Review section 53

This study was undertaken in association with the Ma- rylebone Centm on the co-operative inquiry principle, regarded by its proponents as an important research tool, although others might see it mom as joint self-education. The principle is that all involved in the inquiry have equal status as co-researchers andco-subjects, deciding together the methods to be used, the outcome and the conclusions.

The format of the study was that each patient was seen by each of the practitioners and then by the group as a whole to plan a management strategy. There were 3 waves of about 4 patients each, with group meetings between to consider what had happened and develop plans. The study did not conform strictly to the principles of co-operative inquiry because the patients played a rather minor role: each was heavily out-numbered by practitioners at the meetings, making it unlikely that the patients’ view was adequately represented.

The study floundered initially because its aims were too vague, and the extent of the differences in attitude to pract- ise had not been appreciated This difficulty was not re- solved since one of the practitioners was left with the im- pression that the GPs accorded the practitioners’ approach psycho-social but not medical validity. This has a ring of truth that the medical profession needs to heed. No co- operation with other health professionals will work while we assert that we understand illness and no-one else does. There are some aspects where it may be true, but there are others where our knowledge amounts to little more than labelling and describing the condition, and relieving the symptoms. And we too often avoid asking why that patient has developed those symptoms, how it could be prevented, or why patients with the same diagnosis repond differently to treatment, expecting most of the answers to lie with neuroticism and hypochondria; other practitioners are addressing these questions more seriously.

The authors discussed practice under 3 headings: diag- nosis, psycho-social framework, and practitioner/patient relationships. Differences in philosophical and physical concept of illness made communication difficult, and discussion kept escaping into the easier realm of psycho- social factors, so the report skates over the fundamental question of diagnosis, merely recording differences of approach. This is a pity, since diagnosis is the king-pin on which all discussions of management depend. I was surprised that the paper did not examine the data obtained by different practitioners from the same patient and the constructions put on it: that might have provided a grow- ing point.

On the relationships issue, the difficulties of 4 or 5 therapists relating to 1 patient was of mainly theoretical interest; no practical scheme for collaboration could af- ford such an extravagant arrangement on a regular basis: no insights were offered into the real problems of more than one practitioner treating a patient.

The study sharpened the authors’ appreciation of the difficulties of collaboration but I fancy that the questions they asked in conclusion - how they could improve their

understanding of each other’s practice and how best to relate jointly to patients -might have been asked before the start And I wonder if this is the right way to look for the answers?

Solutions ate needed for the generality of GPs and practitioners throughout the country. Education and un- derstanding are clearly vital, but if 5 years of collaboration has not supplied the answers, something more is needed. What happened to the computer database of case records that was started by the homoeopaths some years ago? Could this be expanded with advantage? Or would a study of symptoms before and after different treatments gener- ate a database from which suggestions for problem pa- tients could be derived? I hope that the search for answers will widen to give results that can be used elsewhere.

Honor M Anthony MB ChB

Research Co-ordinator, Airedale Allergy Centre,

Keighley, W York

Kottow MEL Classical medicine valternative medi- cal practices. J Med Ethics 1992; 18: 18-22.

Pietroni PC. Alternative medicine: methinks the doctor protests too much and incidentally befuddles the debate. J Med Ethics 1992; 18: 23-25.

The title of Dr Pietroni’s response to Dr Kottow’s paper may be on the long side, but it admirably sums up the views of both doctors and, to some extent, my own.

In his critique of alternative medicine, Dr Kottow im- plies that he is working from an objective, scientific stance. He acknowledges that there are reasons for dissat- isfaction with modem medicine with its excessive em- phasis on technology, and that this lack of interest in the ‘patient’s need for comfort and support’ . . . ‘provides an easy bonus for alternative approaches’. This, however, does not validate alternative medicine, which Dr Kottow criticises for its lack of attention to diagnosis (‘the most powerful tool of medicine’), its lack of validation and reliance on empirical and anecdotal data, its lack of cause/effect rationale, and its metaphysical approach to health and illness.

Recently I was talking with a healer who had partici- pated in some properly conducted, totally successful, scientific trials. No scientific paper has published the results. The healer’s chief conclusion is that science itself is a belief system, whose upholders feel threatened by anything likely to shake it This strikes me as relevant to the approach taken by Dr Kottow.

For, while constantly citing science as the ultimate standard, Dr Kottow’s actual argument does not strike this lay readeras scientific. As DrPietroni points out, he starts with a false premise, equating ‘alternative medicine’ with

54 Complementary Therapies in Medicine : Review section

‘holism’, and ignoring the fact that the word ‘alternative’ covers a huge range of therapeutic approaches.

Many ‘alternative’ attitudes are, as Dr Pietroni also writes, shared or under debate by scientists and doctors, including theories of causality and an interest in treating the whole person. Dr Kottow dismisses the placebo as unimportant, and appears to discount the importance of the patient/practitioner relationship.

Dr Pietroni answers the majority of Dr Kottow’s criti- cisms succinctly. What I find most worrying is that while Dr Kottow claims that ‘alternative therapies employ ra- tional language with the explicit purpose of clouding issues’, his own, highly slanted use of language provides a very curious picture of alternative therapists.

He accuses them of ‘reducing the patient’ to their hol- istic perspective, to become ‘an acquiescing appendage’. By requiring individuals to take responsibility for their health they ‘diminish’ . . . ‘the diseased, deficient, unin- formed and untrained patient’ . . . ‘the sick person has become deranged, . . . dependent on the enlightened thera- pist’.

I don’t know what alternative practitioner left such an impression on Dr Kottow. I have on occasion felt both deranged and diminished in the presence of hospital con- sultants - one reason I initially began to explore altema- tive therapies.

It is good that there should be a serious exchange of views about and between complementary/alternative and classical medicine. However, in the last 10 years the former has become well-established, and it is dishearten- ing when the same criticisms are brought out again and again as if they were new. Is it not time for scientists to take these as read, and act on them, perhaps by instituting truly objective research of their own, or at least examining the easily examinable facts, such as the clinical research that has already been carried out, with an open and un- biased eye?

Anthea Courtenay Writer andjournali.st on health and

complementary therapies

Charlton BG. Philosophy of medicine: alternative or scienti$c? J R Sot Ned 1992; 85: 436-438.

Dr Charlton is perplexed by the continuing popularity of alternative medicine at a time when scientific medicine is progressing from strength to strength. He sees the emer- gence of the double blind trial as one of the great achieve- ments of modem medicine, bringing the possibility of fair objective assessment of therapies whose outcome would otherwise be clouded with the uncertainty arising from the placebo effect. Yet in spite of the availability of this method, he is surprised that the public are so often content

to turn to untested alternative systems, provided by prac- titioners whose training and knowledge are questionable by medical standards.

Admittedly, conventional medical practice cannot al- ways be based on objective certainty, but at least it is based on rational probability, derived from scientific knowledge and recognised standards of training. Alternative medical practices too are in their way rational, but the systems on which they ate based have no proven foundation. More- over, the various alternative medical systems (e.g. homoe- opathy and acupuncture) are incompatible with each other and with conventional medicine. The survival of such systems requires a form of double think by their supporters and a suspension of critical judgement. The author is not convinced by such clinical trials as have reported on the effectiveness of homoeopathy.

Dr Charlton is fully committed to the principles of scientific (‘pathological’) medicine, but sees no point in trying to suppress alternative medicine, which after all has some features which might be incorporated into conven- tional medicine. In any case, he sees the alternative prac- titioner as being in a strong position: his implicit belief in the system he practises, however illogical, impresses his patients, to whom he is able to give more time than the conventional GP can.

However, Dr Charlton does not acknowledge the other side of scientific medicine: the suspicion, even fear, often generated by the knowledge that there are side effects and dangers tomany drugs, some of which are overprescribed. This fear and the reaction to it were recognised in a British MedicaZ Journal editorial in 1980 entitled ‘The Plight from Science’ .l More recently, a major reaction against science, and nuclear power in particular, has been noted in Russia2 where glasnost has permitted an open recogni- tion of alternative medical practices and the activity of many mystic healers.

Human beings are as much (perhaps mote?) ruled by emotion as by reason. A good anecdotal account of a new and appealing ‘cure’ impresses more than the most me- ticulous double blind trial, and after all, many orthodox practices have arisen from intelligent observation of ‘an- ecdotal’ case histories.

It’s quite right and proper to require evidence that a new therapy is effective, but as Prince Charles said, some part of our mind must remain open to the unknown and the unexpected. And who is to know when an enhanced placebo response becomes an aspect of self healing?

J.A. Cosh MD FRCP Consultant Physician (retired)

References

1. The tlight from science. (editorial). BMI 1980; i: l-2. 2. Kapitza S. Antiscience tmnds in the USSR. Sci Am 1991; August:

18-24.