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Leonard Leibovici Department of Internal
Medicine E, Beilinson Campus, Rabin Medical Centre, 49100 Petah-Tiqva,
Israel
leibovic{at}post.tau.ac.il
Proponents of alternative medicine can be compared to
cuckoo chicks in that they are using false signals to gain nourishment from a legitimate scientific and medical frame. Rather like the reed
warbler parent,1 the guardians of this frame are not
equipped to recognise loud signals as false.
Warbler chicks increase both their gapes and calling rates as they grow
hungry. When the parent is a reed warbler and the nestling is a cuckoo
chick, the cuckoo produces a loud begging signal. The sound not only
matches the total calling rate of four warbler nestlings but rises so
fast as the cuckoo grows that it soon sounds like eight little
warblers. This signal fits overwhelmingly with what the warblers want
to hear, if only imperfectly with what they expect to see. Still, it is
so clamorous that the warbler parents ignore the missing visual cues
and feed the cuckoo chick
to the detriment (and ultimately death) of
their own offspring.
1 2
Summary points
Empiricists are not equipped to recognise the loud signals of
alternative medicine as false
A deep model of the physical world is essential for choosing hypotheses
to be tested and for learning from failures
Practices of alternative medicine that do not fit even at the far
fringes of the model should not be tested in humans
Our decisions on which practices to test and which to adopt should be
based on three things: empirical evidence; our deep model of physical
world; and our commitment to the wellbeing of our patients
Two conceptual frames are relevant to the present discussion. One (the
empirical-social construct) is ill equipped to deal with the clamour of
alternative medicine. Like the warbler, it ignores the absence of vital
cues because of the loud signal. The other frame (the "deep model"
empirical one) has deficiencies but is better protected against a loud
false signal. Even firm empiricists, should use some of the protective
mechanisms offered by the second frame. Both frames are defined by
several assumptions.
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The first frame: empiricism and social constructs |
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Medicine is a social construct
For example, the "ABC of Complementary Medicine" defines
medicine as the "politically dominant health system of a particular
society or culture in a given historical period."3 Alternative medicine is defined as practices outside this construct.
Boundaries of medicine are defined in social terms
Thus the questions used to define these boundaries are: what is
acceptable? is it in common use? how is it paid for? what political
structures support it? what social needs does it fulfil? Articles or
reviews that have as their main purpose answering these questions are
an important service.
We firmly believe only in empirical proof
We are lucky to live in a time when a potent methodology was
developed to search for empirical proof. Its epitome is the randomised
controlled trial.
The origin of hypotheses does not matter
Empirical proof is so powerful that we really do not care about
the origin of the ideas we examine. The opposite is true: practices or
hypotheses from everywhere are welcomed to be tested. It fits with our
self image of open mindedness and fairness. When the boundaries of
medicine are shifting (and they shift because of social and political
forces, by definition and belief) we will be able to use our empirical
methodology to test what should or should not be adapted from the
practices that are straddling the border now.
Our mission is (and always was) mainly to alleviate
suffering
We should not be too squeamish about using anything that does it.
Be humble
A combination of old-time patriarchalism and "scientific"
hubris spawned a hardhearted and conceited breed in medicine. A bit of
competition will do no harm.
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The second frame: empiricism and deep models |
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The scientific method changed the practice of medicine
Medicine is a social construct. However, the most powerful tool we
have acquired is what, for lack of a better term, can be called
scientific medicine. It is such an effective tool that it changed
radically the practice of medicine (and probably society as well, by
changing life expectancy) in the past century.
Scientific medicine consists of empirical testing and a deep
model
The core of scientific medicine is not empirical testing alone.
Empirical proof (elicited using the best methodology) is very
important. Standing alone, however, empirical proof might (and has)
failed us. By definition, it is not protected from a small chance of
error. Even with the best methodology, it is not easily guarded from
inadvertent introduction of bias and from fraud.
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sometimes even with surprisingly correct methodology. In the Louvre
there are Babylonian clay figures of livers of sacrificial animals that
were modelled before major battles, and the prognostication has been
written on them before combat. If you were to be presented with a set
of one thousand prognostications like these, all made before the battle
and all of them successful, would you believe in the method? Or would
you be looking for the hand of the priest? Even the most ardent
empiricist will reach a limit of credulity in empirical proofs.
Scientific medicine was successful because it combined empirical proof
with a deep model. This combination guards it, to a great extent,
against chance, bias, and fraud. We will accept an empirical proof if
it fits (even at the far, nebulous margins) the model of the physical
world that we use. The model applies to the whole of the physical
world, including our bodies. This model changes. A scientist can be
defined a person who looks for explanations at the far fringes of the
deep model and brings these fringes to the centre.
The building and falsification of bold hypotheses is at the core of the
scientific method. However, there are hypotheses that cannot be
accommodated even at the fringes: that livers of sacrificial beasts
will predict the future; that a substance that causes complaints similar to the ones observed in a patient will, if diluted to an
infinitesimal concentration, cure them.
The deep model is essential for choosing hypotheses and learning
from failures
A deep model is necessary to choose the hypotheses we are going to
test. Resources are limited. The moment we give up on the model, we
should test everything. How do we choose what to test? There are
thousands of practices, with a multitude of variations. It is easy to
show that a way chosen from the framework of the "social construct"
and does not use a deep model will soon encounter paradoxes and contradictions.
Scientific medicine does not contradict compassionate and
emphatic practice of medicine
On the contrary, the offer of partnership in the way to health and
well being should include the explicit science of medicine. We
encounter patients with ideas and frames of mind different from ours.
Scientific medicine, including a common and basic model of the physical
world, can be explained and offered to most patients, without reaching
a conflict with their beliefs and religion. But magic (ways to
influence directly the "basic stuff" of the universe) is contrary
to religious beliefs and is an effrontery to the common sense of our patients.
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Back to the warbler nest |
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Advocates of alternative medicine signal loudly to the adherents to the first frame: they clamour that empirical testing is what really matters. If a procedure has not been tested, it has the legitimate status of "test pending." There is no way to differentiate between good and bad candidates for testing among the pending procedures.
The boundaries between medicine and "complementary" medicine can be defined by surveys and public opinion. This is what the public wants. If you are against these practices, you are outmoded, narrow minded, conventional, disrespectful of the common wish. Attesting to the success of this signal is the BMJ's ABC of complementary medicine,3 a JAMA editorial,4 and many surveys on the use of alternative practices. 5 6
What is so bad about responding to these signals? None of us
would renounce the postulates of the first frame. But without keeping
in mind the checks of the second frame, we may end up by upholding
practices which, given an explicit choice, we would rather not
we
would throw our warbler chicks out of the nest.
The deep model of alternative medicine is anthropocentric magic. The explanations of the practitioners of alternative medicine are giving our patients a set of magical rules to control the physical world, rules that have the human as the fulcrum. They are saying that herbs are beneficial and can do no harm; a substance that causes complaints similar to those observed in a patient will cure them if diluted to an infinitesimal concentration; "we will adjust your Qi force"; these are phenomena that work only on the living human, and not on any other component of the physical world. I would guess that none of us are firm believers in magic. Honouring our patients, are we ready to offer them these explanations?
All alternative practices are effective in minor ailments, usually waxing and waning ones, but not in severe conditions. These various interventions (needles and drugs, colours and lights, manipulation of the spine and caressing of soles, single atoms and megadoses of vitamins) are effective to prevent the common cold, but not to treat pneumonia; to treat asthma, but not anaphylactic shock. What explanation do we have for this dichotomy?
Using the "social frame" for definitions, we are exposed to intense manipulations. Manipulations of the media and the political system can create quite an impression about what belongs to the "politically dominant health system." Lately we have witnessed these manipulations time and again.
If we start with a very low, infinitesimal, belief in our hypothesis, even a successful randomised trial will not sway us by much. Our belief in the efficacy of the treatment will remain low. Thus a controlled trial of homeopathic drugs in humans is unethical: a successful trial, without an explanation, will lead to naught.
The second frame has obvious shortcomings. The deep model has overtones
of a religious orthodoxy. But it is guarded from becoming such by
constant testing and change, and by holding no idea of the physical
world as sacred. By using our model of the world as a filter, we might
lose some worthy ideas.7 But our loss of sensitivity will
probably be more than compensated by the gain in specificity. And
worthy ideas have a way of returning.
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Conclusion |
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The core of scientific medicine has withstood tests again and again during the past century. For the first time in thousands of years we have a system that works. Please ask yourselves if by embracing the first frame entirely we do not undermine a good thing instead of finding ways to repair its faults.
I am convinced that we should base our decision on whether to
adopt a practice or not on three legs: empirical evidence; our deep
model of the physical world; and our commitment to the wellbeing of our patients.
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Footnotes |
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Competing interests: None declared.
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References |
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| 1. | Kilner RM, Noble DG, Davies NB. Signals of need in parent-offspring communication and their exploitation by the common cuckoo. Nature 1999; 397: 667-672. |
| 2. | Mock DW. Driving parents cuckoo. Nature 1999; 97: 647-648. |
| 3. |
Vickers A, ed.
ABC of complementary medicine.
BMJ
1999;
319:
693-696 |
| 4. |
Fontanarosa PB, Lundberg GD.
Alternative medicine meets science.
JAMA
1998;
280:
1618-1619 |
| 5. |
Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, van Rompay M, et al.
Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
JAMA
1998;
280:
1569-1575 |
| 6. | Elder NC, Gillcrist A, Minz R. Use of alternative health care by family practice patients. Arch Fam Med 1997; 6: 181-184[Abstract]. |
| 7. | Rigas B, Feretis C, Papavassiliou ED. John Lykoudis: an unappreciated discoverer of the cause and treatment of peptic ulcer disease. Lancet 1999; 354: 1634-1635[Medline]. |
R Brian Haynes Department of Clinical
Epidemiology and Biostatistics and Department of Medicine, McMaster
University, Hamilton, Ontario, Canada L8N 3Z5
bhaynes{at}fhs.mcmaster.ca
Cuckoo indeed! Practitioners of complementary
medicine beware: conventional doctors are adopting some of your young
as if they were their own. Soon you won't be needed by a society that would like to have alternative treatments paid for by tax dollars, not
directly out of pocket, provided no doubt through "one stop shopping" at a conventional doctor's office. And conventional doctors won't be kind to alternative treatments. Most won't have the
training to deliver them. They will mix them with their own treatments,
treatments that may counteract or drown any beneficial effects. So,
complementary practitioners, start taking care of your own
young.
And how might you go about this, you ask? Embrace empiricism, of
course. In the long run, it is the only way to gain the legitimacy that
you seek. But don't bother with "deep models." Deep models are for
snobs, oppressors, and wishful thinkers. The flat earth, phlogiston,
bleeding, cupping, oppression of women, the Aryan Race Does conventional medicine voluntarily test its ministrations? Some of
its practitioners have contributed to the science, but most have
cooperated only to the extent that legislation has decreed and publicly
funded support has directed. Yet, society has enormously rewarded the
medical profession for its grudgingly empirical approach: doctors are
well paid, medical research is richly supported by increasing amounts
of public funds, and society has legislated that some companies must
pay empiricist research doctors to test their products.
The spotty nature of the evidence for many medical treatments,
however, illustrates that the "empirical champion" status enjoyed by the medical profession is largely externally driven. Public and
professional support is mainly directed towards selected treatments, notably medications. What about the non-pill-like treatments of medicine such as surgical procedures, bed rest, machine based treatments such as ultrasound, "counselling," tincture of time, and
so on? Do they work? Who knows? Do doctors get paid for them? You bet.
No profession should be fully trusted to test itself. The medical
profession can't take much of the credit for its current state of
empirical foundation. And medical doctors aren't above using its
empirical support to discredit competitors. If you complementary practitioners want to retain and grow your turf, wake up to the benefits of empiricism!
So what should complementary medicine specialists do? Form
professional societies. Demand to be regulated (in the usual genteel professional fashion). Set standards for practice and use these standards to certify practitioners. Send your best and brightest for
research training and have them seek money for research from funding
agencies (no better time for this than now). Demand that manufacturers
of complementary products be regulated too

(Credit: CEPHAS)
How about a randomised controlled trial of the stone age diet?
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Take care of your own young
what are these
but "deep theories"? Any good empiricist can attest to the facts
that theories are cheap and sound evidence is hard won. The human mind
can concoct a theory to support any set of notions and observations.
The path that conventional medicine is currently
very
recently
treading has brought it past many useless and obnoxious
treatments, through adopting a scientific, show-me-the-evidence, approach. That convincing evidence is difficult to secure is protection enough against wasting time and effort to test frivolous health claims.
![]()
Empiricism and reward
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A call to action
some of them are getting
away with fraud and murder and will disgrace you in the process.
Educate your practitioners to appreciate evidence from empirical
research. Form a Cochrane Complementary Alternative Medicine Review
Group to summarise the evidence that supports or refutes your
practices. Proudly endorse the treatments that have been shown to work,
and forsake the ones that don't. (Perhaps you could begin by getting
rid of some of the treatments that are useless or harmful, such as
carotene.
1 2
) Then you can afford to be as prideful as
conventional doctors.
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References
1.
Omenn GS, Goodman GE, Thornquist MD, Balmes J, Cullen MR, Glass A, et al.
Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease.
N Engl J Med
1996;
334:
1150-1155 2.
Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group.
The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers.
N Engl J Med
1994;
330:
1029-1035
© BMJ 1999
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