From Library Journal
Copyright 1999 Reed Business Information, Inc.
From The New England Journal of Medicine
The Alternative Medicine Handbook, by Barrie R. Cassileth, is organized as a reference on the most commonly used complementary and alternative therapies. Cassileth brings to this work an appropriate base of experience; she holds teaching appointments at Harvard University and Duke University, is a founding member of the advisory council to the National Institutes of Health Office of Alternative Medicine, and has published extensively on the subject in peer-reviewed medical journals. Dealing with a broad range of material, from the use of shark cartilage to the traditions of ayurvedic medicine and the tenets of shamanism, she summarizes each therapeutic approach -- its history, the beliefs on which it is based, and the therapeutic claims made for it -- and analyzes any research-based evidence of its efficacy. For the physician who wants to advise a patient, Cassileth offers a balanced approach, providing information on certain treatments that appear to be safe and of possible benefit, as well as caveats against the indiscriminate use of others.
Discussing herbal remedies and nutritional supplements, for example, Cassileth notes that few physicians and patients are aware that the Dietary Supplement Health and Education Act of 1994 eliminated the requirement that these products be reviewed by the Food and Drug Administration. As a consequence, she cautions, they are no longer evaluated for either safety or purity; sometimes they contain none of the advertised components, and they are not evaluated to determine whether they support a promoter's claims. Furthermore, labels on these products rarely include information about risks, side effects, or possible harmful interactions with other substances. This lack of federal oversight is, appropriately, currently under review. Following the lead of H.L. Mencken, who observed that for every complex problem, there is a simple solution -- and it is wrong, Cassileth suggests that physicians should remain open to unconventional ideas but must help their patients understand the need for a scientific approach to complementary and alternative medical practices and products.
With the growing dominance of economically driven managed care in American medicine, decisions about treatment are subjected to greater scrutiny by parties outside the traditional doctor-patient relationship. The second book reviewed here, Alternative Medicine and Ethics, focuses largely on issues facing policy makers. The six essays in this book vary in their clarity and insight. Stephen Barrett argues forcefully that although the science-based medical community tests its theories and practices in order to develop a coherent body of reproducible experience and knowledge, the alternative-medicine community has no such commitment. Vimal Patel, whose essay supports alternative therapies, attacks organized medicine for its "befriending relationships" with the tobacco and pharmaceutical industries, cites examples of contraindicated surgeries performed to enrich surgeons, hails the 1994 Dietary Supplement Health and Education Act, and stresses the importance of "healing" the patient without necessarily curing the patient's illness.
The remaining essays deal with ethical challenges alternative medications pose for the pharmacist, the legal and ethical dilemmas surrounding prayer as a method of alternative healing for children, and the ramifications of the increasing insistence that complementary and alternative therapies be covered by health insurance. Discussing the issue of insurance coverage, S. Mitchell Weitzman argues that, on the one hand, complementary therapies such as yoga, meditation, and dietary modifications can reduce the cost of surgical or medical treatment of heart disease, but on the other hand, reimbursement for such approaches will reduce the resources available for established methods of care.
As we deal with the issues raised by complementary and alternative medicine, we must be prepared to give credence where it is due. Many of the currently approved remedies originated, after all, in folk traditions: digitalis, chloroquine, and aspirin are examples. Other treatments that may have originated as alternative approaches include use of a form of vitamin A to treat acute promyelocytic leukemia, application of electric currents to speed the regrowth of bone, and use of high-intensity light to treat some forms of depression.
As philosopher Carlyle Marney wisely cautioned, "A window stuck open is as useless as a window stuck closed. In either case, you've lost the use of the window." We must continue to insist on the painstaking accumulation of evidence in the scientific testing of each new breakthrough, especially since, according to a recent article from the National Institutes of Health Office of Alternative Medicine, complementary and alternative approaches are amenable to the same testing used for standard medical treatments (J.S. Levin, et al. "Quantitative Methods in Research on Complementary and Alternative Medicine." Medical Care 1997, vol. 35, pp. 1079-1094).
Reviewed by Avrum Bluming, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.