Book Review

Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer

N Engl J Med 1994; 331:1244November 3, 1994

Article

Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer
By Michael Lerner. 626 pp. Cambridge, Mass. MIT Press, 1994. $24.95. ISBN: 0-262-12180-8

Michael Lerner has undertaken to present a road map of the maze of therapeutic options presented to patients with cancer by doctors, family members, neighbors, friends, and the media in contemporary America. The book is for patients, and thus should be interesting to the physicians who care for them. Lerner discusses how to make choices among the conventional therapies for cancer, as well as among a variety of unconventional therapies (including nutritional treatment, pharmacologic treatment, physical and “energetic” approaches, exercise, massage, therapeutic touch, chiropractic, and traditional Chinese medicine). The author stresses the importance of a conventional oncologist for every patient with cancer, but acknowledges that many patients will concurrently seek out unconventional healing techniques. He offers his evaluation of a variety of unorthodox approaches to cancer, discussing the studies that have been performed (with references).

Lerner warns of the dangers inherent in both conventional and unconventional therapies: faddism, charlatanism, insular viewpoints, disdain for the ideas of others, and depersonalization of the patient. He emphasizes the necessity for the patient to understand that there is no single solution for everyone but rather that therapy (or therapies) must be adjusted to individual needs. He notes the acceptance of unconventional therapies in other countries and finds the mainstream American medical establishment rather more closed-minded than people in other, equally advanced nations. He speaks with approbation of the beginning of an acceptance of investigation into unconventional therapy by the National Institutes of Health, as well as (laudably) encouraging practitioners of alternative medicine to fund and conduct their own research.

Having said all this, and acknowledging my bias as a conventional practitioner, I did not find the book, as proclaimed by one of the cover blurbs, “balanced and practical... a responsible weighing of the risks and benefits of conventional and complementary cancer therapies.” Perhaps this is because of the difficulties inherent in comparing science with nonscience, rationality with belief, and the studied with the unstudied. I believe the author understands these difficulties. He points out that physicians are trained as scientists and thus are “part of a culture that thrives through the inculcation of doubt.” In his analysis of conventional medicine, the author has all these doubts, since the conventional scientific literature is replete with not only the successes but also with the failures of orthodox therapy for cancer. But far fewer studies cast doubt on the validity of unconventional therapies, and these studies have been conducted by conventional scientists (and thus generated by the “enemy camp”). Scientific studies in support of unorthodox therapy are, of course, accepted as favorable evidence, but the “scientific analysis” of some unconventional treatments is anecdotal or pseudoscientific at best. Lerner presents both sides, but unequally. Hence, he judges conventional therapies rather harshly but is less critical of unconventional therapies. Conventional treatments must be shown scientifically to work, whereas unconventional treatments are presumed beneficial (or at least largely harmless) unless there is scientific evidence that they do not work. In describing one unconventional therapist whose theory is “so broad it applies not just to cancer but across the board to many other conditions for which he has devised treatments... itching, insomnia, vertigo, migraine, and hearing impairment... radiation burns... osteoarthritis, rheumatoid arthritis, convulsions, variations in the pathogenesis of infectious disease, the seventh day post-operative bleeding in prostatectomies and nasal plastic surgery, and the seven day worsening of heart infections... AIDS, heart irregularities, Crohn's disease, colitis, unconsolidated fractures, prostate hypertrophy, and, very notably, drug addiction,” the author notes that this “potentially monumental contribution... remains almost entirely outside the orbit of mainstream science. We may be the poorer for it.” If it works, we sure are.

In his discussion of conventional therapy, much of the advice Lerner gives is defensive. Though much of what he says is true, the emphasis on the negative is off-putting. He recommends that the patient go to a medical library and check out the books on his or her cancer, buy a medical dictionary, obtain review articles on the specific cancer and the treatment options, run computer reference searches, and “keep an eye on what the oncologist or radiation therapist is recommending and whether he is providing you with all the information you need.” He warns the reader about iatrogenic disease, noting that “the medical profession as organized today rarely does an adequate job of tracking and coordinating all aspects of treatment and of minimizing errors of omission or commission. The sooner you realize this, the less likely you are to suffer from iatrogenic health problems.” He also suggests a contract between patient and physician, written by Harold Benjamin, founder of the Wellness Community in Santa Monica, California, which specifies the responsibilities of the oncologist and the patient and requires the signatures of both. Although such a contract may be pragmatic and useful, it suggests a mutual distrust between patient and physician and has all the negative implications of a prenuptial contract. In short, the author suggests that inherent distrust is a wise posture in conventional therapy. As for unconventional therapy, he notes that “for some patients the mystery of a closed therapy contributes to the numinous quality of the remedy.... this is a psychologically potent process with significant placebo potential which may arguably enhance prospects for recovery, irrespective of the pharmacologic action of the therapy itself.” It seems to me there is a serious double standard here.

Michael Lerner has used, and rightly so, what is perhaps our greatest strength (our self-critical literature) to expose our greatest weakness: the failures of our therapy. He speaks in the language of science when criticizing science but in the language of belief when promoting systems predicated on belief. Perhaps the success of unconventional therapies is this: magic is more enthralling than the mundane, hope is better than reality, and there is a deep need in all human beings -- particularly those afflicted with terrible disease -- to seek miracles. I cannot recommend this book to my patients, though I too am of the opinion that humans need more for healing than conventional medicine often offers. Physicians, on the other hand, may find the book interesting as an illumination of the thought processes and beliefs of intelligent laypeople. By reading this book, they may gain some insight into the feelings, fears, and hopes of their patients, and so pay attention to these things.

Faith T. Fitzgerald, M.D.
University of California, Davis, School of Medicine, Sacramento, CA 95817

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