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‘... it is not so much the treatment on offer that determines whether the medicine is orthodox or alternative, but the quality of evidence adduced in its favour.’—Editorial, Lancet, 1989; ii: 901
The expansion of complementary and alternative medicine (CAM) during the past two decades has generated many articles in medical journals; and, whether the authors are for or against CAM, the emphasis has been on its distinction from evidence-based medicine (EBM). In this paper I look instead at points of convergence that might open the way to future coordination, collaboration and integration.
For our purposes, the most suitable definition of integration is ‘the combination of previously racially segregated social facilities into a nonsegregated system’ (Collin’s English Dictionary). In the past, scholars and investigators polarized the debate by disparaging references to the other side. For instance, CAM was portrayed as user-friendly, holistic, mild, simple and liberal,1 EBM as technological, aggressive, and paternalistic;2 or, in the other direction CAM was dismissed as a form of magic3 while EBM reigned supreme through its foundation in experiment and reason.4 Voices towards mutual understanding have not been absent, but the conventional physician usually wishes the complementary practitioner to perform his art in the manner of a conventional physician, and vice versa.
There are philosophical differences. EBM is mainly based on modernist assumptions, while CAM is chiefly akin to postmodern reasoning.5 EBM gets its scientific rigour from positivism, empiricism and experiment. CAM gains its appeal by addressing the patient’s spirituality and social sensitivity, the mind–body relationship and the role of nature in healing, and by an absence of authoritarianism.6,7 Even when subscribing to the biopsychosocial paradigm, medicine has undeniably lost some of its Hippocratic holism; but CAM advocates face an equally cogent complaint—how are people to be protected against quackery?8 The dialogue can be focused on two major areas—the relation between modernism and postmodernism; and the notion of spirituality and the mind–body relationship.
Normal or modernist science claims to be objective, socially neutral, reductionistic and primarily materialistic. Postnormal science, which is akin to postmodernism, rejects scientific certainty and objectivity. In medicine, the postmodern view has been judged applicable to general practice9 and psychiatry,10 as well, of course, to CAM therapies.5 Some writers of the postmodern school see the quest for truth as a struggle for power, in which their societal (subjective) approach is pitted against reductionism. In doing so, they are hardly breaking new ground. Even in the mid-19th century the societal aspects of science were being examined by such scholars as Auguste Comte and Karl Marx. Though themselves products of the Enlightenment, both criticized crucial aspects of Enlightenment mainstream thought (in Cours de philosophie positive and Das Kapital, respectively). In theory, such ideas come together in today’s prevailing doctrine that patient and doctor participate jointly in a healing process aimed not at a single ailment but at the patient’s individual priorities and way of life. But certain CAM advocates enquire just how often this actually happens in consultations geared to EBM.
Conventional practitioners tend to avoid spiritual issues,11 not least because these are not part of medical education. In CAM, by contrast, issues of spirituality loom large. Many CAM therapies are closely associated with religions or philosophies representing long traditions of healing. Yet, although EBM reflects the split between religious spirituality and science-based healing in the 20th century, even strong advocates of this approach see the need to address mind and body as a continuum.
Much has been written on the need to examine CAM scientifically and to reach conclusions on its therapeutic efficacy. From the evidence that has emerged so far, no firm conclusions can be drawn on either the safety or the efficacy of most therapies.12,13 The practical difficulties of studying certain therapies have generated diametrically opposite conclusions—that CAM should be free from scientific scrutiny and that therapies that cannot be evaluated scientifically should not be permitted. In both instances, the scientific scrutiny under discussion is the randomized controlled trial. Some CAM therapies, homeopathy or herbalism for instance, can be tested in this way, but others, such as acupuncture or chiropractic, are less suitable and the paucity of controlled trials does not reflect on their efficacy. Even in EBM, the conducted ‘observational’ study has its place.14 Whether the therapy in question is conventional or complementary, the best research strategy has to be found and applied. Already, there is much evidence from psychiatry that the way forward lies in collaboration rather than confrontation.