Sounding Board
Engineers, Cranks, Physicians, Magicians
N Engl J Med 1983; 308:960-964April 21, 1983DOI: 10.1056/NEJM198304213081611
- Article
Medicine in industrialized nations is scientific medicine. The claim tacitly made by American or European physicians, and tacitly relied on by their patients, is that their palliatives and procedures have been shown by science to be effective. Although the physician's medical practice is not itself science, it is based on science and on training that is supposed to teach physicians to apply scientific knowledge to people in a rational way.
The practice of medicine in the United States and in other industrialized nations is a form of consultant engineering. The subjects are people rather than bridges, but in many respects the professions of medicine and engineering are alike. We expect skilled engineers to be able to learn from experience and to get better at building bridges, because we believe that their training has subjected them to a rational discipline that has made them good learners about such matters. Sometimes, of course, we are disappointed. It is entirely the same with physicians, who must apply both explicit scientific principles and also a great deal of tacit knowledge to the treatment of their patients. Medical training is supposed to make physicians good at applying scientific knowledge to sickness, and it is also supposed to make medical doctors good at acquiring through practice an abundance of tacit knowledge useful to their craft.
There is no reason, either historically or logically, to conceive of the science used by physician engineers as necessarily physical science. Engineers need not care in principle whether the generalizations on which they rely are psychological, physical, or psychophysical; what they care about is that the generalizations be applicable and that their reliability be scientifically demonstrated. A great deal of what physicians learn consists of biologic and biochemical generalizations, broadly construed, but they also learn a substantial body of psychophysical generalizations, which can be regarded as bridging the crevasse between mind and body. For example, generalizations concerning the effects of drugs, correlating the location of pain with other physical symptoms of disease, and positing the causal factors in dizziness and senility connect the mental with the physical and are thus useful for medical engineering. If physicians learn relatively fewer generalizations that are entirely psychological or social in nature or that posit psychological mechanisms for physical effects, the reason is not that such generalizations are alien to the "medical model" but that relatively few of them are applicable and scientifically warranted.
There are alternative conceptions of the physician. Some of them play a dominant part in the understanding of medicine in other societies, and some serve to qualify the conception of the physician as engineer even in our own society. One such conception is that physicians are consolers. Another is that they are magicians who exercise occult powers to bring about healing. As magicians, they possess magical powers either because of the occult knowledge they possess or simply because of who they are — for example, because they stand in some special relation to gods or demons. Again, the physician may be understood to be someone who applies a reliable body of knowledge that is not warranted by science or by magic but is simply known and, so far as the community is concerned, always has been known. The warrant behind this conception of the healer is tradition and "common knowledge."
These distinctions are more logical than sociological, and a society may combine several of them in the roles it assigns to healers. A medicine man can combine traditional therapies with magical claims, and both with a bit of consolation. A physician engineer can act as consoler; nothing in either logic or social psychology forbids it. But certain combinations are impossible or extraordinarily unlikely. A physician engineer cannot honestly claim powers of magic or occult knowledge. The principles governing scientific reasoning and belief are negative as well as positive, and they imply that occult doctrines are not worthy of belief. Moreover, physician engineers have no immunity to moral or ethical constraints. On the contrary, they are by training and by culture enmeshed in a tradition of rational thought about the obligations and responsibilities of their profession.
Is there another, holistic, conception of medicine distinct from those described above? Certainly, many people seem to think so. In 1978 a group of medical and osteopathic physicians formed the American Holistic Medicine Association, which now publishes a journal and whose meetings have been recognized for educational purposes by the American Medical Association. Popular bookstores are filled with works on "holistic medicine," many edited by medical doctors and some recommended by such political eminences as Edward Kennedy and George McGovern. The same shelves boast best-selling books on holistic medicine authored by professors at distinguished medical schools and, in at least one case, by a physician administrator at the National Institutes of Health. The therapies described and recommended in a typical book of this genre include biofeedback, hypnosis, psychic healing, chiropractic, tai chi, iridology, homeopathy, acupuncture, clairvoyant diagnosis, human auras, and rolfing. One of the larger books of this kind was even subsidized by the National Institute of Mental Health.
What ties together the diverse practices described in such books as Health for the Whole Person, Ways of Health, and The Holistic Health Handbook? In part, a banal rhetoric about the physician as consoler; holistic dentists, for example, promise to take account of the spiritual factors affecting their patients' teeth. In part, familiar and rather useless admonitions about not overlooking the abundance of circumstances that may contribute to one condition or another. Such banalities are often true and no doubt sometimes ignored, with disastrous consequences, but they scarcely amount to a distinctive conception of medicine. Holist therapies can be divided into those that are adaptations of traditional medical practices in other societies — Chinese, Navaho, and so forth—and those that were invented, so to speak, the week before last by some relatively successful crank.
Insofar as it extends beyond banality, the holistic medical movement constitutes both a deliberate attempt to substitute a magical for an engineering conception of the physician and an attack on scientific understanding and reasoning. Although the holistic movement does not contain a conception of medicine distinct from those we have discussed, it does contain a reactionary impetus to return the practice of medicine to the practice of magic and to replace logic and method with occultism and obfuscation.
Several conceptions of "holism" have been developed in the writings of holistic practitioners and their advocates. Most of them are vacuous: they are banalities of orthodox medicine, or they have no medical content and no applicability to any possible practice of medicine; they merely sound nice. Some are patently false. A much-repeated and trivial thesis, and moreover one that is said to characterize the sense in which holistic medicine is "holistic," amounts to no more than this: mental and physical properties are interdependent. Mental states affect physical states, and physical states affect mental states. No one doubts it. To make such a claim seem somehow profound, holistic writers invariably conjoin it with a discussion of Cartesian dualism, insinuating that modern medicine follows Descartes in postulating an impassable chasm between the mind and the body. Modern medicine does no such thing, and could not even if it wanted to, since Descartes held no such view.
Another doctrine said to be holistic is that one's state of health is affected by everything. Whatever this means, it has nothing to do with any possible practice of medicine, for no one can attend to everything. If physicians cannot distinguish relevant from irrelevant factors, important from unimportant causes, then they can do nothing. A variant of this doctrine is not vacuous but merely vapid: "Fundamental to holistic medicine is the recognition that each state of health and disease requires a consideration of all contributing factors: psychological, psychosocial, environmental, and spiritual." 1 This is not a new revelation about medicine. Insofar as such multiple factors are known and believed to be important, they are routinely addressed in conventional medical practice. Patients who suffer from coronary heart disease may be treated with beta-blockers and antiplatelet drugs, and they may also be advised to change their work, their diet, their smoking habits, their exercise habits, and their living conditions.
A stronger thesis, also presented by the writer quoted above, is that "all states of health and all disorders are considered to be psychosomatic," which is to say that psychological conditions are major causal factors in every illness and in all morbidity.2 So understood, the claim does not present an alternative conception of medicine, only a patent falsehood. Psychological states are not in any ordinary sense causal factors in Down's syndrome, cholera, nephritis, or a host of other disorders. Of course, psychological states may affect how an affliction is endured, even if they do not cause the affliction, but that is a different matter. Even if we believed (albeit mistakenly) that psychological conditions were an important causal factor in every disorder, this imagined fact would not itself require a change in the conception of the physician as engineer. It would require that scientists try to identify such factors so that physician engineers might apply the additional knowledge.
These rhetorical flourishes fail to constitute a distinct conception of the physician's role, of medical knowledge, or even of nature. However, an extraordinary vision of the functioning of the body and mind that runs through much of the holistic literature is utterly different from the scientific viewpoint. The holistic claim is this: The entire body (and psyche) can be treated or diagnosed through the treatment or observation of a special part of the anatomy. However much this notion of holism may be at odds with the themes that seem to run through the holist doctrines, it characterizes many of the treatments described in the literature on holistic medicine. Chiropractors, iridologists, reflexologists, tongue diagnosers, zone therapists, and many others all claim to treat or diagnose the whole from some anatomical part. Of course, they differ about which part, but that does not seem to bother either them or the editors of holistic books. Almost invariably, this rhetoric claims that manipulating a part of the body somehow restores an inarticulated "balance" or "harmony" to the whole.3
At the base of the litany that each person must be treated as unique, that every part of the body is interdependent on every other part, and that body and mind are inseparable is the claim that holistic practitioners are absolved from demonstrating causal relations between their treatments and alleged therapeutic gains. They are under no obligation, they believe, to reconcile their claims about therapy with what is known about the causal pathways of the body. Their emphasis on the power of the mind is part theme and part tactic: the mind is supposed to be able to exert its power on parts of the body without causal mechanisms, without intermediate effects, and without regard to the laws of nature. The holistic practitioner sees the body in much the same way that magicians of old viewed the universe. The body becomes the last bastion of magic.
A magical view of the mind and body is antithetical to the scientific viewpoint, however much holistic therapists may parade what they take to be the trappings of science. Consequently, they make every effort to disparage rational assessments of their practices. A magical view of nature and mind and a mystical conception of knowledge are opposed not just to scientific conclusions but to scientific reasoning. Beyond disparaging the sort of rational assessment of their wares made by, say, the Consumers Union, holistic advocates attack reason itself.
Sobel, a doctor of medicine, charges that "Competition and ethnocentrism have often prevailed over any real concern with the relative value or efficacy of different therapies," and that "There are substantial barriers to a serious and dispassionate evaluation of unorthodox medicine, not the least of which are posed by economic and political forces. . . ."4 These statements are doubtless true, but so what? Are there no objective, dispassionate evaluations of various holistic practices? What is wrong with the careful, reasoned evaluations of therapies, such as chiropractic, that are offered by the Consumers Union?5 Although Sobel does not say so, the reader is left with the impression that because it is obvious that some evaluators are prejudiced by irrelevant factors, all negative assessments are unfounded. This is argument by innuendo. Having no tenable thesis of any interest, the holistic advocate states a claim that is a perfect banality and hopes the reader will draw a sweeping conclusion that is completely unwarranted. It is a tactic used throughout the literature on holistic medicine.
We are repeatedly told that holistic medicine has not really been investigated, that funds ought to be made available for conducting tests of holistic practices, and that meanwhile we should keep our minds open about holistic techniques. Although it might be interesting to know more about the physiological pathways that are correlated with such processes as the placebo effect, this has nothing to do with taking seriously the claims advanced by iridologists or zone therapists or even chiropractors. The claim to diagnose by examining the eye or to cure by massaging the foot is completely bogus; we know more than enough about the workings of the body to be reasonably certain that geometric features of the iris, for instance, do not provide the specific information about disorders that iridologists claim they do. And if a test is really necessary here, it can be and has been run cheaply: iridologists have been shown to fail as diagnosticians.6 Chiropractors and zone therapists could readily devise rigorous tests of their therapies if they wished to, but they don't. Of course, it is conceivable that the beliefs of scientific medicine are in error about one or another of these matters, but that is no reason for using public funds to investigate holistic claims. One cannot justify spending other people's money simply because one can imagine something to be true. The mere fact that holistic medicine is widespread and enduring is no reason to take its claims seriously; superstition, self-deception, stupidity, and fraud are ubiquitous and always have been.
It is unlikely that the lack of evidence concerning the specific curative powers of holistic therapies is the result of a conspiracy of disinterest. There are enormous rewards, financial and otherwise, for scientific demonstrations that new and inexpensive therapeutic procedures are effective. Holistic practitioners know these rewards full well. If they have been unable to produce sound scientific evidence of the efficacy of their therapies, we are not being closed-minded in concluding that the therapies probably have no specific effects of the kinds advertised. Certainly we should leave our minds open, but not, in the words of an eminent philosopher, the late Alan Ross Anderson, so open that our brains fall out.
The most fundamental attack made by advocates of holistic medicine is on reason itself: since science will not warrant holistic medicine, they imply that we should abandon science and the claims of reason. One common line of argument is derived from a radical misunderstanding of the contemporary philosophy of science. Some years ago, Thomas Kuhn claimed that scientific work in any particular field is normally governed by a "paradigm" — that is, by some concrete piece of work done in the past that is used as a model for subsequent scientific work. Newton's celestial mechanics provided a paradigm, as did Dalton's chemistry, Darwin's biology, and Einstein's electrodynamics. A paradigm contains fairly strict rules for determining what counts as solving a scientific problem, although these rules are seldom formulated explicitly. Over time, anomalous cases are collected that should conform to the paradigm but that resist solution. As the number of such anomalies increases and they continue to resist the best efforts to resolve them, some scientists will inevitably begin to lose faith in the adequacy of the paradigm. This crisis of faith leads to attempts to replace the paradigm with a different conception — that is, it leads to revolutionary theories. If one or another of these theories can be applied successfully to the anomalous cases that have shaken belief in the extant paradigm, the new theory may become a competing paradigm, with its own advocates, problems, and standards. Because of this process, it often happens that a scientific subject contains two or more competing scientific paradigms, each with its own advocates. Since the advocates of competing paradigms do not fully share standards of explanation, procedures for interpreting data, or beliefs about how the world works, they tend not to understand one another fully.
Holistic advocates repeatedly cite Kuhn and claim that holistic medicine is an alternative paradigm with its own standards, one that cannot be understood or assessed by the practitioners of orthodox medicine.1 , 4 , 7 8 9 If the claim were valid, holistic practice would have to constitute a scientific tradition, albeit one in competition with the tradition of orthodox medicine. However, holistic medicine is not a scientific tradition. It has no paradigmatic work, no recognized set of problems, and no shared standards for what constitutes a solution to those problems; it also lacks the critical exchange among its practitioners that is characteristic of the sciences. Cranks have been common throughout the history of science, as Kuhn, a distinguished historian of science, knew well. The work of cranks does not constitute a scientific revolution, and no cranks appear among Kuhn's many examples.
Advocates of holistic medicine also attack reason on the basis of cultural relativism. Sobel claims that one person's physics is another's pseudoscience — in short, that evaluations of medical practices and claims are relative to culture.4 And of course that is correct. They are relative in the sense that they are different. In that sense they are also relative to education, beliefs, and many other things. But the fact that different cultures engender different beliefs does not mean that we should suspend our judgment about such beliefs and become, as it were, acultural. And recognizing that subcultures in our own society differ in their beliefs about medicine and other matters does not in the least mean that a reasonable person should give these many conflicting claims equal credence.
Porkert recommends letting our brains fall out. Chinese medicine, he claims, "reposes upon the inductive and synthetic mode of cognition," whereas Western medicine has a "causal and analytic orientation." 10 Furthermore, observation of experimental results is incommensurable: "Thus. . . two physicians, the first observing in the pattern of the inductive and synthetic mode, the second oriented by causal analysis, will never succeed in making their positive data converge completely — not in spite of, but precisely because of, their high scientific standards." 10 An example of Western standards of measurement is the centimeter-gram-second system of physics; the Chinese standards are yin and yang, wood, fire, earth, metal, and water; and according to Porkert, one is as good as the other at producing knowledge. One can say, specifically and in boring detail, why it is false to state that honest observers cannot reach agreement on their descriptions of experimental outcomes — if not always on their implications. One can enumerate the functions served by systems of measurement and sound experimental designs that cannot be served by notions of wood, earth, metal, fire, and water. In giving the tedious details of such matters, one must use knowledge and reason in a way that is not delimited by geography or nationality. Porkert and his ilk do not want us to use either our reason or our knowledge in assessing the claims of "alternative" therapies and the methods used to support them.
If holistic-health advocates were content with encouraging sensible preventive medicine or with criticizing the economic organization of American medicine, we might be enthusiastic, but they are not. If the movement were without influence on American life, we would be indifferent, but it is not. Holistic medicine is a pablum of common sense and nonsense offered by cranks and quacks and failed pedants who share an attachment to magic and an animosity toward reason. Too many people seem willing to swallow the rhetoric — even too many medical doctors—and the results will not be benign. At times, physicians may find themselves in sympathy with the holistic movement, because some fragment of the rhetoric rings true, because of certain practices and attitudes they encounter in their daily work with colleagues and patients, or because of dissatisfaction with the economic and social organization of medicine. One hopes they will speak bluntly, but it does no good to join forces with cranks and quacks, magicians and madmen.
Clark Glymour, Ph.D.
University of Pittsburgh Pittsburgh, PA 15260Douglas Stalker, Ph.D.
University of Delaware Newark, DE 19711- References
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