Thursday, August 12, 2010

Allopathic medicine and CAM: Nonoverlapping magisteria revisited?

Stephen J. Gould is known to most of us as the evolutionary biologist who brought much scientific thought on evolutionary science to the public. A self-acknowledged Jewish agnostic, he also struggled with how to help the world hold two seemingly conflicting philosophies: that of science and that of religion. He discusses some of his views in this essay and at more length in his book Rocks of Ages. In the essay he says the following:
The lack of conflict between science and religion arises from a lack of overlap between their respective domains of professional expertise—science in the empirical constitution of the universe, and religion in the search for proper ethical values and the spiritual meaning of our lives. The attainment of wisdom in a full life requires extensive attention to both domains—for a great book tells us that the truth can make us free and that we will live in optimal harmony with our fellows when we learn to do justly, love mercy, and walk humbly.
Gould coined the idea of "nonoverlapping magisteria" to describe the complementarity of rather than a conflicted relationship between these two domains of human condition. In this view he echoes another iconic scientist of the last century, Albert Einstein, who concluded that "Science without religion is lame. Religion without science is blind". Both scientists seem to boil the complementary nature of the two fields down to the idea that science asks the question "how?" and religion asks the question "why?", both so necessary for our understanding of life in this Universe. Thus, forcing oneself or others to choose between the two creates a false dichotomy so prevalent in our discourse today.

Along the same lines, I am struck by the nearly always contentious and occasionally hostile conversation about the role of complementary and alternative medical (CAM) modalities alongside of our traditional Western style allopathic medicine. Both sides seem to imply that there is no room for both in our healthcare. And while the allopathic side holds up scientific method and evidence as the oracle of their field, the CAM practitioners, with equal zeal, cite tradition, spirituality and mystery of the human body as the central dogma in theirs. And when each is subjected to a critical appraisal by the other's methods, failure is the most frequent, if not unexpected, result.

So what is the answer? Should allopathic medicine, the side that right now holds much greater power and sway over our healthcare system, let in these pseudo-scientific usurpers even without any scientific evidence that they do any good? Should the two just coexist side by side, much like suggested by Einstein and Gould for science and religion? Well, it's complicated.

It is hard to argue with a straight face that the earth is flat or that it is indeed only six thousand years old, given the plentiful fossil record to the contrary. Believing an ancient text verbatim and denying the reality of the evidence to the contrary is not only a logical fallacy, it betrays stupidity and petulance. Similarly, denying that uncontrolled hypertension is the cause of coronary disease is ridiculous. However, given the complexity of the organism, we know that it is not the only cause of coronary disease. Furthermore, there may be causes that we have not discovered yet because we have either not thought to look or are unable to discern because we do not yet have the necessary scientific tools. This is to say that we know a lot, but probably not everything.

Now, let's move on to treatment of hypertension. The way we establish whether a modality works is through randomized controlled trials, where we look for differences in outcome based on the differences in the main exposure, in our particular case, the treatment for hypertension. Randomization is meant to ensure that the two groups being compared are not different from one another in any systematic way, and we reassure ourselves that randomization worked by looking at aggregate physiologic measures of the two groups, such as average blood pressure, average age, etc, and seeing if they are the same in both groups. If they are roughly equivalent, we say that the randomization worked, and all the differences in the outcome we see must be due to the experimental intervention, in our case the blood pressure treatment.

But what are we unable to measure? Oh so much! The burgeoning science of neurobiology, for example, has raised so many interesting questions about not only what the mind can do to the body, but what the body can do to the mind (please forgive this dualistic language). Why is this important? Because, due to our lack of adequate tools until recently, and because of the overwhelming complexity of the subject, we have traditionally neglected to include any measures of our patients' and trial subjects' neurobiological milieu into the consideration of differences between groups. But if randomization takes care of other systematic differences, should it not take care of the neurobiological ones? Perhaps, but without understanding the magnitude of variability of these characteristics in a population, one cannot begin to know how large a swathe of the population has to be enrolled in a study in order to smooth out these potential differences. And this goes for other so far unknown or unidentifiable characteristics. So what we think we learn from these trials is, much like in any other branch of science, subject to interpretation within the context of our knowledge today, and is, therefore, far from the universal and immutable truth. And the more we learn, the less absurd certain heretical ideas of the past seem. It's OK, we are all in good company. Even Einstein was not infallible: when he said that "God does not play dice with the Universe", he was alluding to his skepticism with regard to randomness of quantum motion, which has since been confirmed.  

But I stray from my main question, which is "Is the dichotomy between allopathic medicine and CAM a false one?" Well, what if we broaden the argument. We know that a human being is a fairly complex animal. As I alluded to above, we are only now beginning to put the data from neurobiology behind the phenomena of the human condition that have been observed for millennia. Such human impulses as the need to be surrounded by nature, compassion and need for retribution are all gaining scientific underpinnings in neurobiological research. So, what we already knew and understood about ourselves is now being explained (the "how") by science. This is comforting, and it should make my evidence-based allopathic colleagues pleased. It should also please the CAM practitioners, as the traditional views of what it means to be human are being validated.

So, what am I driving at? Krista Tippett in the Introduction to her latest book Einstein's God says that "opinion polls create false dichotomies". Since we live in a time when polarization seems to be the norm (just look at our political discourse), it is natural for allopathic medicine and CAM to retreat more deeply into their own corners and to become more entrenched in and convinced of their own singularity. This is the wrong approach. Humans are not all easily-understood physiology, but we are also not all spirit and mystery. We are in fact both. Some of the conditions we define as physiologic illnesses are nothing more that the products of our distorted expectations and philosophies. Some of our impulses to treat cancer with CAM alone are misinformed. If acupuncture seems to help my neighbor with her subjective symptoms of menopause, so be it, I am happy for her, even if I do not fully understand how it works. If yoga gives me a sense of well-being, yet there are no randomized controlled trials to validate this assertion, so what? Perhaps more "N of 1" trials are the way to go for CAM, I don't know. But I do think there is something to the subjective experience, even if we call it placebo effect, which incidentally implies that it is your own organism, with the help of an external stimulus, that has achieved the desired end. Why is this bad? Especially if there is no adverse consequence to counterbalance it? Granted, we have to be conscious of the attendant costs in this mammoth healthcare system of ours. Well, I for one am not averse to subsidizing my neighbors' well-being, even if the science tells me the effect is no different from a placebo. We already pay a premium dollar for interventions that only seem to work in a small minority of individuals who qualify for them based on well-accepted scientific evidence. And this is not even getting into the discussion of how much adverse reactions cost, even when there is no individual benefit of treatment.

It is true that science sets a high bar for gathering evidence. But one must acknowledge the inherent subjectivity in how we define endpoints of importance, and a complete antithesis to clinical sensibility of pursuing the p value. Medicine is and will remain inexact, part science, part art. To hold these two seemingly different philosophies together does not present an internal conflict for anyone, just as holding the methods, aims and philosophies of allopathic practice and CAM should not. Bridging these as nonoverlapping magisteria in healthcare can eliminate much of the conflict felt by the medical profession, and promote a more open-minded and humanistic approach to our public's health.                              



  1. Thank you for this post. I used to pooh-pooh alternative treatments, too, until we moved to Mexico, an area without many people from the USA but with excellent medical care. Here, the doctors come from a culture which traditionally -- whether one is educated in a western sense or is a country person -- unselfconsciously holds a more complete view of what it means to be a human being. Thus, doctors are aware that more than science and indeed more than the addition of socio-economic status affect treatment outcome.

  2. A very balanced article.It is great to find that there are Doctors in Allopathy/Modern Medicine who are having an open mind.As a Qualified Homeopathy Medicine graduate and practitioner,the attitude of my fellow MBBS doctors used to surprise me for 2 reasons.One-in India we learn everthing same at a graduate level except the Pharma/Homeopathic Medicines part and second-both the systems do not fully address the maladies affecting Human system.However ,both are needed in this world for healing!
    Thank you very much.I came to read your article folloing a link on KevinMD.

  3. I think you've missed the point. You state, "If yoga gives me a sense of well-being, yet there are no randomized controlled trials to validate this assertion, so what?" I agree. So what. For me the problem arises when you label yoga medicine and lead people to believe that it will, not might, but will, provide important health benefits when you don't have evidence that that is true and when in fact obtaining such evidence would be difficult or impossible.
    I'm old enough to remember doing yoga because it seemed like an interesting form of exercise. The stretching exercises were similar to those done in ballet classes although there we were taught never to rotate a hinge joint. Many practiced yoga to relax and because they enjoyed it. But relaxing and enjoying something don't seem to be valid reasons for doing things anymore. Now you have to convince yourself and everyone else that anything worth doing is a preventive or curative treatment for disease.
    I too saw your links when they appeared in your comments on MedPage. The article had been forwarded to me. I unsubscribed myself from the site for several reasons, one of which was that they didn't publish my links with my comments.

  4. Another excellent piece. I still haven't read through all your posts but I need to before commenting again as you've already covered some of these issues.

    Now I'm sure you have no problem seeing that I agree near 100% with this piece while also feeling disengaged about CAM myself, as per my comment on your more recent post. So, how informed do you feel medical clinicians should be about CAM? Do you feel that is part of your role? Go on, I can take it!