Faughnan Home | FP Web Starter | Contact Info | Glossaries and Links | Site Contents
Herbal remedies are safe because they're natural. Like all natural
cigarettes.
John G. Faughnan M.D.,M.S. and Emily A. Lagace M.D. Revised: 20-Apr-98
| Contents | See also |
This essay was put together for a "Controversies" section in the Journal of Family Practice. It was published her in July 15, 1998. In Oct of 1998 an editorial derived from this work was published in the JFP: Science and the Alternative. J Fam Pract 1998 Oct;47(4):262-3. Please email any comments or complaints, or editorial reprint requests to me.
To critique alternative medicine, we must first define it. A common definition is to categorize medical interventions that are not taught widely at US medical schools or generally available at US hospitals as unconventional, or alternative, medicine. This definition is used by one of the most commonly cited articles on the use of alternative medicine by Americans, and it puts relaxation therapy, commercial weight loss centers, and homeopathy in the same category [1]. Such a broad definition obscures critical distinctions; it does not reflect the concerns of either healers or patients.
To us the true distinction is between healing that is partnered with science and "evidence-based", and healing that is based upon alternative, non-scientific, ways of organizing the universe. This distinction is partly a matter of how evidence is gathered and used, but perhaps the greatest distinction is a willingness to accept standards of disproof. The scientific physician will accept that a favored therapy has been shown to be ineffective; the non-scientific healer will not. It is true that the everyday practice of the allopathic physician is a mixture of scientific and non-scientific medicine, but our best work combines good science with the wisdom and compassion of the healer. This is the combination that has given us the greatest power to heal in all of human history. We should not discard it lightly.
What evidence characterizes our best, most scientific, medicine? The highest grade, Grade A, goes to therapies that have survived randomized double-blind placebo-controlled clinical trials, with a minimum of positive publication bias. This is a costly and difficult standard to meet, but these are the footings of our edifice. The next grade, Grade B, are therapies that are very similar to those that have passed the Grade A standard, such as a medication that is of the same family as one that has been well tested. Grade C therapies are those that have the least supporting evidence, but have mechanisms of action that are compatible with current models in biology, physics and chemistry. These therapies are good targets for disproof; antibiotic therapy of chronic sinusitis may yet fall into this category. Again, it is this capacity for disproof that characterizes scientific medicine.
By our definition Homeopathy, Iridology, Crystal Healing, Therapeutic Touch, and much of Chiropractic, are at the extreme end of the non-scientific spectrum. Acupuncture covers a wide range; most of it is quite unscientific, but other portions have received some serious study and some early indication of possible, albeit modest, non-placebo effectiveness. The use of Human Growth Hormone to slow aging, and the prescription of antibiotics for viral syndromes, are alternative, non-scientific, therapies. Herbalism is a more interesting case, and it is to Herbalism and Homeopathy that we will return.
But first, what is this thing called science? Three hundred years ago, Francis Bacon developed an empirical philosophy as a reaction to the scholarship of antiquity and the folk knowledge of the day. He wrote that: "…it is the peculiar and perpetual error of the human intellect to be more moved and excited by affirmatives than by negatives…in the establishment of any true axiom, the negative instance is the more forcible of the two.", and that the mind "when it has once adopted an opinion…draws all things else to support and agree with it." [3,4]. He saw that this was the problem with folk knowledge and tradition, and he warned of "fallacious modes of thinking arising from received systems of philosophy and erroneous methods of demonstration" [5]. Bacon’s perceptions of the weakness of unscientific reasoning led him to begin the development of a skeptical, empirical, philosophy that, in time, became science.
Science is characterized by a questioning of common sense and sentiment. It relies on observation and testable predictions, not on authority alone. Science is most profoundly about disproof. Disproof can be deeply unpopular, and science is not always loved. It is a hard thing to see a cherished belief crushed and discarded, to learn that the universe does not agree with us. Newton's physics lives on, but his alchemy is dust.
Science advances through creative destruction, revising or destroying old models, producing new models with yet more powerful predictions. Yes, scientists resist challenges to the established order, and they are also prone to the errors Bacon wrote of. Despite this human frailty, disproof occurs, albeit sometimes with pain and struggle.
Curiously, alternative medicine is often thought of as anti-authoritarian and romantically rebellious. Yet, without a standard for disproof, alternative medicine is a return to the dogmatic world of medieval scholasticism, of "proof" by the loudest opinion or the most intricate argument. Without a standard for disproof Alternative medicine has no limits, and no question without an answer. For every ailment there is a therapy, or several therapies. Eighteen hundred years ago Galen's four humors of yellow and black bile, blood and phlegm, explained all symptoms and all diseases. There is still comfort in this ability to answer every question.
How do two representative types of Alternative Medicine, Herbalism and Homeopathy, measure up to the science, and the scientific medicine, that we advocate? We have no doubt that these therapies are efficacious. We know, from scientific studies of the mind and body, how powerful are the combination of trusted healer and trusted therapy. It is not, however, the inarguable efficacy of mind-body connection that we are concerned with here. Rather, it is the evidence for additional benefit, beyond the power of belief. Since the dawn of time healers have used the therapy of belief, but it is the special strength of scientific medicine that we can give the healer therapy that goes beyond belief alone.
First, Herbalism. How is its current practice non-scientific? Obviously natural products have biological activity! A substance created by a mold to poison bacteria can be neatly hijacked and used as a bacterial poison in our own bodies. The disconnect from science occurs with the proposition that these remedies are safer, and need less regulation and evaluation, because they are "natural". There is nothing in our knowledge of nature to support the belief that natural, herbal, products are uniquely both benign and effective. The lack of standards in this country for potency and content, which implies a belief that activity is unrelated to concentration, is likewise unscientific. Most peculiar perhaps is the belief that the large corporations that sell these products will voluntarily hew to the manufacturing standards that cost pharmaceutical companies so much. Did we learn nothing from the L-Tryptophan story?
This is not to say that the Herbalist’s perceptions of efficacy are worthless. These have suggested directions for scientific research. Once the hard work is done, and toxicity and efficacy characterized, then the product may become a part of the pharmacopoeia. It ceases to be "alternative", and becomes, simply, medicine. Scientific medicine is rapacious in its desire for better therapies. There is no honor in science, if an "Alternative" therapy passes our standards, if it works, then we will make it our own. We should likewise disavow our favored therapies, if they are found wanting.
Homeopathy is a beast of a different nature. It is profoundly unscientific. A Homeopathist matches a patient's symptoms to a poison, that, in active doses, produces similar symptoms. The poison is then diluted until it is all but undetectable, and administered to the patient. In the "standard model" of modern physics it is very difficult to see how increasing dilution can produce increasing potency. Were Homeopathy found to work, we would have a Nobel-prize winning upheaval of our most robust models of how the universe works. Exciting, but not likely.
Homeopathy seems remarkable easy to test with "Grade A" methods. Given the degree of popular interest, it is worth doing those tests well. If it is proved effective, physicists will have much work to do. If it is disproved, scientific physicians can set it aside. Alas, Homeopathists are unlikely to be convinced. Without the standards of disproof that are a part of science, it is always possible to plead "extenuating circumstances". The ultimate defense is the invoke the "observer effect", to claim that the very presence of a skeptical observer negates a therapeutic effect. It is this incapacity to accept disproof that is most characteristic of unscientific healers of any origin.
And yet, what about the demands of patients? Many persons, not a few of them upper middle class and university educated, ask for non-scientific, Alternative, therapies. Marketing departments often like Alternative therapies. They are relatively inexpensive, and they appeal to a desirable demographic -- the young and relatively healthy. Indeed, their promotion may even discourage more conservative, older, sicker, patients from joining a managed care plan. Should not the family physician serve the logic of the marketplace and the wishes of their employers?
It is tempting so say yes. This is not an easy time to be a physician. There is a glut of healers these days, Allopathic and otherwise. Incomes are falling, and it is difficult to retain patients. Adding another marketing niche is appealing.
We recommend saying, respectfully, no. We say this on two counts, one coldly pragmatic and the other idealistic.
As Pragmatists we recognize the importance of "branding" and marketing in the 21st century. Brands are important in the global marketplace, and our "brand" is the uncomfortable but exceedingly fruitful merger of the shaman-healer and the scientist. If we adulterate our "brand", if we become just another healer dealing the therapeutic fad of the month, then the marketplace will discard us. We cannot be all things to all people. We can be the "scientific healers". That, we believe, is what our patients will want in the slightly longer run. Let others do Homeopathy and Iridology. Many societies have split health care into a scientific system and a non-scientific alternative. Perhaps we will follow the same path.
As Idealists we wish first to do no harm, and secondly to server the patient's health. Homeopathic therapies are certainly unlikely to do direct harm, though herbal remedies certainly might. Indirect harm is likely, however. A patient may delay effective therapy while pursuing harmless but ineffective remedies. Patients who seek out a physician for medicine based on science may later feel betrayed by therapies based on non-scientific principles.
When we say we serve the patient's health, we mean our first duty is not to the patient's stated wishes, but rather to their health as we can best understand it. An accountant cannot ethically falsify tax returns, a lawyer cannot ethically advise on breaking the law, a physician should not act against a patient's health even if they ask it of us. Even if a patient is convinced that chronic antibiotics can treat their hypertension, most physicians would not choose this therapy. Most of us do not prescribe recreational drugs, no matter how great the demand. We advise, educate, and then act on behalf of the patient's health. If the patient demands of us remedies that we feel are not in the interests of their health, then we should frankly say that we disagree with such remedies and do not use them. We will provide the best evidence-based care we know, even while the patient sees a separate Homeopath or Herbalist. We should learn the toxicities and medication interactions associated with commonly used Herbal remedies, though, given the lack of standards, this will be rather challenging.
It is easy to forget that we have had scientific medicine only for a short time. Biomedical sciences began their great surge only sixty years ago, and the clinical sciences have gained strength only in the past twenty or thirty years. Those who would turn away from science now should first review a medical textbook from only one hundred years ago. You will find it as filled with worthless remedies as any medieval text, or modern Herbal. Allopathic medicine has spent most of its existence without science, but our great achievements have come with it.
[1] Eisenberg DM, Kessler RC, Foster CF, et al. Unconventional Medicine in the United States. N Engl J Med 1993 Jan 28:328(4):246-52.
[3] Bacon Francis, The New Organon. Ed. Fulton H, Anderson. Bobbs-Merrel Company 1960; p. 51
[4] Ibid, p. 50
[5] Robert Adamson, John Malcolm Mitchell. Francis Bacon. In Encyclopedia Brittanica, 11th Ed. 1911.