The Role of Complementary and Alternative Medicine: Accommodating Pluralism (review)

The eminent ethicist Daniel Callahan edited The Role of Complementary and Alternative Medicine: Accommodating Pluralism as one of a series of monographs from the Hastings Center and Georgetown University that address contemporary topics in biomedical ethics. Callahan notes in his introductory essay that he was inspired to assemble the articles for this book by his curiosity about a professional debate that, to him, seemed "almost inexplicable." What is there about complementary and alternative medicine (CAM), he asked, that incites such hostility from some prominent clinicians and researchers? Clearly, the medical enterprise accommodates some range of philosophical and epistemological approaches. Why not accommodate CAM?

This is a timely inquiry. The Centers for Disease Control and Prevention, in conducting the most complete and demographically representative survey of CAM use to date, estimates that 29 percent of Americans used at least one CAM therapy in 1998. Spiritual healing or prayer, herbal medicine, and chiropractic manipulation were practiced most commonly, but there was substantial use of homeopathy and an array of mind-body interventions. With its broad popularity, CAM is evolving into a nationwide enterprise. CAM products are dispensed in upscale boutiques, while acupuncturists ply their craft in countless storefronts and professional office buildings. The most patrician of academic health centers are offering CAM services and are advertising their availability to attract well-heeled clients. And millions of dollars have been earmarked by the National Institutes of Health and by philanthropic foundations to support formal studies of CAM claims. The appeal of CAM and its emergence into the mainstream has given voice to both supporters and detractors.

In commissioning 11 manuscripts from authors who share sympathetic—if not overtly advocating—postures toward CAM, Callahan affords us insights into one facet of the discourse. Unfortunately, the book affords no primary forum for articulate scholars whose positions are firmly antithetical to CAM. Moreover, it neglects entirely the one aspect of CAM that an audience for this series of books would most expect, namely the ethics of CAM treatment and research. How does one prescribe, either in the context of routine practice or in clinical trials, interventions that are not standardized and for which there may be no data regarding their composition, disposition in the body, or formal toxicology? How does one randomize subjects to modalities about which both they and the investigator may harbor biases?These are formidable subjects for ethical discourse—an opportunity that has been missed by the editor.

Opponents of CAM appear throughout this volume indirectly, as mere projections to rail against, rather than as embodied contributors whose opinions, however disagreeable they might be to some, are to be contended with. The major point of argument in this book is whether and how CAM should be studied. Early in the book, Schaffner takes Marcia Angell, the former executive editor of the New England Journal of Medicine, to task for asserting that "the hallmark of science is its utter reliance on evidence," and that evidence is acquired by formulating a hypothesis, designing a study, collecting data, and then analyzing the data. On the face of it, this is a rather difficult statement to dismiss. The problem for Schaffner, and for Kopelman in her later chapter, is that it is assumed that Angell would only accept placebo-controlled, randomized double-blind trials as providing data worthy of the term "evidence." Several authors in this volume assert that CAM differs in critical ways from conventional medicine, and that it therefore cannot be accurately or fairly assessed with conventional scientific methodologies.

I contend this is an unworthy way of meeting the issue: to set up a straw man (or woman in this instance) for the purpose of assaulting the issue. Had Angell been accorded the opportunity to respond, it is possible that she would have acknowledged the virtue of data acquired by other means, insofar as...