The McGill philosopher and physicist, Mario Bunge once suggested that, rather than dividing disciplines into “sciences” versus “non-sciences,” we ought instead to characterize them as either “research fields” or “belief fields.”  In other words, the cleavage should not be along the lines of subject matter, but according to the habits of mind with which it is approached.  In research fields, ideas gain acceptance to the extent that logic and evidence can convince an habitually skeptical audience.  The burden of proof is always on the claimant and new concepts eventually supplant old ones when they amass more compelling support.  In belief fields, by contrast, ideas are embraced in proportion to the emotional comfort they provide and old dogmas are rarely updated by new discoveries.  Bunge, therefore, would be happy to include among the research fields those areas of the humanities, for instance, where explanatory systems are based on data that have been subjected to critical appraisal, not merely weighed against the hopes and prejudices of their partisans. On the other hand, his criteria would clearly exclude a number of fields that loudly assert their scientific status but fall short of the intellectual rigor and respect for evidence that distinguishes legitimate sciences from pseudosciences.  I submit that it is this fundamentally different attitude toward evidence that separates orthodox biomedicine from its competitors who call themselves the “alternatives.”

 These days, the prestige and influence of science are such that very few fields outside religion and the arts wish to be seen as overtly unscientific.  Not surprisingly, this has encouraged many pretenders, i.e., fields that adopt the outward trappings of authentic sciences but lack their methodological and conceptual rigor, not to mention their storehouse of reliable data.  Some perpetrators are avowed charlatans, far more are sincere but self-deluded. The fringes of medicine have always attracted more than their share of these poseurs but it is ironic that at a time when medical science has never had more to offer, non-scientific therapies are clearly gaining in popularity.  Estimates presented at the 1997 meetings of the American Association for the Advancement of Science were that annual sales of unproven medical products in the US now exceed $14 billion, a figure many times the total yearly expenditure on biomedical research.  A recent US study reported that one-third of those polled had used at least one unconventional therapy in the previous year.  Somewhat lower Canadian participation rates are presented in the present issue of this journal. Admittedly, not all of these products are entirely without merit, but the hazard lies in the fact that so many potential consumers lack the wherewithal to assess the evidence that would separate the safe and useful from the useless or the outright dangerous.

 Alternative treatments run the gamut from reasonable lifestyle and relaxation advice to patently absurd practices such as iridology, crystal healing, and colonic irrigation.  Nutritional pseudoscience also permeates the field. The upsurge of belief in questionable medical practices stems from a number of philosophical and socio-political roots.  Philosophically, it reflects a growing trend toward relativism, the denial that there are objective standards of verification, as epitomized in the “New Age” catchphrase, “You create your own reality.”  Such a climate is a quack’s paradise for it permits any assertion to claim equal footing with any other.  Even in elite academic institutions today, there are strong proponents of the “post modernist” notion that objectivity is an illusion and how you feel about something determines its truth value. To the extent that this has led to a devaluation of the need for empirical verification among the population at large, it has enlarged the clientele for magical and pseudoscientific health products.

 Many New Age beliefs are holdovers from the “counterculture” movement of the 1960s and ‘70s, from whom New Agers inherited a passion for egalitarianism, naturalness, and the primitive—all entwined in a mystical web of narcissism that equates truth with emotion rather than reason.  The counterculture’s “back to nature” remedy for the ills of technological and materialistic society helped revive a variety of folk practices under the “holistic health” banner.

 Oddly enough, there is very little that is new in the New Age.  It is instead a slick re-packaging of very old beliefs.  The “holistic” bent of alternative medicine mingles the “nature philosophy” of 19th-century Romanticism with tenets of ancient Greek and Far-Eastern mysticism.  As such, it plays to the spiritual void in many who have strayed from their religious upbringings—in short, it is yet another attempt to re-unite religion with science.  New Age medicine appeals to those committed to “mind-over-matter” cures, a systemic rather than localized view of pathology, and the all-powerful ability of nutrition to restore health.  Remnants of the counterculture’s rebelliousness survive as nostalgic yearnings for a return to 19th century-style democratized health care (now wrapped in the banner of patients’ rights) and a distaste for bureaucratic, technologic, and specialized treatment of disease.

 A prime example of Bunge’s belief fields, alternative medicine’s spiritual undrpinnings place a naive trust in the benevolence of an anthropomorphized universe and the conviction that health is guaranteed if we simply follow our “natural” inclinations. Disease is seen as a form of hubris that brings us up short when we mistakenly trust in reason over our health-promoting instincts. Given this abiding faith in the natural ability of the body to heal itself, one wonders why the interventions of a healer are necessary at all, unless it is merely to fill the role of bill collector.

 The core of alternative medicine is the scientifically-discredited doctrine of vitalism.  It posits a “vital force” that pervades the universe and animates living organisms. Believers say this ethereal “energy” is undetectable by conventional instruments but, paradoxically, it can still influence bodily organs that are also made of physical matter. Anything that impedes or “unbalances” this energy flow, in or around the body, causes disease.  Detecting these blockages is entirely subjective, however. They are purportedly caused by such things as “devitalized foods,” psychological strain, “autointoxication” (accumulation of bodily wastes), idiosyncratically-defined metabolic disturbances, colon toxicity, nutrient malabsorption, and “liver sluggishness.”  Germs, in this scenario, are not specific disease-causing entities but parasites that attack a weakened body that has fallen into an unbalanced condition. Therapy, then, consists of restoring normal flow by “balancing,” “cleansing,” or “detoxifying” the system with what amount to magical rituals.  In keeping with holistic doctrines, treatments are aimed at restoring “whole body balance,” whatever that may mean. E.g., “natural” herbs or “therapeutic touch” are supposed to rebalance “energy fields,” thereby “treating the whole person.”

 By reasserting belief in a moralistic force that governs the natural universe, New Agers have also revived the age-old penchant for blaming the victim. The ancient Greeks, for instance, shunned the sick because health was considered synonymous with virtue and those who were ill were therefore despised by the gods.  It is only a small step from exorcizing evil spirits to “realigning energy fields” with “therapeutic touch.”

 Belief in the efficacy of holistic remedies rests on personal testimonials rather than controlled clinical trials.  In the US, the Office of Alternative Medicine was established (by a small group of devotees in the US Congress, not the relevant scientific bodies) under the National Institutes of Health. It promises to provide the long-awaited empirical support for unorthodox medicine but, plagued by internal strife and the resignation of its first director, it has yet to finalize its research protocols (standard evaluation methods are, for some reason, considered inappropriate). Doubters, on the other hand, continue to provide trenchant critiques of this panoply of alternative practices.     The newsletter and briefs of the US National Council Against Health Fraud supply similar information, as will a new journal, Reviews of Anomalous and Alternative Medicine.  The latter is about to commence publishing under the editorship of Wallace Sampson, M.D. of the Stanford University School of Medicine.

 Public acceptance of alternative medicine has been fuelled by a sense of disillusionment many have come to feel toward all authority figures in these troubled times. The rush to dethrone physicians is born of an odd mix of social envy, nostalgia, and disappointment, the latter arising from a number of admittedly over-reaching promises upon which biomedicine has yet to make good.  Disaffection has also been prompted by a growing feeling that medical care has become too rushed, overly-technical, and depersonalized. Other detractors are unhappy at the lack of cures for certain chronic conditions which biomedicine does not always manage as well as sufferers might wish. This disenchantment has been intensified in some quarters by a renewed willingness to entertain grand conspiracy theories. An anti-science and anti-physician backlash has resulted from this need to believe that secret plotting on the part of powerful self-serving cabals underlies society’s shortcomings.  As a powerful institution with political aims of its own, medicine has filled the role of villain for various conspiracy mongers.  Proponents of alternative medicine have been quick to capitalize on this climate of suspicion because it supports their claim that their rejection by orthodox practitioners is merely a ploy to protect the influence and earnings of the medical establishment.  Unfortunately, many in their audience seem incapable of separating whatever misgivings they might have about the socio-political activities of doctors as a powerful, self-regulating profession from the question of whether the treatments biomedicine has at its command are genuinely better than those of the “alternatives.”

 The willingness of many to accept the claims of dubious healthcare providers must, in large part, be blamed on the low level of scientific literacy in the public at large.  Surveys consistently demonstrate that, despite our overwhelming dependence on technology for our safety, food supply, health, transportation and entertainment, the average citizen of the industrialized world is shockingly ignorant when it comes to even the rudiments of science. The profit-driven media do little to alleviate this state of affairs and, in fact, their fondness for pseudoscience often worsens the problem. With such a weak grasp of how the natural world works, most people lack the basic knowledge to make an informed choice when they must decide whether an aggressively marketed health product is a sensible buy or not.  Although Blais et al. report in this issue of CJPH that clients of alternative medicine tend to have more years of education than non-users, it is still a safe bet that they are not better informed about basic science. For even an elementary understanding of chemistry should raise strong doubts about the legitimacy homeopathy;  a passing familiarity with human anatomy would suggest that “subluxations” of the vertebrae cannot cause all the diseases chiropractors believe they do; and a quite modest grasp of physiology should make it apparent that a coffee enema is unlikely to cure cancer.  But when consumers haven’t the foggiest idea how bacteria, viruses, carcinogens, oncogenes, and toxins wreak havoc on bodily tissues, shark cartilage, healing crystals, and pulverized tiger penis seem no more magical than the latest breakthrough from the biochemistry lab.

 If most alternative therapies violate well-established principles of physics or biology and cannot pass controlled clinical trials, why do so many sellers and purchasers believe that they work?  First, of course, there is the ubiquitous placebo effect.  Just as important, however, is the self-limiting nature of many complaints.  Because many conditions respond well to “the tincture of time,” neither the healer nor the client can know, without a control group for comparison, whether the recipient would have recovered just as well without the treatment. Alternative healers also benefit from the fact that many disorders, such as arthritis, digestive problems, and multiple sclerosis, have their “ups and downs.” Understandably, sufferers tend to seek help at the troughs of these cycles, so a bogus treatment will have many opportunities to receive credit for an upturn that would have happened anyway.  Because these factors bias one’s perception of treatment efficacy, double-blind, randomized, placebo-controlled trials are absolutely necessary in evaluating all putative therapies.  The “alternatives” have a variety of self-serving reasons why they should not be held to this standard.

 Similarly, there are many people who have psychological and social needs that foster the erroneous belief that they are sick. Although the diagnosis of hysteria has gone out of fashion, there remains a large cadre of “somatizers” who tend to express their psychological difficulties in a language of physical complaints. Alternative practitioners cater to the “worried well,” providing the personal attention, existential support, and reassurance that (probably unknowingly) motivated the visit in the first place. Psychosomatic complaints are best relieved by counter-suggestion and reassurance, but for various reasons, somatizers cannot accept mere counseling—sad to say, many still view psychological disorders as somehow shameful.
The alternative healer will supply the needed physical diagnosis the scientific practitioner will not. He or she will suggest that dubious “energy imbalances,” “environmental sensitivities,” or nutritional deficiencies are responsible for the malaise.  Ironically, the “alternative” will do this while maintaining all the while that all disease stems from psycho-spiritual causes.

 Why are beliefs in dubious therapies so resistant to counter-arguments?  Espousal of alternative medicine tends to be embedded in a larger network of metaphysical beliefs, meaning that an attack at this point threatens the entire worldview.  This will be resisted with passion.  “Cognitive dissonance” is one mechanism that helps overcome such threats by filtering and distorting information that offends one’s core beliefs and self-esteem.  When it would be too disquieting to admit that time, effort, and money has been wasted on a useless therapy, there is pressure to distort one’s perceptions and memory to find some benefit from the expenditure.  Illusory impressions of therapeutic success can also stem from well-studied judgemental biases.   When we rely on informal reasoning, departures from formal logic frequently lead to false beliefs. A nice example of how these “heuristic biases” have led to erroneous conclusions about causes and cures for diseases is found in a recent study by Redelmeier and Tversky.  Alternative healers rarely keep systematic outcome statistics, leaving them prone to these mental slippages that overestimate successes and explain away failures.  The pioneers of the scientific revolution were well aware of these self-serving biases when they devised observational safeguards that try to “stack the deck” against our human tendency to jump to comforting conclusions.

 Holistic medicine tends to fill the void some feel has been created by the technocratization and depersonalization of orthodox medicine.  Alternative healers provide comfort and possibly add to the quality of life for those for whom neither they nor orthodox physicians can offer a cure.  Its emphasis on interpersonal relations, healthy lifestyle and disease prevention, and its advocacy of using the least invasive effective remedy are worth encouraging.  Alternative practices should continue to be carefully combed for those that can pass scientific scrutiny.  However, the “alternatives’” tendency to divert patients from more effective, scientifically proven therapies are costs to them, and its popularization of pseudoscience and magical thinking are costs to us all.  The burden of proof remains on the proponents—our demand should always be for objective evidence, for as Francis Bacon warned, “...what a man had rather were true he more readily believes.”
 

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