More heat than light is being generated by the resurgence of the debate on orthodox evidence-based medicine versus the so-called pseudo-science of alternative therapies.
Unfortunately the voices of medical historians and social scientists, along with those of consumers, seem to be muted. As both a researcher and user of health services, three aspects of the Friends of Science in Medicine’s’s current campaign and commentaries on it seem remarkable to me.
The absent patient
First, they disregard what is now commonly discussed as the patient experience – so here’s mine. In the early 1970s, I knew little of chiropractic. But when I consulted my local general practitioner about recurrent headaches, I was prescribed anti-inflammatory medication to no useful effect. A friend recommended seeing her chiropractor.
I took her advice and came away absolutely astonished at being asked about diet, constipation, lifestyle and having my eyes and mouth scrutinised as well as my back adjusted. My headaches eased as I was taught to attend more to posture and diet.
In late 1979, I became ill with what was (once they had a name for it) chronic fatigue syndrome (CFS). Over the years, I consulted several fine doctors known to be interested in managing CFS with whatever medication seemed to work for particular individuals. Success was limited.
In 2002, I first attended an extraordinary medical doctor. Over time his detailed diagnosis, strict dietary regime, vitamins and homeopathic treatments worked. Evidence-based? Friends and colleagues commented on my transformation. I lived the evidence, but not in the eyes of the mainstream medical profession.
This doctor had been a suburban GP for some 20 years but was frustrated with not making people with today’s lifestyle and chronic conditions really well. Instead, as he puts it, he was being an unpaid salesman for the pharmaceutical industry.
So one day he just walked out and started again, retraining in several alternative modalities. His very busy practice is now based on a quite different ontology and epistemology than those of orthodox biomedicine.
Rather than a “curing disease” perspective, it aims to support the intrinsic energy system of a living body, just like chiropractic, to make people better. This is in stark contrast to the paradigm underlying modern medical science.
Lack of critical reflection
The second problem with recent debates, then, is the lack of critical reflection on philosophies of health and the politics of medicine. As medical philosopher Drew Leder has pointed out, historically, medicine’s model of knowledge was based on a dead rather than a living body, that is, on studying cadavers.
But most modern scholarship asks critical questions about what knowledge is, and who defines evidence – as well as in what context and in whose interests the answers are.
Gaining and maintaining medical power is clearly a highly political process of “shoring up the troops” and fighting off other contenders. Evan Willis has documented such struggles and exactly how the Australian medical profession achieved public legitimacy in spite of internal conflicts. Doctors’ organisations either subordinated (nursing and midwifery), limited (physiotherapy, optometry) or discredited other forms of clinical practice (homeopathy, chiropractic).
The third issue is critical analysis of the evidence-based medicine movement itself. Lively debates about the movement’s claims continue among medical philosophers, such as Andrew Miles, in publications, such as the Journal of Evaluation of Clinical Practice.
The peer-reviewed journal Social Science and Medicine even published a special issue on the topic in 2006.
These critics argue that simplistic over-emphasis on the evidence generated within the experimental, quantitative paradigm of Enlightenment science is inadequate because it diminishes clinical practice. Waymack and Charon, for example, point to the importance of patients’ subjective narratives and the “biopsychosocial” processes involved in interactions with care givers.
The randomised-controlled trials and systematic reviews espoused by evidence-based medicine are also increasingly recognised as inadequate or inappropriate for many aspects of health care. And some medical practitioners (such as Greenhalgh) have moved on from the dominant scientific paradigm, emphasising new understandings of human bodies as complex adaptive systems.
Humanistic medical approaches support a holistic understanding of the dynamic human body more compatible with the claims of alternative modalities. They’re also consistent with the growing strength of the patient-centred or, more radically, person-centred care movement in quality improvement circles.
Finally, critics such as Claire Wendland and Helen Lambert go further. Why do some findings, such as the now discredited obstetric term breech trial, get taken up rapidly while others do not? And how does medicine interface with the interests of the corporate sector?
Investigations such as those by Harriet Washington, Marc-André Gagnon and Joel Lexchin, and Ken Harvey (among others), into the politics of research funding and publication, make it clear that modern medicine is not squeaky clean. Rather, in line with the history of modern medicine, they show the insidious effect of Big Pharma’s influence.
Most of us want health care that has been critically scrutinised by accountable institutions and shown to work rather than cause harm. Some alternative treatments no doubt can be found wasteful or otherwise wanting. But mainstream health care also has significant problems, such of drug utilisation and medical error.
The answer lies not in more rigid insistence on the primacy of biomedicine, in spite of its great contribution to saving lives (including those of two members of my family recently). Instead, more attention to history, politics and philosophy, along with a large dose of humility, would allow us to move beyond outdated forms of professional territorialism and provide better care that responds the needs of patients.