(Re)considering the “Alternatives”

Late in the last century, a long-form essay by Arnold Relman, former editor-in-chief of the New England Journal of Medicine, appeared in The New Republic (December 13, 1998). Titled “A Trip to Stonesville: Andrew Weil, the Boom in Alternative Medicine, and the Retreat from Science,” I gave a copy of it to every student, resident, colleague, friend, and family member I could find. Relman, who died eight years ago, was an articulate, resolute advocate of upholding the highest standards of medicine against countervailing forces. One of those countervailing forces in his (and my) view was the increasing popularity of “complementary and alternative medicine” (CAM), in particular its instantiation of growing anti-scientific, anti-rational sentiment in our society. In that piece, Relman’s exposure of the myriad intellectual sleights of hand committed by one of the chief proponents of the alternative medicine industry was masterful, culminating in his conclusion that an “integrative medicine” that purports to meld fundamentally antithetical approaches to reality is a conceptually incoherent non-starter.
 
In my article, “Epistemic Humility: Accruing Wisdom or Forsaking Standards?,” and in “Epistemic Humility, Justice, and Honesty in Clinical Care” (Waterman 2022), my response to published commentaries, I describe my reassessment of that earlier position. What has changed over the two dozen intervening years? If anything, the backlash against rational thought, most recently embodied in Trumpist politics, has shown itself to be even more pernicious than Relman (or I) imagined in 1998. But medicine is both an intellectual and a practical enterprise. My own recent experiences with persistent pain made explicit to me what millions of people already knew too well: conventional medicine has little to offer many patients seeking relief from a variety of common ailments. And some of those sufferers (me, unfortunately, not among them) have found benefit in treatments that fall into the (highly heterogeneous) category of CAM.
 
As their titles indicate, my recent articles frame my reassessment of this topic in terms of the virtues of epistemic humility: recognition of the consequences of our own inevitable parochialisms in apprehending the world. But how should such humility manifest? I have not renounced, nor even seriously questioned, Relman’s contention that only interventions whose efficacies are demonstrable should have a place in clinical practice. The question about which I counsel humility is: What counts as evidence that a treatment is worthwhile? Conventional thinking within scientific medicine tends to discount (implicitly if not overtly) the value of reports of the usefulness of some of the therapies generally included under the CAM heading. And the reasons for that are not difficult to identify. One is that crediting such interventions as helpful would seem to endorse as valid the mechanisms by which their practitioners and proponents claim they exert their effects. As those purported mechanisms are in some instances dubious (or simply absurd) by even the most generous assessments, denying the efficacy of the treatments might seem imperative to the defense of scientific standards in medicine. The question then becomes whether we can disentangle the skepticism with which we assess purported mechanisms of therapeutic effect from that with which we evaluate claims of efficacy. 
 
In his above-referenced essay, Relman’s enjoins us that “all proposed treatments must be tested objectively.” This, I am now persuaded, is where we might find an intellectually credible and pragmatically beneficial resolution. “Objective” demonstration of efficacy has come to connote “superiority relative to a suitable placebo condition.” But what if many or most CAM interventions themselves work via “placebo” mechanisms? That is, what if – as seems exceedingly likely – these treatments exert their effects primarily through hopeful expectancy and related phenomena? The demand for superior efficacy relative to placebo conditions becomes nonsensical if the interventions in question are themselves placebos. Is that a problem? “Placebo” does not denote “ineffective”; the therapeutic power of placebos in a number of contexts is well demonstrated. Nevertheless, the familiar associations of placebos with inertness and, worse, with deception make it difficult to acknowledge simultaneously that many CAM therapies (not to mention many components of conventional ones!) exert their effects via hopeful expectancy and that they provide bona fide relief to many people. But if that formulation is accurate, the task before us – which has already begun in different settings – is to determine how best to exploit the therapeutic power of placebo treatments without the deception (inadvertent or otherwise) entailed in the fanciful explanatory stories that often accompany their administration. That project has the potential of improving countless lives and is in the best tradition of scientific medicine. 

G. Scott Waterman is Professor of Psychiatry Emeritus at the University of Vermont Larner College of Medicine, where he also served as Associate Dean for Student Affairs. His philosophical interests include psychiatric nosology and philosophy of mind in medical education, discourse, and practice. He is a member of the Executive Council of the Association for the Advancement of Philosophy and Psychiatry, and Chair of the Advisory Board of the University of Vermont’s Miller Center for Holocaust Studies.