REVIEWED BY DOROTHY G. BARNARD, DD
Daniel Callahan, ed.
Georgetown University Press, Washington, DC, 2002, 208 pp., $44.95, $33.50 (paperback)
This is a small but meaty and provocative book. It gives the reader an overview of the various arguments for and against what has become known as "complementary and alternative medicine" (CAM). In addition to its balanced presentation, it points the way to possible future validation of CAM and dialogue concerning it. This is a hot and timely subject treated with scholarly seriousness and intensity.
Although, as its editor, Daniel Callahan, notes, the book is targeted for medical practitioners, researchers, and scholars of medical issues, other types of readers may well be enlightened by the work presented by these scholars. The book should interest both those who are convinced of the merits of CAM and those who seriously question the efficacy of such therapies.
The scholars selected to present articles for this collection are from varied disciplines: medicine, philosophy, research methodology, cultural and folklore studies, and sociology. From the standpoint of these disciplines, they discuss both the methodological problems and the cultural perspectives associated with issues in CAM. The authors present carefully reasoned arguments from various vantage points. As the dialogue continues between CAM and conventional orthodox medicine (COM), many in the health field can benefit from the ideas presented here.
This volume can be used as a reference book and a starting point for study and future discussions. The many footnotes at the end of the chapters further increase the book's value as a resource. The biographical information on each writer reveals impressive credentials. The index provides another advantage for study and reference. The format—which mixes chapters on methodology with chapters on sociology—is helpful and effective. As the reader progresses through the book, he or she can almost feel the tensions involved in the discussion.
Callahan invited 11 scholars to participate in this project. These highly competent persons were sympathetic to CAM, but they were also willing to subject it to criticism. All believed "that CAM is a social and medical phenomenon worth taking seriously." Although many physicians in COM oppose the use of CAM, the public spends billions of dollars on these new therapies, out of pocket. Where is COM failing to help? And why do so many people—including many well-educated, middle-class people—believe CAM is helpful?
Each author was asked to write an article from his or her specific point of expertise. Callahan posed four questions for their consideration: (1) Is there only one acceptable method of scientific evaluation? (2) How tolerant should medicine be of different methodologies and standards of evaluation? (3) What is meant in saying that a therapy does or does not "work"? (4) What is a suitable research agenda for CAM?
Underlying these questions are two others: What is the meaning of the public interest in CAM? What is lacking in COM?
The first essay, by Kenneth F. Schaffner, considers CAM's efficacy from the perspective of methodological pluralism. We are dealing with two different worldviews, Schaffner says. CAM, he suggests, has evidentiary standards that are different from COM's. CAM can help us realize that the influence of belief systems may have powerful effects on health and disease, and "that discerning these effects may require a relaxation of the most Procrustean standards" (p. 12).
David J. Hufford approaches pluralism from a cultural perspective, asking whether what he calls "prior plausibility" is relevant for new therapies. Theory takes precedence over evidence when unconventional claims meet conventional dogma, Hufford writes. "If medical research were more open to such outside claims, medical progress would be better served than by a tenacious triumphalism asserting that contemporary medical science already knows everything worth knowing except for those new things which it will discover entirely on its own" (p. 23).
Loretta M. Kopelman, on the other hand, argues that CAM must be judged by the same standards as COM. Bonnie B. O'Connor suggests that CAM pushes us to consider methodological innovation. "A truly integrative approach to health care will have to accommodate multiple conceptual and healing models, effectively combine qualitative and quantitative research methodologies, and give weight to patient as well as professional interests, problem definitions, and outcome measures," she writes (p. 70).
Howard Brody discusses the placebo effect in CAM. David B. Larson and Susan S. Larson write about spirituality and its role in healing. To be fully competent and compassionate, they say, a physician must learn to address a patient's spiritual needs. Asbjorn Hrobjartsson and Stig Brorson take on the difficulty of properly interpreting results from randomized trials of CAM in a way that upholds rigorous standards. Wayne B. Jonas looks at the methodological problem of assessing CAM and proposes different levels of assessment. Tom Witmarsh discusses homeopathy, concluding that physicians using conventional medicine often provide effective care for patients despite the absence of [random control trials] to validate the treatments they provide.
Paul Root Wolpe considers the impact that CAM is likely to have on medical culture. "COM does not recognize the mythological, ritualized, and culturally embedded aspects of CAM's philosophy and praxis," he writes. "One of the strengths of CAM is the relationship with the healer, the sense of personal responsibility and the cultural and ritualized environment in which it is offered. "COM tends to deny the role these dynamics play in healing" (p. 169). In the concluding essay, Alfred I. Tauber asks: What is medicine? If we define medicine as science, he writes, we must admit that traditional aspirations of science are inadequate in addressing medicine's moral mission, which is providing care. Care must address the needs of psyche and the person embedded in culture. Care for the patient, as CAM providers remind physicians, is commitment to the ill. Trust engendered by compassion is the mandate.
Is it possible that medicine, as we of the West have traditionally understood it, is missing something very important because scientific success has blinded it to other possibilities? Will Western COM ever recognize the Eastern thinking that underlies much of CAM? No single worldview encompasses all of the truth. With humility our scientific, Western COM may in time learn from the Eastern viewpoint and CAM.
Dorothy G. Barnard, DD
Director of Mission
St. Luke's Hospital
St. Louis