If there’s one message that I’ve been trying to promote, regardless of whether it’s on this blog or my not-so-super-secret other blog, it’s the concept that there should be one standard of evidence—one scientific standard of evidence—for evaluating health claims and medical treatments. It doesn’t matter if it’s the latest drug from big pharma, the latest operation from a hot shot surgeon with a lot of creativity and not necessarily the most rigorous dedication to science- and evidence-based medicine, the woo-filled claims of alternative medicine practitioners, or the seemingly “evidence-based” claims of physicians deluded enough to “integrate” quackery with medicine and call it “integrative medicine.” That’s the beauty of science. Unfortunately, those who would “integrate” pseudoscience into medicine have been very successful in promulgating a double standard, in which the pseudoscientific medicine is held to a lower standard of evidence.
Coming in a close second as a theme of this blog is the demolition of a false dichotomy promoted by purveyors of “integrative medicine”—or “complementary and alternative medicine (CAM)—or whatever the buzz word du jour is to describe it. That false dichotomy is the claim, seemingly endlessly repeated by everyone from Andrew Weil to David Katz to just about every advocate of “integrative” medicine willing to join with naturopaths, practitioners of traditional Chinese medicine, reiki practitioners and other “energy healers,” and homeopaths in their quest to be a “holistic physician.” In fact, that’s the dichotomy. They argue that, in order to be a truly “holistic physician,” you have to embrace pseudoscience of the sort practiced by the aforementioned practitioners of pseudoscientific medicine, or, as David Katz seems to argue, that you’re “abandoning patients” if you don’t consider these modalities seriously. Of course, David Katz is (in)famous for a quote in which he advocated a “concept of a more fluid form of evidence than many of us have imbibed from our medical educations” and was willing to embrace homeopathy based on anecdotal evidence.
So why is this happening? Well, I know one reason it’s happening is that too many physicians buy into some seriously bad logic, logic that was unfortunately on display on the blog of a cardiologist named Michel Accad, who wrote a post describing (he thinks) How Western medicine lost its soul. Whether or not you ascribe to the concept of a “soul” or not, the post is the very false dichotomy I introduced this post with—on steroids. It also irritates the crap out of me that he chooses to use the term “Western medicine,” which is, as I’ve described more times than I can imagine, a rather racist construct, in which we (white and European) “Western” doctors are dedicated to science, in contrast to those “Eastern” practitioners, who are more “holistic” and “spiritual.” It’s just a gussied up version of the old racist trope about “mysterious Orientals.” I’m sure Dr. Accad didn’t mean it that way, but that doesn’t mean the term doesn’t imply a difference where there is none. Let’s just put it this way. I’ve met a lot of kick-ass doctors using science-based medicine who are Asian, particularly Japanese surgeons. Science is science, and science-based medicine is science-based medicine, no matter where it is practiced.
My pet peeve aside, I tried to ignore the number of times Dr. Accad referred to “Western medicine” and looked at his arguments:
Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine. For most people, there is a clear distinction between the two. Sure, some licensed physicians claim to provide holistic care, but this usually means that they might add an alternative form of therapy to standard treatment, or perhaps that they strive to be exceptionally considerate. The holistic character of the care rarely, if ever, comes from Western medicine per se.
But holism shares with health the same etymological meaning: the Greek holos and the Old English hale both refer to the idea of wholeness. So why does conventional medicine seem so unable to attend to the complete welfare of the patient? Why, despite the manifest efficacy of scientific treatments, do growing numbers of patients consider their medical care altogether unhealthy?
The response to Dr. Accad’s first observation is rather trivial. There’s a reason why doctors claiming to be “holistic” use some alternative medicine is because purveyors of “integrative medicine” have been exceedingly successful in promoting that very false dichotomy, that concept that in order to practice “holistic medicine,” you have to embrace various forms of pseudoscientific medicine. This message has in particular permeated large swaths of medical academia, leading to a term that I like to use to describe this phenomenon, quackademic medicine. It’s become, in essence, a matter of definition: Holistic is basically defined these days as using some form of alternative medicine.
How frequently do you recall hearing homeopaths, naturopaths, and practitioners of TCM claim that, unlike that nasty, reductionistic “Western” medicine, they treat the whole patient. Often they will even add the phrase “body, mind, and spirit,” as in “We treat the whole patient, body, mind, and spirit.” My typical response is that this claim is utter poppycock. It’s marketing, not a real statement of what these alternative practices actually entail. After all, a good primary care doctor using science-based medicine does provide “holistic” care—and effective holistic care because it’s based in science. It is true that it’s become quite difficult to provide holistic care under the current model, in which spending more time talking with patients is not incentivized (quite the contrary, unfortunately). However, that’s a problem with the system that doesn’t require embracing pseudoscience to fix. It’s a problem that requires money and a will to change our reimbursement model.
Actually, though, there’s another reason why an unfortunately large number of doctors seem to be attracted to nonsensical quackery to the point of wanting to “integrate” it into their practice. Two rasons, actually, but they are related. The first is a belief in dualism, which is the concept that the mind is separate from the body, that there is “something” (be it soul, mind, or whatever) that is separate from the meat and machinery that make up our bodies. Related to that is the concept of vitalism, which is the concept that there is a “vital force” that animates living matter, that makes it living. There’s a reason why so much alternative medicine, such as homeopathy, is rooted in vitalism. TCM, with its concept of qi, or the life energy, is largely based on vitalism, in which acupuncture redirects the flow of qi and
Dr. Accad makes it very clear that he wants the “soul” back in medicine, believing that that nasty science has removed it. He even quotes Thomas Aquinas:
The bodily unity in matter and form—a holistic concept in the fullest sense—has been a foundational principle of Catholic anthropology ever since 1312, when the Council of Vienne declared this account of man to be doctrinal truth. And for Aristotle and Aquinas, this substantial unity is not unique to mankind. All natural things necessarily exist by virtue of the union of these two essential principles: each material body is brought into existence as such by a particular substantial form. In the case of living organisms, the substantial form is also the animating principle, or soul, of the body.
Dr. Accad then goes on to point out (correctly) that this is not a concept unique to Catholicism and Christianity, but that it was widespread in many cultures. So what’s the problem? What do you think? It’s modernity and those nasty scientists like Descartes, who taught materialism and his “conceptual sundering of body and soul.” Yet, even complaining about this development, Dr. Accad has to concede that materialism has resulted in science that has produced some fantastic results in medicine:
The heightened attention given to the material aspects of the universe promoted the achievements of a bewildering revolution in the empirical sciences. And under the influence of the new sciences, diseases came to be conceptualized in similar terms: illnesses are accident of nature due to defective arrangements or to faulty motions of material stuff. Fix the defect and you fix the patient. This approach has yielded such astounding benefits to mankind that Descartes’ dream of conquering illness through the methodical application of empirical science seems to be well under way.
Well, yes. Given that human beings are biological organisms, if you figure out the biological cause of a disease it becomes possible, through the “methodical application of empirical science” (as Dr. Accad puts it) to intervene and even reverse the course of the disease. No spirit is needed for science to do its job in medicine, and that is clearly what bothers Dr. Accad. He goes on and on, lamenting the severing of the soul from the body, conceptually speaking, and discussing how scientists sought to identify the “vital principle of living organisms” through the study of vitalism, mesmerism, romanticism, and idealism in the eighteenth and nineteenth centuries. He especially laments how “when these efforts at grasping the essence of life proved futile or problematic, the inconvenient soul fell into neglect and was finally abandoned altogether as a subject worthy of inquiry or acknowledgment in polite scientific company.”
Of course, this is how science works. When scientists seek out a phenomenon to study and fail to find it, sooner or later there comes a point when they give up, when they conclude that the phenomenon doesn’t exist or isn’t as they believed it to be and move on to more promising areas of inquiry. This is as it should be. As I like to put it, you can believe in a soul if you like, but in the absence of evidence for its existence that’s all you have: belief.
So what’s the problem? Dr. Accad thinks we as “Western physicians” practicing “Western medicine” need to somehow bring the “soul” (whatever that means) back into medicine:
Thus deprived of spirit, the human body assumed for the scientist the status of a mere, albeit complex, machine. And as the material successes of biomedical science multiplied, the mechanistic metaphor was adopted by the practicing physician as well. Over the last 100 years, the medical profession, with the help of government, academia, and big business, has turned Western medicine into a “health care delivery system” where biological material is the input, and health the hoped-for output. Accordingly, the noble medical enterprise must now be pursued in the most efficacious, safe, efficient, and accessible manner. Standardization has become its prime mode of operation.
Gee, Dr. Accad, you say that as though it were a bad thing. Sorry, I couldn’t resist. I promise not to interrupt his finale:
The only wrinkle, of course, is that the raw material under process is a person: individual, substantial, rational, and—as Karol Wojtyla emphasized—self-determining and “incommunicable.”³ Ill-suited for the assembly line, that person is now protesting. Increasingly, men and women seek the holistic practitioner to attend to the neglected half of their being. Meanwhile, the massive delivery system, wobbling on a foundation of faulty mechanistic assumptions, threatens to collapse at any time. Yet the remedy seems so simple. But will Western medicine ever bring the soul back to the patient’s body?
So let me get this straight. In order to “fix” what he calls “Western medicine,” Dr. Accad thinks we should do … what, exactly? How does a system of medicine “bring the soul back to the patient’s body”? What, exactly, does that mean? Dr. Accad doesn’t tell us. Rather, he pines for a day when the soul was considered. The most charitable interpretation is that Dr. Accad means the soul as a metaphor for the psychosocial needs of the patient, for a human being’s need for empathy, caring, and the “human touch.” Certainly, near the top of the list of valid criticisms of our current system of delivering health care would be how it disincentivizes physicians, particularly primary care physicians, from spending a lot of time talking to their patients, often leaving them 12 minute time slots to deal with complicated patients. How would “bringing back the soul” fix that problem? It wouldn’t. It’s also a fallacy that patients seeking “integrative medicine” are dissatisfied with their medical care. Most are not. Whatever Dr. Accad is trying to say, in the context of his post I do not think he is using the soul as a metaphor. He really seems to mean “soul,” as in the religious concept.
Be that as it may, what Dr. Accad posits is a variant of the same false dichotomy that argues that you have to embrace pseudoscience in order to be a truly “holistic” physician. In this case, all you have to do is to embrace the concept of something that science can’t measure or identify. According to Dr. Accad, medicine would return to the halcyon days of yore, when doctors were doctors, patients were patients, and everything, apparently, was awesome if only modern medicine would “bring back the soul.”
Whatever that means.