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Change in My Position on Intercessionary Prayer Since Writing the Article
In my "Conclusions and recommendations," I classified intercessionary prayer (prayer for one person by another) as one of those treatments that has "neither theoretical nor empirical proof for their effectiveness but have a following and are known to be harmless" and meriting neither widespread recommendation nor a large share of research budgets. Fortunately, some researchers have been ignoring my recommendations and continuing to study it. The fact that the jury may still be out on how well it works does not mean that we should seldom recommend it or cease studying it. It certainly does no harm, and it may even benefit the person praying along with the intended beneficiary. I would now put it in Category 4, "Those that seem to work based on anecdotal and other forms of evidence of questionable validity but cannot adequately be tested with existing science and technology" and does merit further research and should be recommended. There may come a time when it would be appropriate to say "enough is enough" with respect to testing the power of intercessionary prayer, but it would be premature to do so now.
Unsnarling the CAM knot
Arthur Preston Smith
Noetic Health Institute, Foothill Ranch, CA
A few years ago two editors of the New England Journal of Medicine, a relatively conservative publication on these issues, made what seems to be an intelligent proposal on how the medical establishment should handle complementary and alternative medicine (CAM):
Although this definitely would be a move in the correct direction, implementing such a proposal is fraught with intellectual, political, economic, technical and logistical problems. This essay concerns the intellectual problems. Without a general understanding of where we are and where we need to go, other problems are secondary. Some intellectual problems are pseudo-problems, easily resolved with a little clear thinking. Nevertheless, they surface repeatedly in the debate over CAM or integrative medicine.
Such pseudo-questions are resolved fairly easily with a little reclassification and clear thinking. However, there are the two genuinely difficult questions:
These problems became apparent to me when I read the transcript Is Integrative Medicine the Medicine of the Future?, a debate between Dr. Arnold Relman, academic physician extraordinaire, and Dr. Andrew Weil, world-renowned physician, best-selling author and pop-culture advocate of the complementary and alternative (Relman and Weil 1999).1 Each defended his position passionately, even eloquently, but their arguments recalled the parable of four blind men describing an elephant. (Each man feels a part of the elephant and gives a reasonably good description of what he could sense through his hands, but none accurately describes the elephant.)
Relman’s position was a defence of modern science, the empirical methodology we use to determine whether our theories describe reality. CAM includes a potpourri of modalities — including some proved to be fraudulent. Fraud isn’t the medicine of the future — is it? (The question might be less rhetorical than you think.) For now we will assume that fraud is not good, but Relman doesn’t stop there. He argues:
Had I written such a statement in an undergraduate philosophy paper, without an elaborate argument in its defence, my professor almost certainly would have docked me at least one letter grade. First, it is false. Mental causation with respect to illness is fact. We’re even learning the molecular biology of how it does so (Stefano et al 2001). If mental activities such as beliefs, attitudes and emotions could not affect physical matter, how could there be a placebo effect? If Relman is right, then somebody should tell the Food and Drug Administration to stop requiring blind and double-blind studies of new drugs. They shouldn’t be necessary because the placebo effect ‘contradicts’ the laws of physics and therefore cannot exist. Second, what Relman considers the ‘modern scientific view of nature’ is not a set of scientific theories, in the sense of having been verified with controlled studies or experiments, but a set of metaphysical theories. Although it has been a popular worldview in academia for a few decades, it is no more empirically verifiable than the Christian Science worldview that mind is the only reality and matter is but an illusion of mortal mind.
Weil (Relman and Weil 1999) likewise starts out strong — and also shoots himself in the foot. He begins by arguing that patients turn to alternative medicine for good reason — or, actually, several good reasons. One is that they have tried conventional medicine, and it has not worked. Although, according to Relman’s ‘modern scientific view’, the human organism is nothing more than a complex machine, patients resent being treated like inanimate objects. They want a practitioner who will listen and understand what they are experiencing. Alternative practitioners, for whatever reason, seem more willing to do this.
Sometimes, when the conventional practitioner can’t fix the machine, he tells the patient that nothing more can be done. This reason to stop treatment is much less acceptable to the patient than it is to the doctor. The patient tries alternative means. Weil then argues that CAM modalities are generally less harmful, in terms of side effects and iatrogenic illness, than conventional medicine. He argues that conventional medicine maintains a double standard with respect to evidence, ignoring studies that demonstrate CAM’s effectiveness, while using therapies whose effectiveness is dubious at best. Says Weil: ‘You can’t demand evidence and then, when evidence is presented that contradicts your preconceptions, say you aren’t going to look at it.’ Then comes the shot in the foot:
Extrapolating from Relman's arguments, one could easily ask the questions: So what is the role of the truth in all this? So what if the public, possibly under the influence of a snake-oil salesman or a slick, Madison Avenue advertising campaign, wants a bogus treatment. Does that mean it works? What happened to proof? Where’s the evidence, the truth? Wantonly giving up our intellectual integrity is bound to cause serious problems for both doctor and patient.
You might ask: Can’t there be middle ground? To have intellectual integrity, do we have to accept, without question, all beliefs, including the metaphysical ones, of the medical establishment? Integrative medicine offers that middle ground, and mainstream medicine is definitely showing signs of accepting it. But if the Relman-Weil debate is any indication, we are far from understanding what that middle ground should be.
Some so-called problems in the debate over CAM are not real and can be resolved by clarity of language.
What is conventional medicine?
Although this should be fairly straightforward, the concept actually has at least two meanings. One is ‘medications and surgery’; the other is ‘diagnostic and treatment modes that have been verified as effective via scientific testing.’ Angell and Kassirer (1998) have expressed a preference for the latter, but not everyone agrees. In 1993, when working on my dissertation, I asked a retired immunology professor from a reputable medical school why he had intentionally omitted any reference to the new science of psychoneuroimmunology in the latest edition of his immunology textbook. He replied, ‘Because it has nothing to do with the practice of medicine. You will go to a psychologist or, possibly, a clergyman, for that kind of thing, not a doctor.’ In one sense, he was right. Drugs and surgery are not typically used as mind-body modalities. We don’t treat cancer with antidepressants, notwithstanding the well documented link between depression and cancer.
One would hope that medications and surgery would be a subset of scientifically tested medicine, but that is not always the case. At present, surgical procedures are considered so straightforward that they usually are not subject to placebo studies. This may change soon. In the summer of 2002, the New England Journal of Medicine published a single-blind study by Mosley et al on the effectiveness of arthroscopic knee surgery as treatment for osteoarthritis. All subjects were told that they might receive a sham operation. Those who received the sham procedure received a single superficial incision into the knee. While the surgeons pretended to operate, videos of operations played on monitors, leading each subject to believe that he was receiving an operation.
The researchers’ conclusion in the article abstract reads, ‘In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure (Mosley et al 2002, p 81).2
What is remarkable about these findings was not that the actual procedures didn’t work, but that the sham procedure did. An article on the study in The Wall Street Journal contained an interview with one of the subjects who had received a sham operation. He told the Journal that he didn’t care whether the operation was a sham because he was free of arthritis a year later. Not all conventional medicine, including most surgical procedures, has been subject to rigorous, scientific verification.
Solution: We define ‘conventional medicine’ as medications and surgery or as evidence-based medicine and then stick to whatever definition we choose. Better yet, follow Angell and Kassirer’s recommendation that we dispense with the phrase ‘conventional medicine’ altogether and simply use the terms ‘medication,’ ‘surgery,’ and ‘evidence-based medicine’ when that is what we mean. Intellectually, this seems the best choice, but politics and economics often trump intelligence.
What is complementary or alternative medicine (CAM)?
CAM includes all treatment modes not considered conventional medicine. When used in place of ‘conventional’ medicine, we call them ‘alternative’ medicine. When used along with ‘conventional’ medicine, we call them complementary. Integrative medicine combines both conventional and CAM modalities.
The definition of CAM is even less clear than that of conventional medicine. Because it is defined in terms of conventional medicine, all the ambiguity in conventional medicine also exists in CAM. For some, CAM means any modality other than medication and/or surgery. For others, it means all treatments without scientific validation. Under this definition, arthroscopic knee surgery for osteoarthritis, considered conventional medicine under the first definition, would be classified as CAM under the second. Meditation for treating high blood pressure, a CAM modality under the first definition, would be conventional medicine under the second. Also, under the first definition, conventional medicine could include some forms of quackery and fraud, but (one would hope) the intellectual discipline of scientific research would prevent it from becoming so under the second.
The more difficult challenge in formulating a clear definition of CAM is that it defines what mathematicians would call a ‘negative space’. Not a bad mood, but something defined in terms of what it is not. It is like the concept of ‘cities other than New York,’ which includes San Francisco and Boston as well as Fargo, North Dakota, and Midland, Texas. I have been to all four cities, and the advantages and disadvantages of living there are completely different for Boston or San Francisco than for Fargo or Midland. People who like living in Boston or San Francisco probably would not like living in Fargo or Midland, and vice versa. Any attempt to place value judgments on negatively defined concepts such as CAM would necessarily lead to overgeneralisation. The best we can do to clarify it is to define what we mean by conventional medicine.
Solution: Drop the terms alternative medicine, complementary medicine and CAM as soon as we can agree on a more appropriate scheme to classify modalities.3
These three phrases are too vague to be useful and can cause misunderstanding and miscommunication. Instead, follow Angell and Kassirer’s approach. Classify modalities in terms of their methodology and how well they have been verified.
What is ‘science’?
One of the more destructive intellectual problems in the debate over integrative medicine is the tendency to confuse empirical science with theoretical metaphysics. If I could accomplish one thing in my career as a philosopher of medicine, it would be to lift this cloud of confusion from the debate. The problem is rampant among CAM proponents and opponents. Even among reputable scientists, there seems to be disagreement as to whether science consists of a collection of academic disciplines, a method of deductive logic from first principles, a ‘view of nature’ (in Relman’s terms) or ‘paradigm’ (in Thomas Kuhn’s), a method of empirical investigation, or some combination of the above.
Science as a collection of academic disciplines
I encounter this interpretation most often among CAM proponents, especially among homespun metaphysicians who avoided those ‘hard’ sciences in their education if they possibly could. For them, science is simply a collection of subjects taught in school. All one needs to be scientific is to be speaking about biology, chemistry or physics. For some, one needs only the jargon of science, even as metaphor. The simple statement ‘As Einstein said, it’s all energy’ is enough to validate scientifically everything from mind-body medicine and homeopathy to gem elixirs and flower essences.
I do not deny that the material universe is all energy. That is a verified theory of physics. What I deny is the usefulness of such a broad statement to explain any particular phenomenon or validate any particular scientific theory. You might as well say, ‘It’s all God.’ (In fact, I like this one better. At least the statement is overtly metaphysical and not pseudo-scientific.)
Science as a method of deductive logic
Before the 17th century, science was mostly a process of deductive logic. Consider the following line of reasoning used by certain CAM proponents:
This is the basic reasoning behind the denial of illness’s reality by Christian Science as well as some forms of New Thought. Before the 17th century, this type of deductive logic was science. Some characteristics of scientific principles under this definition are those of ‘immutable law’ and ‘absolute certainty.’ We know them by logical reasoning; empirical testing is superfluous. This approach reads like a bumper sticker: ‘My mind is made up. Don’t confuse me with facts.’
Many opponents of CAM, while well educated in empirical science, are ignorant of metaphysics. They fall into the same trap but from the other side. Consider this line of reasoning:
Their basic modus operandi is the same as that of the Christian Scientists: logically deriving a conclusion on the basis of a metaphysical assumption. We don’t know that the forces of physics discovered to date are the only aetiological forces any more than we know that God is perfect. No experiment has ever been designed to test either proposition. Yet this seems to be the gist of Relman’s argument to Weil against mind-body medicine as cited earlier.
Science as a worldview or paradigm
These days, we hear Kuhn’s term ‘paradigm’ to denote just about any kind of theory, but the term for Kuhn meant much more. To him a paradigm was a set of assumptions about the universe, usually fundamental and metaphysical, that have been so widely accepted for so long that people have lost sight of the fact that they are just assumptions or even that they consciously believe them at all (Kuhn 1970). If you were educated in a North American university in the 20th century, particularly during the second half, you were taught, overtly or covertly, a set of metaphysical theories that David Ray Griffin and other philosophers called the ‘late modern worldview’ (Griffin 1997). (Although he never spelled it out in his debate with Weil, it is almost certainly what Relman meant by ‘modern scientific view of nature.’ I prefer Griffin’s terminology because it is not a set of scientifically proven theories but a set of metaphysical assumptions.)
The difference between ‘early’ and ‘late’ modern worldviews is the absence of God in the latter. Each sees the universe as a giant, law-governed mechanism with no internal intelligence. In the early modern view, the laws of nature were created and imposed on the material universe by God. In the late view, with God not in the picture, these ordinances somehow are enforced nevertheless — even though the legislature has long since adjourned and the executive branch is permanently out to lunch. The late modern worldview includes the following metaphysical assumptions:
Each proposition is either too broad or too complex to be proved by controlled study or experiment, and all remain open to debate. They are therefore metaphysical theories not scientific ones.
If you studied liberal arts, your education in this worldview might have been overt in that these propositions were taught as metaphysical theories. You probably learned that they were superior metaphysical theories, or even the correct metaphysical theories, yet they were still metaphysical theories. However, if you were educated in the ‘hard’ sciences, especially the biological ones, you probably learned them as what Kuhn described as a paradigm, a set of beliefs so well established that nobody even debated them. Biology and organic chemistry professors didn’t waste class time explaining why they don’t believe in God or the soul. What they did (and often still do) is select and teach curricula based on those assumptions. These metaphysical doctrines were taught indirectly by presumption and assumption. You never learned that they were metaphysical because they were never openly discussed. Having learned them from the people who taught principles of organic chemistry, molecular biology, embryology and physiology, it is easy to see how one would come to understand them as ‘science’ and view anyone who doubts or challenges them as ‘unscientific’, even if his credentials are impeccable.
This is what happened to UCLA neuropsychiatrist Jeffrey Schwartz in 1997. In addition to his training in medicine and neurology, Schwartz has extensive background in Eastern and Western philosophy, as well as a reasonably good grasp of modern physics. However, a distinguished colleague and former president of the Society for Neuroscience labelled Schwartz ‘not a scientist’ when Schwartz suggested his own version of mathematician-physicist John von Neumann’s metaphysical theory that the universe is ultimately not composed of ‘bits of matter’ but of ‘bits of knowledge’ (Schwartz and Begley 2002).4 Under the late modern worldview, this is heresy.
Science as a method of empirical investigation
For many scientists (Angell and Kassirer included), science is neither a set of academic disciplines nor an exercise in deductive logic nor a metaphysical worldview. It is simply a method of learning about nature that uses controlled studies and experiments. I was abruptly reminded of this interpretation when I submitted an early draft of my dissertation to physicist Anthony Smart. Although, according to the reductionism of the late modern worldview, all biology reduces to chemistry, and all chemistry reduces to physics, the physicists are the scientists most likely to reject the late modern worldview. Smart had no problem with my central thesis that the mind can heal. What he objected to was my assertion that ‘most scientists’ subscribe to the late modern worldview. ‘No they don’t!’ he wrote in large red ink across the top of the page. ‘Where would you get a crazy idea like that?’ He accused me of maligning the whole scientific profession with such a remark.5 Then came the lesson: ‘Science is nothing more than a method of inquiry’, he continued, ‘of testing hypotheses via controlled studies and experiments’.6
Yet there is another reason for adopting this definition that may be even more important. When science went unconscious, that is, when the metaphysical assumptions associated with it moved out of open debate and became absorbed in the late modern worldview paradigm, we may have lost sight of science’s original purpose, as well as the real nature of its tremendous payoff. The purpose of science is to maintain intellectual integrity. To remove its discipline from the medical field and open medicine to all the ‘cures’ and panaceas being sold to the unsuspecting public under the name of ‘alternative medicine’ would be a tremendous public disservice. This is what Relman really fears about opening up medicine to CAM, and I share his angst as, I suspect, do most believers in evidence-based integrative medicine.
To address these concerns, we need to go deeper and understand how the scientific method safeguards intellectual integrity. Clearly it is not designed to be a protection against delusions or logical fallacy. Experiments don’t cure psychosis, nor do they expose logical inconsistencies. What the scientific method does is enable us to be more realistic in our predictions of the future. Predictability is the payoff of science. It allows us to engage in activities that yield predictable results. It is this power that has given humankind mastery over nature through technology.
Although it does not presuppose all metaphysical assumptions of the late modern worldview, the scientific method does presuppose one proposition of metaphysics: that history will repeat itself. This is the presupposition of both science and inductive logic, on which it is based. The way science works is this: first we entertain a hypothesis that a certain series or class of events might have a tendency to repeat. We then design and conduct experiments and controlled studies to see if the events in question do repeat, and if they do, then we can safely assume that they will do so again.
Science also tries to be as precise as possible in identifying which phenomena repeat, how, and under what circumstances. We knew for years that aspirin worked as an analgesic, but we didn’t know the specific biochemical processes by which it worked. Once these were discovered, we were able to develop other non-steroid, anti-inflammatory drugs (NSAIDs) that used this same process with fewer side effects, based on the predictability of the underlying biochemical mechanism of aspirin (Smith 1998).7
Predictability is essential to the public practice of medicine. By ‘public practice’ I mean using modalities that work for everybody, not just a specific individual at a particular time. Anecdotal evidence can tell us that five years ago John Smith’s lung cancer disappeared shortly after he began sleeping with a quartz crystal on his chest, but it cannot tell us if Suzi Jones’s lung cancer will respond in the same way. Scientific testing answers, or tries to answer, this question of predictability, which is why we need evidence-based medicine. The difference between medicine that has been scientifically tested and that which has not is that we don’t know the likelihood of success with the latter. Scientific testing gives both the doctor and the patient reason to believe that the treatment will bring about the desired result — or at least increase its likelihood — as well as verify its safety. For this reason I stand with many CAM opponents in vehemently objecting to dropping the scientific method as a means of evaluating the effectiveness of treatment modes, even if it means giving second-class status to untested ones that often work.
Solution: Medicine should define science as a method of empirical investigation and drop both its explicit and implicit acceptance of the other definitions I listed. Under this definition, science makes only one metaphysical assumption: that past events tend to repeat. Its use is also restricted to its original purpose, to give us a reliable means to understand how the human organism functions, and, in that context, determine which treatment modes are predictably safe and effective.
The misnomer of scientific impossibility
The scientific method’s success in enabling us to predict events has made some so infatuated with its power that these believers hope we eventually will be able predict everything and manipulate life completely. I don’t share this view. Infatuation and hope do not make reality, as a girl in high school taught me.
The predictive powers of the scientific method are greatly overstated in the late modern worldview, which asserts the metaphysical principle of determinism: that all events can be, at least in theory, predicted from rules derived from applying the scientific method to past events. Science not only enables us to identify those patterns of events in nature that repeat, but it also gives us a window on the laws that require nature to participate in these patterns for all eternity. From this come the notions of ‘scientific possibility and impossibility.’ Phenomena that comply with these laws are allowed to exist. Those that don’t are not; they are ‘scientifically impossible.’ Should we encounter such a phenomenon, we must pay any price and use any means to expunge from our minds any belief that it did happen. Phenomena that ‘science’ prohibits from occurring (and us from believing) include: psychic phenomena such as clairvoyance, psycho kinesis, telepathy and precognition; flying saucers from remote regions of outer space carrying little green men to Earth; and, at one time, the flight of the bumblebee.
The confusion arises from ambiguities in the assumption that events are predictable based on their repetitive patterns in the past. This is the one metaphysical principle that scientific investigation necessarily presupposes. However, it has at least two possible interpretations. One is that some events tend to repeat themselves, and that scientific investigation can identify them. The other says that all events must repeat themselves in ways that scientific investigation can identify. The scientific method works under both interpretations, but the second entails a metaphysical doctrine that the laws science discovers are somehow imposed on nature and enforced.
This second interpretation made much more sense in the 17th century, when scientists almost universally believed in a God who makes and enforces his rules over nature. However, it makes much less sense for atheists and agnostics. I have no quarrel with someone who chooses to believe, as a matter of religious faith, that God governs the universe through scientific law. What I deny is that the scientific method itself either presupposes or implies such an interpretation. All that science itself entails is that some patterns of events in history repeat, not that all events must repeat according to patterns that scientific study can identify. Scientific laws are merely descriptive not proscriptive.
In logic or mathematics, the only way to prove something impossible is to show that it is either explicitly or implicitly self-contradictory. If it is consistent, it is possible. Anything that is actual is also possible. This notion of scientific impossibility is a central issue in the debate over CAM, in which skeptics claim that certain CAM modalities are impossible, even though, in some cases, the events in question are actual. For example, Relman lists the following claims, ostensibly made by Weil, that he believes to be false (Relman and Weil 1999):
For somebody with a medical background, the preceding statements may seem roughly equivalent. All pertain to the effectiveness of treatment modes that are unproven or at least not well understood. To a philosopher or logician, the first six statements and the last two are in different logical categories. The first six are questions of empirical fact or actuality, ie testable hypotheses. They merely describe what is or is not so. If the data supports Relman, then so do I; by the same token, I also could agree with Weil. The last two statements are about possibility. Relman does not say that ‘therapeutic touch and other forms of so-called energy medicine’ don’t heal disease or that ‘belief alone, without any physical intervention’ doesn’t cure organic disease, but that they can’t. He is asserting that we know a priori that the effectiveness of these modalities has been proved to be impossible, even in theory. No evidence to the contrary is even worth examining. Weil lets Relman have it on this point:
If we view science as ‘just a method,’ as others and I would advocate, then the very notion of proving something impossible scientifically is itself impossible. When we discover what appears to be a ‘violation’ of the laws of nature, it is incumbent upon science to modify those rules. If it were shown, by means of appropriately controlled studies and experiments, that God intervened and healed from incurable diseases those people who prayed correctly, then it is our scientific understanding of disease, not of God, that would need modification. Science cannot prevent God, the mind, or even flower essences and gem elixirs from healing — regardless of whether these modalities actually heal. Science does not dictate what the universe can or cannot do. It can attest that certain phenomena are extremely rare, or even unheard of, but it cannot prohibit them from existing.
The reason that mind-body and so-called ‘energy’ medicine are believed to be impossible is that they are believed to violate the law of conservation of matter/energy, which says that matter and energy can be neither created or destroyed, but, per Einstein’s equation E=mc2, they can be converted from one to the other. According to this argument, the mind cannot even move the brain. The so-called ‘violation’ here is not the law of conservation of matter/energy per se, but the materialist metaphysical theory of the late modern worldview. Because the mind is composed of neither matter nor energy, it cannot possibly cause anything physical, which takes us directly to the philosophical problem of mind-matter interaction.
The way that modern philosophers have handled this problem of mind-matter interaction is a monumental intellectual blunder that has wreaked havoc in both science and religion. However, regardless of your position on that issue, belief does, as Norman Cousins said, become biology. Evidence to that effect can be found in the placebo effect, in the new science of psychoneuroimmunology, and in the countless controlled empirical studies of ways in which our thoughts, beliefs, emotions and attitudes affect our health.8
Even if we assume that belief is nothing more than a word to denote firing neurons, we know that those firing neurons affect the body. If they can cause us to perform delicate surgical operations, prescribe appropriate medications or write essays, then there is no reason why they couldn’t also participate in regulating the immune system. And, in fact, they do. We are even discovering the molecular biology of the process. If the mind can affect the brain, there may be an extra step involved, but the result would be the same. Whether the mind affects matter or simply is matter begs the question. Either way, it is active in disease aetiology.
Regarding various forms of ‘energy medicine,’ some modalities may still work — even if we don’t know how. Others may not. The effectiveness of others may not be measurable with today’s technology. Those that have sufficient anecdotal evidence to support them, such as acupuncture, should be given further testing. However, nothing should be ruled out as ‘scientifically impossible’ if the implication is that no evidence in its favour, no matter how strong, merits examining. To do so is to confuse empirical science with speculative metaphysics.
Solution: Drop the notion of ‘scientific impossibility’ from our vocabulary, substituting terms such as ‘rare,’ ‘unheard of,’ ‘extremely unlikely,’ or ‘implausible.’
Remaining, genuine problems
If we choose to take the course recommended by Angell and Kassirer (1998), two very real questions not based on confusion and misconceptions remain. The first is whether there is anything about the scientific method that favours conventional, allopathic medicine, ie medication and surgery. In other words, is conventional medicine inherently more testable and predictable than CAM? The second is whether it is always a good idea to restrict medical practice to include only those modalities that have been scientifically tested, and, if and when it is not, how do we handle the exceptions?
Does science favour allopathic medicine?
Some CAM advocates argue that the rise of allopathic medicine in the 20th century was the result of a political power grab by the American Medical Association (AMA) in the early part of the century. CAM opponents counter that allopathic medicine was the only modality to survive the Federal and State legislation (passed pursuant to the 1910 Flexner Report9 with support from the AMA) which resulted in the large-scale closure of most non-allopathic American medical schools over a ten-year period following the release of the report, because the allopaths were the only practitioners willing to submit to the discipline of the scientific method. When osteopaths accepted the same discipline, they were welcomed into the field of conventional medicine. Science favours allopathic medicine because allopathic medicine favours science.
Although I am an outspoken supporter of some forms of CAM, namely mind-body modalities, I admit that there is some truth to opponents’ argument for three reasons. The first is that the scientific method is a means of maintaining intellectual integrity, along with establishing predictability; the scientific method is definitely biased against all forms of quackery and fraud, which are almost always CAM by definition. Second, in addition to quackery and fraud, CAM also includes most honest yet poorly understood modalities. Because science works better with knowns than unknowns, it would be biased against poorly understood forms of CAM.
Finally, there is another reason why science might also indirectly favour allopathic medicine. CAM proponents often criticise allopathic medicine for being behind the times in viewing the human organism as a mechanism governed by Newtonian mechanics. However, the scientific method does deal more effectively in this world of classical, Newtonian-Einsteinian physics. Science favours it because its natural domain happens to include the things that are most predictable, namely particles at least as large as atoms and systems at or near thermodynamic equilibrium. Newer scientific models, such as quantum mechanics, which describes the way things behave at the subatomic level, and chaos theory, which describes the behaviour of systems far from thermodynamic equilibrium, both deal with inherently unpredictable aspects of nature. If we are looking at nature with an eye for predictability, we will be much more successful with clocks and solar systems than electrons, tropical storms or the human brain. For these reasons, science will probably always find surer footing in allopathic medicine than in CAM.
However, this in no way justifies the systematic exclusion of all CAM modalities from the medical mainstream, even if some are poorly understood, work according to principles on the outer frontiers of science or are just plain fraudulent. Obviously fraud should be exposed and stopped, but the status of other forms of CAM under the discipline of science is much less obvious. As Angell and Kassirer (1998) suggest, some will be tested, proven effective and incorporated into conventional medicine. Others might still be worth trying in some circumstances, such as when conventional medicine has failed, even if airtight proof of their effectiveness is not available. The worst thing that conventional medicine can do is to pretend that CAM doesn’t exist and hope it will go away. At the very least, it should be aware of CAM, its promises and its risks. If it is going to set itself up as the gatekeeper of intellectual integrity in medical care, mainstream medicine owes it to the public to be a source of complete and accurate information about the safety and efficacy of all available treatment modes.
Solution: Science doesn’t necessarily favour allopathic medicine per se, but it does favour those aspects of reality described by classical physics, on which allopathic medicine is based. Remember: The payoff of the scientific method is predictability, and this is the arena where events are most predictable.
To what extent should all medicine be subject to the discipline of science?
This is fundamentally a moral question. Are there values in medicine that are higher than intellectual integrity? There are reasons to think that there might be. If lying to the patient heals him, shouldn’t we do it? In the 19th century, physicians routinely prescribed placebos intentionally — often achieving desired results. In banning this practice as unethical, have we served the patient’s best interests?
Intellectual integrity is not always healthy. For example, you are more likely to survive a heart attack if you are in denial about it, because the upset that results from acknowledging the truth can exacerbate the heart attack (Hackett et al 1968). There is evidence that being in denial also helps people with cancer (Pettingale 1981). Chances of survival for people with AIDS are improved by sustaining positive beliefs, even if those beliefs are unrealistically optimistic (Taylor, Kemeny et al 2000).
One thing some physicians do in the name of integrity borders, I believe, on malpractice: telling a patient that he has only so long to live. This is wrong even when the patient demands it. My pathologist father said once, ‘After over 20 years of medical practice, I’ve long since ceased predicting the length of human life. I’ve seen people you’d think were on death’s door go on and live for years. Others who seemed almost perfectly healthy only lasted a few weeks.’ The fact is that you don’t know how long someone will live unless you are a precognitive psychic. It would be far better simply to suggest that they get in order their affairs and any unfinished business with associates and loved ones and live every moment to its fullest.
In spite of these reservations, I find myself agreeing with Relman’s basic argument that intellectual integrity is essential for good medicine. Deceiving the patient, under the pretext of intellectual paternalism, shows disrespect for the patient and is unethical on that basis alone. Furthermore, we now live and work in cyberspace, where people can go online and quickly become informed on any medical topic. If you routinely lie to your patients, even benevolently, you will get caught.
In an interview with Transitions magazine (Anonymous 2002),10 I was asked point blank how doctors could use the placebo effect. I replied, ‘The same way porcupines mate — very carefully.’ If the patient finds out you are deceiving him, you lose your credibility. One problem with conventional medicine is that it underrates the power of the doctor as placebo in downplaying the art of medicine against the science. I have heard that one-third (Sternberg 2001) to one-half (Stefano 2001) of the benefit of proven drugs is due to the placebo effect. Deceiving the patient may work in the short run, but over time, it is likely to backfire.
However, I also think that science should be restricted to this role of preserving intellectual integrity. It should not be used as a pretext for trade union political manoeuvers or to deny patients access to treatments that realistically might work for them. Moreover, the notion of scientific impossibility is itself a misnomer and has no place in medicine, unlikelihood, yes, or even implausibility, under certain circumstances, but not ‘impossibility.’
In executing its role as guardian of integrity, science should focus on classifying treatment modes based on the predictability of the outcome. Because allopathic medicine focuses on those aspects of nature that are predictable, it will most likely continue to score relatively high on this scale compared to many forms of CAM. Some forms of CAM, including some labelled ‘impossible’ even in theory, may turn out to be unpredictable even in theory, which could land them in permanent scientific limbo. However, as science progresses, other forms of CAM may become more predictable.
One of the great errors of the modern worldview was to postulate the metaphysical proposition that every event in the universe is predictable in the sense that we can identify all the necessary and sufficient conditions for an event to occur from the laws of science. In physics, this issue arose in the debate between Einstein and Niels Bohr, in which Einstein is reported to have said, ‘God does not play dice with the universe,’ in rejecting Bohr’s theory of random events in quantum mechanics. Bohr’s position has since been empirically verified and is generally accepted among physicists.
More relevant to health care is the new science called ‘chaos theory’ (Gleick 1987). Chaos theory emerged when researchers from widely disparate sciences (mathematics, population biology and meteorology, among others) made common observations about ‘dissipative’ systems far from thermodynamic equilibrium. By definition, these systems require a steady supply of energy from outside the system. Examples include storms, animal populations and markets. From a reductionist point of view, the behaviour of these systems as wholes cannot be predicted based on the behaviour of the parts. However, they often can be predicted, at least to some degree, when seen as a whole. Meteorologists, for example, can in no way predict the path of a snowstorm along the Atlantic coast of the United States by tracking individual molecules of air and water — even if they had the technology to do so; their behaviour is too turbulent and chaotic.
Because the human body itself is a dissipative structure, medicine probably never will be an exact science. Within the body, the most dissipative organ is the brain. Although it typically consists of only a little over 2 percent of the body’s mass, it consumes 70% of the glucose used by the body and 25% of the oxygen and nutrients. It is, and behaves like, a dissipative system. It would be impossible to predict my typing of this essay based on the firing of neurons. Even if we knew the general principle of how the mind-matter interface works in the brain, we probably never will be able to predict even something as mundane as a passing thought from our knowledge of firing neurons.
However, the unpredictability of dissipative structures from reductionist analysis is only half the story. When viewed as a whole, many dissipative structures become surprisingly predictable. For example, by viewing a storm from a satellite hundreds or even thousands of miles above it, meteorologists can make reasonably accurate short-term weather forecasts. The same can be said for my writing this article. When you consider that I have ideas to express and that at least one serious periodical has expressed interest in publishing those ideas, both the aetiology and predictability of my typing an essay becomes much clearer and simpler.
Sometimes the order that emerges out of chaos in these systems is downright spooky. Ary Goldberger, a cardiologist of the Harvard Medical School and Beth Israel Deaconess Hospital in Boston, is also an avid student of chaos theory. Knowing that both electrocardiograms (EKGs) and lines of classical music yield a jagged, chaotic curve, similar to that of the coastlines of Maine, Norway or British Columbia, he tried mapping an EKG reading to a corresponding series of tones. What came out was a series of lovely, tonal melodies that he and his musician and medical student son Zach embellished and recorded onto a CD titled ‘Heartsongs: musical mappings of the heart’ (Goldberger 1999).11 When I listened to an excerpt from the CD, the only thing that seemed ‘missing’ in a musical way was a resolution, an end; probably fortunate absence for the patients from whom the EKGs were taken.
In any case, the scientific study of modalities that rely on chaos dynamics is going to be much harder than for fundamentally mechanistic processes, and their predictability is going to be that much more problematic.
And the difficulties don’t end there. Some modalities, such as acupuncture, lack a scientific theory altogether. Acupuncture refers to the ancient Chinese concept of qi (pronounced ‘chee’ and translated into English roughly as ‘material force’) that has no referent in Western science. We don’t know how it works, but it has millennia of historical experience, along with a growing number of controlled studies, that testify to its effectiveness.
Mind-body modalities (some would include acupuncture in this category) are especially problematic (Gerber 2001).12 One reason is that neither Western science nor Western philosophy has agreed on a metaphysical model, let alone a scientific one, to explain mind-matter interaction in the brain. The other is that you can’t test mind-body modalities against placebo, because the placebo effect itself is a form of mind-body medicine. Distinguishing the effects of the placebo from those of the real thing is especially difficult when they are the same thing. Christian Science and New Thought openly admit that the power of prayer is fundamentally a form of the placebo effect, citing passages in the New Testament about the importance of believing in the power of one’s prayers. The form of CAM now called ‘energy’ medicine, which theoretically works at the level of the mind-matter interface, is subject to the same problems.
Solution: The scientific method should be used whenever possible to determine the predictability of all treatment modes’ safety and effectiveness. Although at times a little dishonesty is helpful, it should be used very sparingly, or it will backfire. The role of science should be limited to its function of maintaining intellectual integrity. It should not be used as a tactical weapon in trade-union turf wars whose primary purpose is putting competitors out of business. Likewise, its name should not be invoked to defend positions that are largely metaphysical and not supported by evidence. Used in these ways, it serves to undermine intellectual integrity, not to maintain it.
Conclusion and recommendations
In spite of these difficulties, the method of scientific investigation is still the best we have to determine how well we can predict a given modality’s safety and effectiveness, even if we don’t understand its underlying principles. I agree with Angell and Kassirer that the categories of conventional medicine and CAM be abolished.
‘CAM’ and ‘conventional medicine’ carry too much intellectual baggage. Instead we should refer to individual modalities by name — without classification as either conventional or CAM — under the general category of integrative medicine. However, the division of all modalities into just two categories, those that have proved safe and effective in controlled studies and those that have not, does not take into account the varying degrees of verification that the scientific method offers. It also could result in denying the patient access to treatment modes that might be appropriate under certain circumstances. I propose that we use instead the following seven categories:
Using science to classify modalities in this way would protect the intellectual integrity of medical practice and allow consumers full access to any treatment modes that work best for them. These categories are not entirely discrete; they lie on a continuum. However, the classification of all treatment modes into one of these would allow patients to make better-informed choices. It also would improve decision making on how best to allocate research funding.
The title of this paper was inspired by David Ray Griffin, my philosophical mentor in graduate school, whose monumental book Unsnarling the World-Knot: Consciousness, Freedom, and the Mind-Body Problem promises a viable way out of the quagmire that has trapped academic philosophers studying the mind-body problem for five decades, and has impeded progress in properly understanding integrative medicine.
1 I would like to thank Dr Emeran Mayer and his staff at the UCLA Center for Integrative Medicine for posting a transcript of the debate on their website www.uclamindbody.org.
2Website of The New England Journal of Medicine, http://content.nejm.org/cgi/content/short/347/2/81. The page contains the abstract to the article. Subscribers can go from there to the text of the article. References to the study also appeared in the July 11, 2002 issue of The Wall Street Journal.
3 I would cease using the terms with this paragraph right here if I already had alternatives. I continue to use the terms for the remainder of this article because my recommended classification scheme is in the conclusion.
4 Schwartz collaborated with a science writer from The Wall Street Journal on the book The Mind and the Brain: Neuroplasticity and the Power of Mental Force (Schwartz and Begley 2002), which includes one of the most lucid layman’s explanations of the theory of quantum mechanics that this author has ever read.
5 Anthony Smart, PhD, a physicist with a career in private industry that included an assignment as mission scientist for a space shuttle launch, gave this response. My original remarks were in an early draft of the introduction to my dissertation, which I had passed on to him for review and comment.
6 Philosopher Ken Wilber speculates that there is a reason for this in explaining why physicists, more than other scientists, tend to embrace mysticism. In his introduction to Quantum Questions: Mystical Writings of the World’s Great Physicists (Wilber 1984) he reasons that the radical changes in physics during the 20th century have given physicists some intellectual humility. Quantum Questions is an anthology of the metaphysical views of great 20th-century physicists.
7 Physicists, who like even more precision, seek to reduce their theories to a mathematical expression called a LaGrangian. For a physicist, if you have a LaGrangian that accurately describes a locus of points, derived from your experiments and plotted on a chart, you are as close to reality as you’re going to get. It doesn’t matter if the equation implies bizarre, counter-intuitive concepts such as the ‘curved space’ of Einstein’s theory of general relativity, or the quantum mechanical notion that particles don’t exist as particles until they are observed. Obviously, biologists have to sacrifice a little mathematical precision for more complete descriptions of the phenomena they observe.
8 I devoted seven out of ten chapters of my doctoral dissertation to the subject: The Power of Thought to Heal: An Ontology of Personal Faith (Smith 1998).
9 Abraham Flexner was not a physician, but a teacher, who was working for the Carnegie Foundation for the Advancement of Teaching at the time.
10 Reprints are available at http://www.noetichealth.com/transitions.htm.
11 The CD is available on eBay or from Amazon.com. The artist is listed as Zach Davids, which is Zach Goldberger’s stage name.
12 Richard Gerber’s book (Gerber 2001) is about the ‘energy’ medicine that Relman criticised. I suggest reading Gerber with skepticism — not in the sense of a priori denial, as it is commonly used today, but in the original, philosophical sense of suspending judgment. Like many others involved in the debate over integrative medicine, Gerber isn’t always careful in separating empirical science from speculative metaphysics. Before dismissing the more speculative aspects of his work automatically, remember that yesterday’s science fiction is today’s science fact.
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