From The New England Journal of Medicine
However one regards complementary and alternative medicine, there is little question that it represents a major sociocultural phenomenon. Large numbers of the general public, including many patients, use the products and services of complementary and alternative medicine. In 2000, Americans spent $10 billion on herbs, vitamins, and other dietary supplements. The estimated growth in the number of chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, and other nonphysician clinicians between 1995 and 2005 is double that of physicians. This situation is replicated in most developed countries. There is some research data and a great deal of speculation about what contributes to this substantive degree of interest in therapies often denounced by scientists and medical practitioners as unproved, nonsensical, or inconsistent with a scientific understanding of human physiology and disease. Most research projects attempt to define the problems -- desperation, depression, ignorance -- that bring patients to complementary and alternative medicine. But if one moves away from the assumption that the behavior involved is likely to be deviant, other factors can be posited as having major if not primary roles. Over the past few decades, patients have become increasingly interested in forgoing passivity in the doctor-patient relationship and demanding full information and something akin to a partnership role. There is a desire for more control over one's own health care and an unwillingness to rely exclusively on health professionals. This is, after all, the era of do-it-yourself money management and house repair, a preference for control and personal involvement that extends to health care and other areas of life. Furthermore, health information, albeit full of inaccuracies, is readily available on the Internet, and physicians today are familiar with patients who arrive for appointments with reams of printouts in hand. Thanks in no small part to managed care, mainstream health care has become more impersonal, and time spent with physicians has diminished. Complementary and alternative medicine and its practitioners offer something that patients want and do not get in mainstream medicine, which is the basic issue addressed in this very interesting book. In the introductory words of its editor, Daniel Callahan, the contributors to the book are "sympathetic to CAM [complementary and alternative medicine], take it seriously, and yet are quite willing to subject it to criticism." The chapter authors represent a spectrum of fields from which the sociocultural underpinnings and implications of complementary and alternative medicine come to light -- medicine, philosophy, culture and folklore, research methodology, and sociology. A contentious argument tackled early in the book reflects many of these perspectives. Marcia Angell and others have stated that studies must offer plausible biologic mechanisms for reported effects and that in the absence of plausible mechanisms, research on complementary and alternative medicine has no validity. Critics of this "prior plausibility" requirement claim that it is spurious. An example of this type of clash is the moxibustion study reported in the Journal of the American Medical Association in 1998, in which 260 primigravidas in the 33rd week of pregnancy, all with fetuses in breech presentation as diagnosed by ultrasonography, were randomly assigned to receive standard care or treatment with moxibustion, a traditional Chinese therapy for breech birth that involves burning moxa rolls on the corner of the fifth toe. It sounds absurd, but the results favored the Chinese method (P<0.001). Angell argued that burning Artemisia vulgaris on the fifth toe (and presumably anywhere else) cannot affect a fetus, so that data showing it did so must perforce be wrong. Moxibustion is not supported by Western medical tenets, but it was supported by research data. This clash of belief systems leads to questions discussed in this book. Is it appropriate to reject data on the basis of theoretical inconsistencies? Should theory be given precedence over rational inquiry? How might mainstream medicine deal with such challenges? Certainly, controlled trials are necessary for complementary and alternative medicine, but how can we deal simultaneously with its often incompatible explanatory systems? It is argued in this book that the value of positive results of research on complementary and alternative medicine is not impaired even if those results are discovered to be attributable to placebo effects alone. Placebo effects add to the benefits of conventional therapies as well, and the goal, it is stressed, is to benefit patients, regardless of the placebo contribution. Placebo benefits stem from patients' belief in the value of treatment but also from spiritual, cultural, or emotional aspects of the therapy -- aspects of health care that are desired by the majority of patients across studies. The conclusion of several contributors is that the health care system must adopt a philosophy better attuned to the need of patients for comprehensive care, a philosophy that can accommodate unusual beliefs and the desire for individualized attention and cultural sensitivity. As someone embedded in mainstream science, working with patients who have major, potentially fatal illnesses and who are eager for such attention, I found wanting in this book attention to the practicalities of implementing the authors' recommendations. Patients deserve access to complementary therapies that have been shown to reduce pain and suffering. Health care programs should provide access to proven approaches in culturally sensitive ways and on an adjunctive basis. Bringing this level of sensitivity and effort directly into the doctor-patient relationship -- "medicalizing" it and asking the physician to assume responsibility for the provision of supportive care -- seems an impossible task. Others in the health care system can provide such adjunctive care. That caveat aside, Callahan has brought together a thoughtful group of authors whose insights and conclusions, although controversial, are enlightening and challenge us to adopt broader perspectives in seeking to understand the very important sociocultural phenomenon that complementary and alternative medicine represents.
Barrie R. Cassileth, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an out of print or unavailable edition of this title.
Review
"Highly recommend[ed]... as a resource for all researchers and investigators, academics and scholars, and students both favorable or opposed to complementary and alternative medicine (CAM). This thought-provoking and exciting book is unparalleled in the field. It offers food for intellectual thought and meets the need for elucidating critical yet balanced discourse on the meaning and therapeutic values and efficacy of CAM." -- Doody's Review Service
"Although many books are available about CAM, this books makes its mark because it explores the relationship between CAM and conventional medicine." -- The Annals of Pharmacotherapy
"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." -- Health Progress
