.

A frequent criticism of alternative therapies is that any improvement that patients may experience is wholly the product of placebo effects, and thus of no real value. This reflects the biomedical purists' understanding of disease which equates placebo effects with a sham treatment. There remains the conviction among many in medicine that any therapeutic effect that cannot be defined biologically is the product of a gullible patient and a deceitful practitioner. But Engel's formulation implies that it is entirely proper and necessary to provide therapies that maximize these extrabiologic effects. Others have also rejected the notion that to administer a placebo is the same as doing nothing, or worse, committing a fraud [15]. While it might strike some as an exercise in euphemism and obfuscation, the use of the term nonspecific treatment effect, rather than placebo, represents a more nuanced and complete understanding of this phenomenon.

The limitations of the biomedical model are clearly seen when studying low back pain. In the absence of any gross anatomic lesion, there is not a great deal that can be meaningfully said about the causes, prevention, and treatment of low back pain that conforms with the biomedical model [16]. Several decades of research have failed to identify any important physical factors (posture, strength, type of injury, degree of degenerative changes, etc.) that predict the occurrence, affect the prognosis, or define what treatment regimen will be most effective for low back pain. A recent study on the effects of a back pain prevention program based on sound biomechanical principles failed to show any benefits from such a program [17]. Neither has the chiropractic profession been able to demonstrate that properties of vertebral alignment or misalignment are related to the phenomenon of back pain. To date, the most important variable identified as a predictor of back disability is not a physical, but a social variable: job satisfaction [18]. While there may yet be important undiscovered physical principles that explain back pain, it is clear that to ignore the psychosocial component is to limit the potential improvements that can be made in managing this problem.

It is also evident that even when physical causes are obvious, extra-biologic factors remain important. Every disease process, particularly chronic disease, is accompanied by a functional or reactive component to that process: fear, loss of control, anxiety, behavioral changes, and generalized suffering. The degree of suffering or loss of function a person experiences as the result of a physical illness is not in direct proportion to the degree of the physical complaint. These reactions create patient needs which are independent of the pathologic changes which initiated the process. Alternative care is sometimes criticized for doing nothing other than addressing this component of illness. But these needs are real and legitimate, and in many clinical circumstances there may be nothing else to do except to address this component of the patient's illness. To the extent that medicine fails to value this type of care, and to the extent that medicine views its role primarily as that of "lesion management," it will fail to meet many patients' needs and these patients will inevitably turn to others.



THE AHC FALLACY

Engel's criticism of the biomedical model has been seized upon by AHC advocates and interpreted as an invitation to reject the methods and conclusions of biomedical science and to invoke their own metaphysics as explanations for health and disease. While critics of AHC-may fail to appreciate the value of addressing the psychosocial component of disease, its advocates often fail to recognize that these factors may be responsible for patient improvement. The failure to recognize the role of psychosocial factors in their patients' improvement leads alternative practitioners to the erroneous conclusion that this improvement is evidence of the validity of their underlying theoretical constructs.

Thus AHC has turned Engel's analysis upside down. It has replaced the biomedical model not with the biopsychosocial model, but with a biochiropractic, bioayurvedic, or biohomeopathic model, whereby biologic effects are presumed to result via the hypothesized mechanisms that define these alternative systems. In this way AElC repeats the same reductionist error as medicine and in a far less convincing manner.

The alternative care movement also frequently distorts the meaning and significance of the role of the mind or psyche in disease. Engel's observation that psychologic factors are important in understanding disease processes does not imply that the mind can be used as a therapeutic tool. Many AHC practices are predicated on the belief that thoughts, feelings, emotions, and mental imagery can be used to directly influence and correct aberrant biologic functions. The belief that tumors can be made to shrink, immune systems made whole, and cardiovascular disease reversed through cognitive or meditative effort is not a logical corollary of the biopsychosocial model and these effects remain undemonstrated.

In a curious way, both ends of the spectrum of belief in alternative health care converge and stumble over their understanding and appreciation of the biopsychosocial model. Neither the skeptics nor the advocates appear comfortable with the conclusion that patients may experience substantial benefits from AHC that are not derived from changes in any biologic variables or that it is a valid end in itself to promote patient well-being via psychosocial mechanisms.



SAFETY

Much of the anxiety expressed by skeptics regarding alternative therapies concerns the question of safety. These therapies, many of them being untested and unregulated, may be hazardous. There are abundant anecdotes and case reports of AHC-related mishaps, most of them resulting from vitamin toxicity or contaminated herbal preparations. There is little doubt, particularly with respect to the nutritional and herbal supplements, that these practices are not as safe as they could be, and that some sort of standardization and regulation could eliminate most adverse incidents. If herbal or botanical preparations do have beneficial biologic effects, it is only because they contain pharmacologically active ingredients (i.e., drugs) and the fact that they are in some respect "natural" in no way ensures that they are safe. A recent series of papers and editorial comment in the New England Journal of Medicine has highlighted this problem [1921].

But even with this shortcoming in mind, the alarm and apprehension expressed by many concerning the safety of AHC seems unwarranted. By their very natures, which are largely conservative, noninvasive, or even inactive, alternative therapies tend to be intrinsically safe. The evidence regarding spinal manipulation, the most aggressive and potentially hazardous of the alternative therapies, indicates a more than acceptable level of safety, particularly when compared to other treatment options [2224].

Critics also raise the safety issue by suggesting that alternative health care may cause "indirect toxicity" whereby patients postpone or abandon effective medical care in favor of ineffective, if innocuous, alternative care [25]. The Eisenberg study on unconventional medicine does not support this argument [1]. In this study, only 4% of respondents with a medical condition who used unconventional therapy did so without also seeing a medical physician. There were no examples (out of 1,539 respondents) of patients using unconventional therapy, but not a medical doctor, for the treatment of cancer, diabetes, lung problems, skin problems, high blood pressure, urinary problems, or dental problems. The survey found that by far the most common reasons for utilizing unconventional medicine were for conditions (back pain, headache, anxiety, sprains or strains) which are very unlikely to represent a serious underlying condition.

There is no evidence that patients are abandoning safe and efective medical care for unproven and hazardous alternative practices. In fact, the inherent benign and safe nature of AHC is a principal attraction for patients. They correctly perceive these treatments as being less likely to do harm than medicine. Suggestions of systematic and pervasive threats to public health and safety remain undemonstrated.



CONCLUSION

There has always been an active and vocal movement within medicine and its allied sciences to expose the shortcomings of alternative health care. The debunking of pseudoscience and the effort to protect the public from harmful practices are legitimate and honorable enterprises. However, the impulse to deplore any health care practice which does not conform to established scientific principles should be tempered by several considerations:

  1. The unorthodox theories that characterize many AHC practices may obscure valuable therapeutic modalities. It is easy to become distracted by the implausible conjectures of some alternative systems, but the proper question to ask is not whether the theories make sense, but whether the practices themselves make sense. Those practices for which plausible mechanisms can be hypothesized should be investigated, and embraced or rejected as the evidence dictates. The scientific attitude toward those practices should be one of ruthless and rigid skepticism. There is no rationale for holding AHC to a different scientific standard or to employ different methodology in its study than is conventionally used [26]. But if neither theory nor practice can be made to conform to some reasonable understanding of physical laws, there is no obligation, scientific or otherwise, to expend effort or expense in their study. In such cases, the burden of proof lies with the advocates of those AHC systems.

  2. Patients' needs may extend beyond the resolution of specific lesions or pathologies. And these needs are sometimes effectively met by alternative practitioners. The existence of extra-biologic factors in the etiology and resolution of the disease state does not, of course, suggest the inevitable efficacy of alternative health care practices. AHC practices may also be ineffective in addressing these factors, but there is clearly something to be learned from alternative health care about the psychology of health and disease which all health care practitioners might profitably adopt for their own use.

  3. The promotion of scientific literacy should not be confused with patient care. Promoting scientific literacy is a noble endeavor, but a physician's office is not the proper place to pursue this objective. A fierce rationalism is not necessarily a patient's only proper response to a health crisis. Unless some harm is likely to result, patients' best interests may be served by listening attentively and nonjudgmentally as they describe a belief about their health that is at odds with one's own. If a patient reported that he felt much better after having his auras balanced, what would be accomplished by confronting this perception other than to prove that the physician is smarter than he? It is not inevitably true that scientifically naive beliefs about health and disease result in harm to patients.

  4. The standard of comparison should not be perfection. Critiques of alternative health care should not proceed from the assumption that in utilizing alternative health care patients are abandoning a perfectly ordered, intrinsically safe, and predictably effective medical health care system. It is too easy to document the uncertainty of medical outcomes, the degree to which medical decisions are guided by economic self-interest, and the harm which routinely results from conventional medical care to make this assumption credible.

    At the same time, uncritical acceptance of alternative health care should also be tempered:

  5. The recent enthusiasm for AHC is largely a cultural rather than a scientific phenomenon. While in the short term this cultural shift may provide some new opportunities for the chiropractic profession and others, the public's present fascination with AHC will have little effect on the long-term vitality and growth of our profession. The pendulum will likely swing (and this may already have begun) away from the current fashionability of AHC.

  6. A far more important and durable trend than the current cyclic upswing in AHC is the recognition that health care providers must be held accountable for the safety and effectiveness of their practices. Orthodox methods of investigation and research will be the basis by which those practices are evaluated. The label, "alternative health care," will not excuse any profession from the requirement to demonstrate safety and effectiveness.

The chiropractic profession occupies a position midway between mainstream and alternative health care; it is the most orthodox of the alternative systems. This position can be exploited to the advantage of both the profession and the public if the strengths and weaknesses of these two polarities are fully and rationally assessed.


Received, September 24, 1998

Revised, October 21, 1998

Accepted, October 23, 1998

Reprint requests: Craig F. Nelson, Northwestern College of Chiropractic, 2501 W. 84th St., Bloomington, MN 55431.



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