Pekka Louhiala argues that "there is no alternative medicine" because
"it escapes a meaningful definition, and 'alternative medicine' cannot
be clearly differentiated from conventional medicine" [1]. I do not
consider that his arguments are valid.
Louhiala does not mention the proposed definitions for "alternative
medicine". For example, Eisenberg defined alternative medical therapies
as "interventions neither taught...
Pekka Louhiala argues that "there is no alternative medicine" because
"it escapes a meaningful definition, and 'alternative medicine' cannot
be clearly differentiated from conventional medicine" [1]. I do not
consider that his arguments are valid.
Louhiala does not mention the proposed definitions for "alternative
medicine". For example, Eisenberg defined alternative medical therapies
as "interventions neither taught widely in medical schools nor
generally available in US hospitals" [2]. Cochrane collaboration
defined: "Complementary and alternative medicine (CAM) is a broad
domain of healing resources that encompasses all health systems,
modalities, and practices and their accompanying theories and beliefs,
other than those intrinsic to the politically dominant health system of
a particular society or culture in a given historical period. CAM
includes all such practices and ideas self-defined by their users as
preventing or treating illness or promoting health and well-being.
Boundaries within CAM and between the CAM domain and that of the
dominant system are not always sharp or fixed" [3]. I do not consider
that these definitions are exhaustive, but they capture what I think is
the most essential.
These definitions consider that the relevant factor for setting up
the boundary around alternative medicine is by the lack of social
acceptance within mainstream medicine. Thus, alternative medicine
consists of interventions that are outside of the "conventional" or
"medical school" medicine. The definitions above do not consider
whether a treatment is effective or not. Effectiveness is located on a
different dimension and it is not part of a relevant definition for
alternative medicine.
Louhiala formulated numerous arguments that do not teach us anything
about the usefulness of the concept of "alternative medicine". Although
I agree that in many cases "modern medicine is much more varied in its
approaches than the propagandists for alternative medicine usually
imply", this statement does not imply any conclusions about the concept
of "alternative medicine".
I do not agree with Louhiala's statement that "alternative medicine
means that the other option is rejected". For example, many of my own
patients describe that they also use some forms of alternative
therapies, but they do not reject me therefore. Nevertheless, whatever
our opinion on this issue
is, that has no importance to the question whether "alternative
medicine"
is a useful concept.
I disagree also with the statement that "if a genuine alternative
medicine did exist, it should produce results that are similar to those
of ordinary medicine". There is much treatment variation
within mainstream medicine, and thus there is no uniform "treatment
result" to which the results of alternative therapists
might be compared unambiguously. Furthermore, when we accept the rather
large treatment variation within mainstream medicine, why should we not
accept variation between mainstream medicine and alternative medicine.
In any case, this issue does not seem relevant to the question whether
the concept of "alternative medicine" is useful.
I agree with the statement that "alternative medicine cannot be clearly
differentiated from conventional medicine". There are numerous cases
where the border between neighboring concepts is fuzzy. Internal
medicine cannot be clearly differentiated from general practice
medicine (e.g. both treat hypertension). Children cannot be clearly
differentiated from adults (e.g. teenagers are biologically adults but
psychologically children). However, the lack of a clear differentiation
does not imply that "internal medicine" or "child" are useless concepts.
Louhiala states that "bundling all the so called alternative therapies
under one heading is misleading. It is hard to see common features
between, say, healing using prayer and healing using megadoses of
vitamins." If alternative medicine is defined by the lack of social
acceptance as described above, that provides an unambiguous
justification to put prayer and megavitamins under the same heading.
Furthermore, there is great variation in the approaches within the
mainstream medicine from surgery to pharmacology to psychiatry. If
Louhiala's argument is valid, we should not bundle such different
methods under the one heading of "medical school medicine".
Louhiala states that "alternative medicine" is a buzzword, which may be
true in certain contexts. However, in mainstream medicine, there are
numerous buzzwords. Laser surgery, computed tomography, broad-spectrum
antibiotics, and many others are in certain contexts used to "impress
laymen", but that has nothing to do whether those methods are useful,
or whether those terms are linguistically sound.
While Louhiala criticizes the vague definition of "alternative
medicine",
he does not consider the definition options for "homeopathy". When I
was young, I studied biochemistry and got a PhD
degree. At that stage of my life, I defined homeopathy as "diluting a
substance to such an extent that there are no molecules left in a
spoonful". Thereafter I studied medicine.
When I started to work as a GP, I realized that there is a
fundamentally
different second definition for homeopathy: "a person goes to a
homeopath and stays there for some time and then leaves". If we ask
whether homeopathy is beneficial for a patient, we should first define
what we mean by "homeopathy", but this was not done by
Louhiala.
In catholic countries, sometimes people go to see a priest for a
confession. I believe that the confession often decreases the anxiety
of a person, and in that respect it leads to positive health
effects. This health benefit has nothing to do whether we think that
there is evidence for God. Similarly, homeopathy as an encounter can be
beneficial for a patient because visiting a homeopath is much more than
biochemistry.
While working as a GP, I have realized that a large
part of the positive health effects that I am generating on my patients
are caused by listening and speaking. Why should we assume that a
priest or a homeopath is incompetent at such an activity? I have seen
many physicians who are rather poor in their communication with
patients. Compared with them, an average priest or homeopath probably
generates greater improvements in health if the major problems of the
patient are
anxiety and depression.
On average, alternative therapists may have better bedside manners than
physicians [4]. Time spent with each patient by an alternative medicine
practitioner
usually exceeds that spent by the average physician. Alternative
medicine practitioners provide patients with understanding, meaning,
and self-care methods for managing their conditions. These elements
are often lost in the subspecialization, technology and economics of
mainstream medicine.
Furthermore, even though it is paradoxical, in some cases homeopathy is
better pharmacology than some popular treatment options of physicians.
If a patient has a viral respiratory infection and a homeopath treats
the patient with a highly diluted solution, the product will not cause
harm. If the same patient goes to a physician and gets antibiotics, the
benefit is non-existent there too, but the harm is not [5,6]. In such a
case, it is the homeopath who follows more closely the guidance "first,
do no harm."
I have a long lasting interest in the concept of alternative medicine.
My personal interest largely arose from my long term research on
vitamin C and the common cold, mainly by carrying out systematic
reviews from various points of view. In the latest version of our
Cochrane review, we pooled the results of 29 placebo-controlled
comparisons measuring the effect of regular >0.2 g/day of vitamin C
[7]. We found that vitamin C shortened colds in adults by 8% (P=0.0002)
and in children by 13% (P=0.0003). In 5 trials with participants under
heavy acute physical stress (3 of them with marathon runners), vitamin
C reduced
the incidence of colds by 52% (95% CI: 36% to 65%; P=0.0000006), but we
found strong evidence with a narrow confidence interval that vitamin
C does not prevent colds in the general population.
Given that there is such a strong evidence, mostly from trials
published already in the 1970s, that vitamin C differs from the
placebo, why does
vitamin C fall under the heading "alternative medicine"? Textbooks on
medicine, infectious diseases, and nutrition have claimed over decades
that vitamin C is useless for the common cold [8-10], and systematic
bias against vitamins in general has been documented in the major
textbooks of
medicine [11,12]. In a Dutch survey, 47% of GPs considered that
homeopathy is efficacious in the treatment of the common cold, whereas
only 20% of the respondents considered that vitamin C was [13]. In a US
survey, 21% pediatricians considered that homeopathy may be effective,
and 21% considered that high-dose antioxidant vitamins may be so (e.g.
vitamin C for the common cold) [14]. Thus, vitamin C is comparable with
homeopathy, and in some cases the credibility of vitamin C is even
lower.
While I was wondering the puzzling discrepancy between the positive
findings in the placebo-controlled trials on vitamin C and
the classification of vitamin C under the heading alternative medicine,
I
started to think that the most relevant way of defining "alternative
medicine" is by the lack of social acceptance. This notion was
formulated to
explicit definitions by other authors [2,3].
Evidence-based medicine emerged because several physicians realized
that many treatments taught at the medical school were useless and
started to speak about it loud. Thus, when a treatment falls into
the
category of "medical school medicine", that will not prove that the
treatment is effective. My own observations on vitamin C showed that if
a treatment falls into the category of "alternative medicine", that
will
not prove that the treatment is ineffective. Thus, social acceptability
and effectiveness are located on different dimensions, and it is the
former that is relevant if we search for a reasonable definition for
alternative medicine. I consider that in his paper Louhiala ignores the
main characteristic that defines alternative medicine [2,3].
At the end of his paper, Louhiala comments that "demand that
alternative medicine be taught in medical schools and/or financed
through public funding has no foundation whatsoever". I disagree also
with this opinion.
Louhiala does not define what he means by teaching. It is possible 1)
to teach the practical methods; how to carry out alternative therapies
at one's own office or 2) to teach about the most usual types of
alternative therapies in a descriptive way, so that a medical student
better understands our surrounding society.
If we follow the definitions described at the beginning of this
comment, it is logically impossible to teach medical students how to
start using alternative therapies, because including a therapy in the
medical school curriculum removes the status "not taught at medical
schools". The therapy that was "alternative" is not so any more.
On the
other hand, I cannot see any basis to oppose the second kind of
teaching. The purpose of education should be to increase understanding
why patients use alternative medical treatments, learning how to ask
about and discuss alternative treatments in a nonjudgmental manner,
learning which therapies can be harmful, and
understanding the basic tenets of the most common alternative healing
systems [15-17].
Furthermore, Louhiala's final comment is illogical. Given that he
states that "there is no alternative medicine", how could "alternative
medicine" be used as a criterion for not financing some activity - if
there is
no alternative medicine.
The purpose of my commentary is not to increase the social
acceptability of alternative medicine. I point out that the lack of
social
acceptability seems to be a reasonable basis for defining
alternative medicine [2,3], but this was not considered by Louhiala
[1]. I do not
hope that the use of homeopathy increases, instead I hope much the
contrary. Nevertheless, the question about homeopathy is more complex
than whether it is absurd from the biochemical point of view.
A Google search with the term "alternative medicine" finds over 10
million
web pages and one survey reported that 40% of Americans had used
alternative treatments over the preceding year [2]. I think that it is
much more fruitful to contemplate on the nature of alternative medicine
[3,4,15-22], instead of trying to argue that such a field does not
exist
[1].
I believe no mental patient should have family members make decisions
for them, as this can make the patient even more irritable. Ask the
patient what they want to achieve. Just like when someone is dying you
wouldn't disrespect their wishes.
You might also be interested in the character of Doctor Bompard (is
this name a French pun?) in Jules Romains' The Body's Rapture and his
long speech towards the end of the book, pages 428-429. This is not
specifically about medicine, though Bompard is a ship's doctor, but about
the purported march forward of science and philosophy since the Renaisance
and of course refering back to the ancient Greeks. In this case it i...
You might also be interested in the character of Doctor Bompard (is
this name a French pun?) in Jules Romains' The Body's Rapture and his
long speech towards the end of the book, pages 428-429. This is not
specifically about medicine, though Bompard is a ship's doctor, but about
the purported march forward of science and philosophy since the Renaisance
and of course refering back to the ancient Greeks. In this case it is not
claimed so much that this is all fraud and self serving deception on the
part of the practitioners but more that people, perhaps the patients
themselves, choose this course rather than confront or deal with
instances in their lives not easily open to rational explanations. Better
the spurious rationality of the medical/ scientific/ philosophic poseur
than the discomfort of the unknown, the unknowable sometimes or the
frankly uncontrollable. He actually makes quite a sympathetic case for
this attitude, a reaction against existance too much in the grip of
propitiating irrational, unknowable forces but nevertheless criticises its
bad faith.
Louhiala does not mention the proposed definitions for "alternative medicine". For example, Eisenberg defined alternative medical therapies as "interventions neither taught...
I believe no mental patient should have family members make decisions for them, as this can make the patient even more irritable. Ask the patient what they want to achieve. Just like when someone is dying you wouldn't disrespect their wishes.
Conflict of Interest:
None declared
You might also be interested in the character of Doctor Bompard (is this name a French pun?) in Jules Romains' The Body's Rapture and his long speech towards the end of the book, pages 428-429. This is not specifically about medicine, though Bompard is a ship's doctor, but about the purported march forward of science and philosophy since the Renaisance and of course refering back to the ancient Greeks. In this case it i...
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