Holism

Holism

		Holism is the belief that entities are greater than the sum of their parts. The belief that individuals must be seen in the totality of their lives permeates alternative medicine. Signs or symptoms are not isolated phenomena to be treated. Rather, the entire physical, emotional, spiritual, and social makeup of the person must be considered. The centrality of this belief to most modes of alternative practice is so pronounced that many people prefer to use the term "holistic medicine." Because holism directly contradicts the beliefs in dualism and reductionism that are central to biomedicine, it is holism, most fundamentally, that separates alternative medicine from the premises of the conventional biomedical model. Holism has two fundamental implications for a system of healing. The first, and most frequently described, is the belief in the interpenetration of mind, body, spirit, and the larger environment. Because this tenet is so crucial, it is discussed at length below. However, holism has an even more fundamental implication as well: the uniqueness of the individual. Holism rejects any separation of the mental and physical realms of life and requires that each individual be seen in terms of his or her uniqueness. In this regard alternative medicine is distinguished from mainstream practice by a matter of degree. Holism is a theme in conventional medical practice, but a relatively minor one. Most mainstream practitioners would concur that individuals are each one of a kind, defined by their own genetic inheritance, personal history, and social position. Nevertheless, in most situations, acknowledging this individuality would have relatively little to do with which specific therapy was offered for a particular set of symptoms, or with the basic understanding of the pathologic processes behind a particular disease. For alternative practitioners, treatment and pathology are often as unique as the person seeking assistance. As Gordon has written, "Each person will require a different approach—different forms of exercise, a different diet, a different pharmacological treatment, and different kinds of psychotherapeutic interventions. One asthmatic adolescent may best be treated in a group that runs several miles a day. Another may be seen in the context of a systems-oriented family therapy. The first may work out her anger and improve her vital capacity through daily running. The second may diminish her anxieties and increase self-confidence through biofeedback techniques." In practice, this emphasis on the uniqueness of the individual permeates alternative medicine, and for many clients is a source of great comfort. For example, homeopathy, a system of treating symptoms with minute doses of substances ("remedies") that in greater amounts would bring on the symptom, offers an extensive and highly personalized diagnostic encounter with the homeopath. According to homeopath Harris Coulter, "Homeopathy holds that the key to the 'wholeness' of the patient, and of the remedy, is found in their peculiarities or idiosyncrasies—in other words in the factors that distinguish this patient and this remedy from other patients and other reme dies that are similar but not the same as this one." In its essence, this view calls the entire biomedical classification of disease into question. Homeopaths and other alternative healers emphasize the immense diversity in symptoms reported by individuals suffering from the same condition or disease: arthritis, gastrointestinal distress, PMS, asthma, etc. They ask why the malady is taking the specific form it has in a particular individual. The biomedical model accepts symptomatic variation (and indeed even documents it) but justifies the clumping together of symptoms on the basis of an underlying physiopathology. Increasingly, alternative modes of care accept this view but raise questions about what it means. Homeopathy is not opposed to acknowledging that arthritis is usually initiated by a chemically induced inflammation. It asks, Why were these chemicals released? Biomedicine answers by citing a problem in the immune system. But, what caused the immune system to malfunction? Homeopathy says the answer will be different for each individual, as it will for the root cause of high blood pressure or any other condition. Linda Johnston, a well-known homeopath, writes, "Modern medicine doesn't bother speculating about the unknown initiating cause of symptoms. . . . Doctors usually want to know just enough to enable them to eliminate the symptoms. . . . These efforts seem beneficial to the patient, however, the disease causing the symptoms has not been cured, it has only been blocked . . . similar to putting a dam across a river." Each of the major systems within alternative medicine holds beliefs that are almost identical to those of homeopathy about the importance of individuality in assessing and treating illness. Ayurvedic medicine is a traditional Indian system of healing that uses diet, exercise, meditation, massage, herbs, light, and breathing techniques to treat illness by restoring inner harmony of body, mind and spirit. The best known practitioner of Ayurveda in the United States is Deepak Chopra, who states that "an Ayurvedic physician is more interested in the patient he sees before him than in his disease. He recognizes that what makes up the person is experience—sorrows, joys, fleeting seconds of trauma, long hours of nothing special at all. The minutes of life silently accumulate, and like grains of sand deposited by a river, the minutes can eventually pile up into a hidden formation that crops above the surface as disease." Traditional Chinese Medicine (TCM) is a three thousand-year-old system that combines acupuncture, diet, massage, herbs, and other treatments to enhance and restore health. The techniques that comprise TCM all explicitly reject treating specific symptoms. Rather, they view problems as reflecting the character of the individual, as expressed through combinations of "yin" and "yang," complementary interpenetrating forces that are reflected in bodily functions and organs and exert their energy through twelve bodily meridians. Naturopathy is a healing system that emerged from the European tradition of herbalism and spa cures, as shaped by the American experience of the Kellogg brothers and their Battle Creek-based sanitarium and health food business. Today its practitioners, licensed in a number of states, utilize a melange of techniques including herbal medicine, hydrotherapy, physical manipulation, homeopathy, and many others. Despite its eclectic nature and the absence of an overarching theoretical system, there is explicit consensus about the necessity of focusing on the person, not on symptoms or disease. This conceptualization is essentially identical to that of TCM. Holism is the most commonly held premise among all alternative medical systems. It is also a view that resonates strongly with fundamental values in American culture regarding the importance and uniqueness of the individual. In this affinity with a core American value, holism offers a connection to the nation's history and collective psyche. This linkage gives alternative medicine the opportunity to present itself as the embodiment of the most legitimate of the culture's goals: allowing individuals to freely assert their individuality

The Core of Alternative Medicine: Age-Old Wisdom Made New

The Core of Alternative Medicine:
Age-Old Wisdom Made New

Attending an alternative medicine conference, scanning the titles shelved under the heading of alternative medicine in a "megastore," or "surfing the net" for sites related to alternative medicine can be both an overwhelming and a puzzling experience. The sheer volume of what is readily available, no less its vague boundaries and overlapping categories, are, at best, confusing. Beyond the rhetorical tides of some of the most popular works (Total Health; Everyday Miracles; Ageless Body, Timeless Mind), the wide range of approaches, techniques, and philosophies encompassed is striking. There are specific healing techniques such as aromatherapy, flower remedies, massage, guided imagery, and acupuncture. Then there are entire systems of medicine: Traditional Chinese Medicine (TCM), Ayurvedic medicine, naturopathy, homeopathy, and mindbody medicine, among others. And there are other things that would seem to be more than a specific technique but less than a fully developed system of medicine, such as qigong, yoga, and herbal medicine. Finally, there are the so-called "New Age" phenomena like crystal healing and psychic healing, which defy simple classification.

		What, if anything, do these have in common? One thing they have in common is that they have typically not been taught about in American medical schools, not been utilized by most physicians and hospitals, and not reimbursed for by most in surance plans. A definition of alternative medicine based upon what it is not is therefore both accurate and convenient. It avoids the need to become embroiled in conceptual questions about the assumptions that underlie words like "health," "illness," and "healing." Not surprisingly, it is this straightforward empirical approach to defining alternative medicine that is used by the federal government and mainstream medicine. The Office of Alternative Medicine at the National Institutes of Health defines alternative medicine as ''an unrelated group of nonorthodox therapeutic practices, often with explanatory systems that do not follow conventional biomedical explanations." In the study conducted by Daniel Eisenberg and his colleagues that appeared in the prestigious New England Journal of Medicine and is the most frequently cited academic report on the subject, alternative medicine was defined as "medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals." Historically, there has been no alternative medicine, but rather many alternative medicines, each separate in its own mind. Practitioners of these alternative modes of care have often viewed each other competitively and acted accordingly, practicing in isolation from one another. Until recently, the various forms of alternative medicine had only been linked negatively by more conventional groups as health fraud or quackery. Organizations like the American Medical Association have been quite willing to describe the approaches now called "alternative medicine" as united by their ignorance, foolishness, and irrationality. But to define alternative medicine only by what it is not avoids important questions about its fundamental nature as well as that of mainstream medicine. The power, prestige, and authority, not to mention financial rewards, accrued by mainstream medicine have typically been justified by its practitioners as emerging from the application of scientific rationality to medical practice. Whatever is taught in medical school, or prac ticed on patients, is assumed by the general public to have some scientific basis. If a specific technique can become "mainstream" simply by its inclusion in a mainstream institution such as a medical school, what role does that leave for scientific rationality as an arbiter? Accepting an exclusively residual definition of alternative medicine may be pragmatically useful, but it is not very helpful in understanding the larger questions about the differences between mainstream and alternative medicine. More importantly, for our purposes, accepting a residual definition alone makes it difficult to understand the growing power and popularity of those techniques and approaches that comprise alternative medicine. If there are underlying themes within this cacophony of concepts, approaches, and techniques, then starting with the assumption that they do not exist will make them harder to find. There is no shortage of alternative medical practitioners who emphatically state that there are underlying commonalities to the wide range of alternative techniques. A number of earlier academic observers have been able to extract a coherent set of common themes from their studies of the topic. However, to specify a conceptually cohesive set of common elements does not necessarily indicate that they are apparent in the everyday practice of alternative medicine. Thus, in laying out the essential core beliefs within alternative medicine (and they are not radically different from those set out by others), my goal will be to show how they pervade the diverse range of alternative techniques and approaches. In order to assess whether or not a cohesive set of core beliefs underlies alternative medicine, we should keep in mind a sense of perspective about the real world. A core set of beliefs in the practice of alternative medicine will likely be no more sharply defined and operational than are core beliefs in the practice of mainstream medicine. In the latter we find brain surgery, psychopharmacology, medical genetics, and psychoanalysis coexisting along with scores of other specialties. Such variety doesn't preclude a common set of beliefs in biomedicine. Rather, it indicates that not every practitioner or specialty relates to these beliefs in the same way, or to the same degree. This is likely to be true in alternative medicine as well. Some observers of alternative medicine have seen only a hodgepodge of practices and points of view, and scoff at the notion that the phrases "alternative medicine" or "holistic medicine" characterize a uniform set of beliefs. As one such researcher commented, "No uniform set of holistic therapies can be identified . . . so much diversity exists among the proponents of holism that it can scarcely be considered a single movement." But, a far larger group of commentators, both favorably and unfavorably inclined toward alternative medicine, have discerned an underlying set of core beliefs or assumptions. Although most observers agree on the existence of a core set of assumptions, there is little consensus on what they are or how many there are. For example, James Gordon, a sympathetic physician writing in 1980, described seventeen distinct elements of what he called "the paradigm of holistic medicine." Almost a decade later, two social scientists, Kristine Alster and June Lowenberg, independently specified twelve core elements operating as "statements and slogans" and "parameters of the new model of holistic medicine" but agreed with the items on each other's list only half the time. More recently, Robert Buckman and Karl Sabbagh found eight "philosophical attractions" common to the work and beliefs of alternative healers, and Bonnie Blair O'Connor found nine "concepts common to many vernacular health belief systems'' in her study of alternative medicine. Yet again, however, the lists are in agreement on few of the terms. This initial appearance of inconsistency is somewhat misleading. A closer reading of these works, and many others, soon reveals that they use a wide array of dissimilar phrases and terms to express a relatively small number of commonly held ideas. A few central themes appear over and over, sometimes with vary ing emphasis, with elements combined in some schema while distinct in others. Those who have studied this phenomenon do not differ over whether a core set of beliefs exists, or even what these beliefs are. Rather, their differences of opinion revolve around to what extent these core beliefs are actually manifest in alternative medicine as it is practiced in the real world. The relationship between theory and practice is what needs to be ascertained. In my view, there are six significant points that distinguish alternative medicine from the medical mainstream: a belief in holism; an emphasis on the integration of body, mind, and spirit; a view of health as a positive state on a continuum with illness; a belief that the body is suffused by the flow of energy; a belief in vitalism; and a distinctive view of the healing process.

The Synergy of Complaint: Birth of a Grievance

The Synergy of Complaint:
Birth of a Grievance

A time like our own, when intensive criticism of medicine has become widespread, offers the potential for even more fundamental critiques and proposals for change. It has not been lost on observers or practitioners that the longstanding critiques of Western medicine as mechanistic, reductionist, and technologically biased can be joined with the recent criticisms of high cost, limited access, inefficiency, and therapeutic ineffectiveness. Taken together, the impact of both sets of criticisms is more than the sum of the parts. If medicine is not only too costly, inaccessible, and ineffective but also fundamentally wrong in its most basic assumptions about the nature of illness and healing, significant improvement can only come through a major change in how we think about health and healing. The problems are so great that a solution will require the emergence of what some have termed a new "paradigm."

		The relatively common use of the terms "paradigm" and "paradigm shift" is traceable to Thomas Kuhn's The Structure of Scientific Revolutions. Kuhn used examples from physics to rebut the idea that scientific change came about through the consistent and gradual accretion of knowledge among experts. Rather, Kuhn asserted, change was generated in bursts—as the accumulation of facts or insights that disproved existing doctrines took hold among researchers who were outside the scientific mainstream. These outsiders focused their thoughts and theories on the inevitable gaps or lapses in what the dominant perspective could explain. A new paradigm was "revolutionary" in Kuhn's view because it aggressively pointed out the deficiencies of the old ways of seeing, and because it offered a new way of understanding in place of the old. The extent to which the new paradigm helped people understand something heretofore incomprehensible would determine its success. Kuhn himself was surprised, and eventually somewhat aghast, at the way his descriptions of changes in physics became used to describe changes (or proposed changes) in many arenas of intellectual and social life. It was far from clear to Kuhn that something as vast as "medicine" was very much like the small world of theoretical physics. Still, both advocates and observers of alternative medicine use Kuhn's terminology in describing the "paradigm shift" to a new "medical model." For example, Deepak Chopra writes, "Each assumption of the old paradigm can be replaced with a more complete and expanded version of the truth." In his call for ''a new medical model," Kenneth Pelletier asserts: Medicine, based upon Newtonian physics, has adhered for some time to one mode of scientific inquiry with inherent assets and often-unacknowledged limitations. . . . Holistic approaches to health parallel the insights of quantum physics in that both supplant the Newtonian reductionist view of the world with the quantum perspective of a dynamic universe. From this new paradigm derive the philosophical and scientific roots for the practice of holistic medicine. In using this language, these and many other alternative practitioners "suggest that a holistic approach to health care is so original that it qualifies as a paradigm shift, that is, an entirely new way of characterizing and approaching the problems of a given discipline." Whether or not alternative medicine does offer a truly new paradigm is open to question. In part the answer lies in specifying whether those who advocate an "alternative medicine" hold a common set of conceptual understandings. This is the subject of the next chapter. But, the answer depends as well on the ability of the new paradigm to successfully respond to the gaps or failures of the dominant biomedical paradigm. An "alternative" paradigm requires something to which it is an alternative. In this respect it differs from a paradigm that claims to be "holistic," "complementary," or "integrative." It is the very ability to point out, emphasize, and respond to the vari ous failures of something else that energizes and gives a raison d'etre to anything that is self-consciously "alternative." Alternative medicine does represent a new paradigm in that it provides a new framing of ideas about illness and the health care system. Situations and circumstances that were previously seen as uncomfortable or unfortunate now are conceptualized as being wrong or unjust. For example, the standard biomedical approaches for treatment of chronic illness and suffering arc not just perceived as inadequate but as grievously and unacceptably limited. Alternative medicine offers the sense that the current situation is riddled with contradictions and that something else, something better, is possible. The future of alternative medicine hinges on its ability to prove that such an approach to health and illness does exist. But, the opportunity for alternative medicine to make its case at this point in history derives from the extent, depth, and acceptance of the notion that existing forms of conventional medicine have come to place an unreasonable burden upon society and hinder our ability to respond to illness. The phenomena described in the following pages are called by many names: holistic medicine, mind-body medicine, East-West medicine, complementary medicine, integrative medicine, and more. The advocates of each term are cogent in offering reasons for why their particular choice best encapsulates the underlying principles of the techniques they use. Often, these advocates disdain the term "alternative medicine" because of its residual character. Alternative medicine is what conventional medicine is not. From a purely clinical perspective this reasoning may be sound, if not persuasive. But the phrase "alternative medicine" best captures the role and meaning of these techniques and approaches to healing in relation to the larger society.

Crisis and Change in the Health Care System

Since the late 1960s, health care in the United States has commonly been described as being in a state of "crisis," "transformation," or "flux.'' While the specifics of what constituted a "crisis" varied widely, academics, journalists and politicians came to agree that we were embarking upon a period of major and significant change.

		Contemporary portrayals of the changes taking place in health care range from the highly optimistic to the very pessimistic. Most of the optimism derives from hoped-for advances in the techniques of care. The public expectantly awaits genetic interventions, improvements in surgical techniques, or new vaccines. But it has generally viewed the ongoing and rapidly accelerating changes in the organization of health care more ambivalently, if not ominously. This fearful or pessimistic view of the evolution of our health care system can be traced to many sources, with a wide range of opinions about which factors have primacy. However, the key elements, regardless of their relative import, are well agreed upon.

		The problem most frequently cited is simply the cost of health care to the society as a whole. In 1960 the United States spent well under 6 percent of its gross domestic product on medical care. By 1989 that proportion had doubled, and by 1994 it was just under 14 percent, where it has remained since. The 4.4 percent growth in health care spending for 1996 was the smallest percent change in over thirty years, but still about 25 percent above the overall rise in the gross domestic product. In absolute terms this expenditure exceeded $1 trillion for health care in 1996, or $3,759 a person. Even with such immense outlays, about forty-two million Americans have absolutely no health insurance coverage. While 99.7 percent of those aged sixty-five and older have coverage via Medicare or some other federally subsidized program, about 22 percent of those between the ages of sixteen and twenty-five have no health insurance at all. A 1996 report from the Census Bureau found that 38.2 percent of the Hispanic population and 30.1 percent of the Black population lacked health insurance for at least some portion of a twenty-eight-month period ending in August 1994, compared to 21.0 percent of Whites. No one is pleased by these figures. Not surprisingly, the majority of money is spent on individuals who are ill. Medical services for those who are the most sick, who also tend to be the oldest and most likely to be covered by insurance, account for a disproportionate amount of health care expenditures. Those with chronic conditions account for about three-quarters of all the nation's health care costs. Ten percent of all Medicare recipients account for 70 percent of the program's outlays. The aging of the American population can only exacerbate these spending patterns. For example, the expected rapid growth among the "oldest old," those aged eighty-five and above, is projected to yield a 600 percent increase in Medicare costs by the year 2040 when the surviving "baby boomers" reach that age. In that same year, the number of nursing home residents over eighty-five years of age is expected to be about three times the total of today's entire nursing home population. Concern regarding health care costs goes well beyond their absolute magnitude. In the United States, a higher percentage of total costs is devoted to administrative costs than in other industrialized nations, and these costs are growing. Despite widespread attention and concern, it appears that the health care system is becoming more inefficient. The current emphasis on managed care and converting nonprofit facilities and insurers, such as Blue Cross, into proprietary operations has heightened this trend. Administrative costs, profit, and costly high technology interventions for those most ill, often during the last few months of life, have been consuming ever larger shares of the nation's total health care expenses. Given the immense amounts of money involved, much of it flowing directly or indirectly from government coffers, it is surprising how little evidence there is that greater expenditures for medical care produce better health or more healing. Although some researchers have argued that there is a marginal gain in the health status of the population in an industrialized nation when expenditures for medical care go up, most economists, epidemiologists, and others have been more skeptical. The proportion of the national gross domestic product spent on health care has been of more interest to politicians, policymakers, and academics than to the average citizen. The typical patient is more concerned with the changing manner in which care has come to be provided. The decade after 1985 saw a massive change in the organization of American medicine in the form of the rise of "managed care." Simply put, this means that large for-profit corporations have become responsible for a growing share of health care services. By 1993, a majority of Americans who were privately insured were in managed care plans that restricted their choice of physicians. Large employers were the leaders in promoting this trend; 65 percent of their employees were covered under managed care plans. The most common form of managed care, the HMO or health maintenance organization, was fast transforming from what was a traditionally nonprofit organization, into a profit-making corporation. Managed care companies themselves were engaged in rapid consolidation. Mergers and acquisitions among managed care plans for the years 1993 and 1994 were valued at about $ 38 billion, and the rate and value of joint ventures has increased since that time. Medicine is no longer largely a cottage industry of small providers (typically individual physicians) who interact through professional organizations and informal networks, sometimes coordinate their work in hospitals, and receive compensation on a piecework basis from both clients and insurance companies. Increasingly, physicians work for large profit or nonprofit corporations under contracts that subject them to detailed oversight, restrict their ability to exercise clinical judgement, and offer financial incentives to limit or skew the services they provide as a means of enhancing corporate profit. Managed care companies behave just like any other large corporation. Medicine is now "big business" and health care is a commodity. It is not necessary here to judge whether managed care is a good or bad thing for the quality of American health care, or the health of the American population. A large quantity of both popular and academic literature has already emerged on that topic. What is clear is that the overall environment in which many, if not most, Americans receive their health care has shifted dramatically. Traditional arrangements and relationships between patients, physicians, hospitals, and insurers have all been changed in such a way as to limit long-term involvement, heighten distrust, and make medicine less "special" for all parties. The sense that health care is a commodity like any other is far more widespread and influential today than at any other time in the past. In addition to these broad changes in the organization of health care, and its rising cost to the nation, there is a growing mood of disenchantment with medicine. A number of recent polls report the public's growing dissatisfaction with managed care. Over half of Americans surveyed in a 1997 Lou Harris Poll felt managed care was actually harmful to their health. What doctors do, and how well they do it, has emerged as a matter of attention and concern in the minds of clients, policymakers, and the general public. A notable but typical example is the controversy regarding the treatment and prevention of breast cancer, which has been highly publicized in recent years. Initially, disputes emerged when data from trials conducted under the supervision of the National Cancer Institute suggested that lumpectomy (surgical removal of the tumor) followed by radiation treatment was as effective in treating breast cancer as mastectomy. These findings suggested that thousands of women had undergone unnecessary body-altering surgery. However, confidence in the enterprise of medical research itself was undermined seriously in April 1994 when the Chicago Tribune reported that one of the participating research physicians had falsified information about the patients he entered in the lumpectomy study, as well as those in a concurrent study, on the use of tamoxifen, a drug used in hormone therapy for breast cancer survivors. Though the falsifications did not influence the outcomes of the study, both the occurrence of the fraud and the fact that project administrators had not disclosed it in the more than four years in which they had known of its occurrence contributed enormously to popular disenchantment with the medical establishment. The public's confusion about breast cancer was heightened in 1997, when the guidelines for using mammography to detect breast cancer in asymptomatic women in their forties became the subject of ongoing debate. The official recommendations of national institutions such as the American Cancer Society and the National Cancer Institute had changed no less than six times during the proceeding few years. Therefore, at the request of the National Cancer Institute, the NIH convened a panel of experts to evaluate existing data and determine mammography guidelines for women younger than fifty years of age. As is common practice when research findings are confusing, the panel reached its decision through a "consensus conference." Traditionally, the conclusions of such conferences are so highly valued that they are used by insurance companies to determine benefits and by doctors and hospitals to determine standards of care. However, when the mammography panel announced its findings, both the health sector and the public responded with outrage. Neither group wanted to accept the panel's conclusion that "at the present time the available data do not warrant a single recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography." The director of the National Cancer Institute, Dr. Richard Klausner, at whose behest the panel was convened, said he was "shocked" and noted that an advisory board to the National Cancer Institute would review the decision the next month. The American Cancer Society issued a statement saying that it was "disappointed'' in the report and stood by its recommendation that women in their forties have regular mammograms. One radiologist said he believed that the panel's actions were "tantamount to a death sentence" for women in their forties and that he "grieved for them." Another radiologist from the Harvard School of Medicine called the report "fraudulent" and admonished that it should not be released to the public until it was "corrected." The panel stood by its findings, noting that the data indicates 98.5 percent of women who get mammograms in their forties receive no benefit and that mammography carries risks of its own, including falsely telling women that there might be a tumor present, treating as cancerous a tiny lump that might or might not be cancerous but would require treatment if it were cancer, and giving women a false sense of security. Members of the panel also characterized the reactions to their report as "scary," and the chairman of the panel noted that "the arguments have gotten so strident that people are unwilling to listen." Some analysts have explained the intensity of the reaction by noting that mammography is a big business in the United States. Others have commented that mammography has been widely promoted to women as a preventive measure that can save them from a dreaded disease, a reassurance and sense of protection with which women are reluctant to part. However, a more basic concern is that when the leading experts disagree so vehemently on how breast cancer should be diagnosed and treated, it raises basic questions about whom the public can trust. While the health issues brought up in the breast cancer and mammography controversies are highly specific, and of greatest concern to only a portion of the population, they are typical of many similar examples. Taken together, the frequency and intensity of such conflicts have abetted the broader decline in confidence about medicine in general. The outpouring of concern about specific medical procedures and practices is, in some large measure, due to the rise in health care costs and discontent about the changing organization of care. Those factors have been central in motivating government and insurance companies to begin evaluating more precisely where their money is going. Increasingly the government and the insurance industry have been funding and carrying out research, varyingly called "health services research," "evaluation research," and "outcomes research," in order to get "hard data" (i.e., statistical evidence, as opposed to clinical reports) about a vast array of clinical procedures and tests. Almost inevitably, the data supports their initial concerns that the interventions are ineffective or overused, fostering still more concern and research. The results of research on medical techniques, judgement, and practices heightens the public's mistrust about mainstream medicine in a number of ways. For example, in the United States each year, over 2 percent of all women have hysterectomies—a rate almost ten times as high as it is for women in France. This finding is typical of repeated demonstrations that regional and national political boundaries strongly influence the utilization of specific medical procedures, even when the incidence of a problem is similar. Results like this, along with research specifying the personal and idiosyncratic factors physicians use in deciding who to treat or what new procedures to adopt, causes clinical decision-making to appear more a matter of social norms and values than of the objective application of rationality. Most unsettling for mainstream medicine has been the repeated finding that many "standard" medical procedures and therapies are of limited value, or even harmful. The culturally cherished "annual physical exam" for adults has been revealed as having no use in the screening for asymptomatic illness. A report in the Journal of the American Medical Association (JAMA) found that the widely publicized and heavily promoted PSA (prostate specific antigen) screening exam for prostate cancer leads to "a net health harm rather than a net health benefit." NEJM published a report concluding that it may be pure coincidence that people with chronic back pain, the second most common reason for visiting a physician, have disc abnormalities. The same prestigious journal reported that experienced board certified radiologists disagreed more than 20 percent of the time when reading mammograms on whether a biopsy should be performed. One study found that the medical records of 60 percent of elderly people admitted to the hospital failed to list the important medications being taken. A review of over thirty thousand randomly selected medical records from acute care hospitals in New York found 4 percent of the patients seriously injured by their treatment. More than 13 percent of these injuries led to death. A study by the American Hospital Association estimated that in 1983, 7 percent of all hospital admissions (approximately 2.7 million admissions in that year) were related to the misuse of pharmaceuticals prescribed by physicians and that such drug-induced illnesses cost up to $5 billion. A 1998 meta-analysis published in JAMA suggested that even when drugs are used properly, adverse reactions kill more than one hundred thousand Americans each year. The significance of these examples lies not in the "facts" they report. Rather, they are important because they represent a large and growing universe of similar findings in the medical literature and because each of them, along with numerous others, received prominent coverage in the popular media. Conflicts, ambiguities, and failures of modern medicine, along with news of "magic bullets" and medical heroism, are a regular part of the news in the 1990s. Cover stories in national magazines, front-page stories in the daily paper, and reports on radio and TV are commonly devoted to the sorts of critical findings cited above. This media attention indicates how important detailed information about health and medicine has become in our collective awareness. Yet often, the substance and tone of what is reported can only raise the consumer's level of skepticism, distance, and distrust. When medical researchers criticize their colleagues for undertreating pain and ignoring the evidence on how well pain medications work if used properly, while the chief medical writer for the Los Angeles Times gives major coverage to the overuse of pain medication and the resulting need for patients to "tolerate discomfort," the underlying message to the general public is one of confusion. Ironically, it is the application of the scientific method to study the effectiveness of medical care that has yielded the intellectual power and empirical analyses which inspire doubt in mainstream "scientific" medicine itself. Observers inside and outside of the medical profession have long commented upon how little of what is considered standard treatment has any documented scientific basis showing it is indeed efficacious. In 1978, a report from the Congressional Office of Technology Assessment indicated that only 10 to 20 percent of all procedures currently used in medical practice had been shown to work in clinical trials. There has been little, if any, improvement since that time. Yet until recently, these research findings have had minimal impact on the public and policymakers. Despite the equivocal evidence, scientific rationality and the practice of medicine have been inextricably linked in the public mind. As the dominance of the medical profession has grown and the expense of medical care burgeoned, the government, insurers, and industry (who foot the bills for most care) have become much more interested in knowing how much rational basis actually exists for the expenses they incur. It has become common for federal agencies such as the National Institutes of Health, the Health Care Financing Agency, and the Agency for Health Care Policy Research, as well as private foundations and "think tanks" such as Rand, to rely on randomized clinical trials, outcome evaluations, and epidemiological research to judge the true value of medical tests and procedures. Those who fund and carry out this research have been quite aggressive in publicizing their findings to the medical profession and the general public. Their predominantly negative or, at best, equivocal conclusions have helped foster and legitimize skepticism toward conventional medicine among policymakers and the general public. Beyond its own intrinsic merit, the outcome of this research has an affinity with a number of other streams of academic thought that have been critical of medicine and the medical profession, such as "labeling theory" in sociology, and "attribution theory" in psychology. These perspectives emphasize the way in which the words we use shape our reactions to phenomena in the world. Both perspectives have stressed the ways in which "medical names" for signs, symptoms, conditions, and behaviors can highly stigmatize the individuals to whom they are applied. Researchers have found this to be especially true in regard to disabilities, physical illnesses like AIDS, and mental illnesses such as schizophrenia. This extensive criticism of medicine has had a broad impact upon society. Analysts and policymakers have come to sharply divergent conclusions. Some view the epidemiologic and health service research as reason for some sort of national health care restructuring based upon federal insurance and increased government involvement in medicine. Others have come to a very different conclusion, arguing that the best policies arc those which treat health care as any other commodity in the marketplace. Individuals, especially those most economically secure and highly educated, have heightened their skepticism about the medical profession and have developed a high degree of "consumerism" toward medical care. Consumer publications such as Consumer Reports magazine and other media directed toward general audiences, such as "lifestyle" sections of many daily newspapers, have begun to report in detail about all sorts of medical and surgical techniques. Much of this material offers "user friendly" summaries of health services evaluations and outcomes research. These popular accounts have encompassed the widest range of medical interventions, including many that emerge from alternative approaches. Typical examples include the use of beta carotene in preventing heart disease and cancer, spinal manipulation as a treatment for back pain, herbal remedies to relieve depression, diet and relaxation techniques to reduce blood pressure, and melatonin for just about everything. Each of these summaries is consistent in noting that regardless of the specific topic being considered, medical experts disagree. This combination of skepticism (sometimes carrying over into overt hostility) toward mainstream medicine and consumerism has become an important dimension of a number of social movements. The women's movement, the gay liberation movement, and movements for the rights of the disabled, chronically ill, and abused all have stressed that a medically dominated understanding of their members' problems is usually not helpful, and that medical solutions to these problems are highly questionable. The gay and lesbian communities' extensive advocacy for the declassification of homosexuality as an "illness" is one of the best examples of a successful challenge to a medically dominated characterization of a group of people. The women's movement has advocated for the reconceptualization of birth as a natural process, not a "medical condition," and the hospice movement has sought to redefine death and dying. Skepticism about medicine is one element all of these movements hold in common. These individuals and groups do not deny that medicine may have much that they need or desire Rather, they wish to carefully evaluate what medicine has to offer, instead of uncritically accepting medical explanations for their problems and medical strategies for their improvement. They want to use medicine on their own terms. They are acutely aware that in the past medicine has harmed minorities and women in their quest for both individual and collective advancement. This outlook is epitomized by The New Our Bodies, Ourselves, the best selling health manual of the women's movement. In the book's chapter entitled "The Politics of Women and Medical Care," the authors cite "thousands" of personal accounts of the harm done to women by physicians and other medical personnel in medical settings who have: not listened to them or believed what they said; withheld knowledge, lied to them, treated them without their consent; not warned of risks and negative effects of treatment; overcharged them; experimented on them . . .; treated them poorly because of their race, sexual preference, age, or disability; offered them tranquilizers or moral advice instead of medical care or useful help from community resources . . .; administered treatments which were unnecessarily mutilating and too extreme for their problem, or which resulted in permanent disability or even death; prescribed drugs which hooked them, sickened them, changed their entire lives; performed operations which they later found were unnecessary, and removed organs which were in no way diseased; and abused them sexually. The New Our Bodies, Ourselves debunks as "myth" popular ideas about the superiority of the American medical system, the contributions of medicine to world health, the scientific basis of medicine, the safety and efficacy of medical treatments, and the role of medicine in promoting health. Furthermore, the authors explicitly critique the medical system as an instrument for the social control and suppression of women. One outgrowth or manifestation of this skepticism is an openness to alternative approaches, as exemplified in the introduction to the book which states that while "we do need professional help with health problems . . . medical approaches are not always the best, with their excessive emphasis on drugs, surgery, and crisis intervention." The book includes information on both biomedical and alternative approaches to health care. Each of these criticisms of mainstream medicine—excessive cost, skewed access, inadequate current health care organizations, and lack of medical effectiveness—has its own history, proponents, strengths, and weaknesses. Yet increasingly they are presented as a coherent whole, reinforcing and deepening each other. Demonstrations that a particular treatment is not very efficacious are strengthened if the treatment is also costly. Organizational arrangements that lead to reductions in desired treatments are all the worse if the reductions are justified by the need for raising corporate profits, or the treatments are allocated such that those most in need are least likely to receive them. Criticisms of medicine and the organization of health care services are widespread across the political spectrum, and these views have taken on a quality of enhanced legitimacy. The coming together of these strands of critical thinking was epitomized in the findings and proposals of President Clinton's Health Care Commission. The commission's final report premised each of its proposals on the acceptance of the criticisms we've just described. The politicians who rejected, and eventually scuttled, the report's conclusions did so not on the basis of a rejection of its premises about the costliness, inefficiencies, or ineffectiveness of medicine. Rather, their opposing views were based upon belief that more governmental intervention would make things worse and/or that a greater role by market driven economic forces, not government mandates, could rectify the situation. Extensive criticism of medicine as an institution in American society is now commonly articulated at high levels of the government, the academy, and the corporate sector of the economy.

Health and Community

Biologists have long noted that all species, plant or animal, live in communities. Existence apart from others for any extensive

length of time is rare and usually futile. Literature, anecdotal commentary, and scores of research reports have set out the consequences of social isolation for the physical health of humans. Anthropologists have described the rapid onset of death in members of small tribal groups who are ostracized, and numerous contemporary statistical accounts show the impact of bereavement upon the short-term mortality rates of those who survive. A typical finding in this literature is that about 20 percent of those who die within a year after the death of their spouse do so in direct physiologic response to the psychological impact of the loss. Scientists have demonstrated the physiological mechanism by which loneliness and isolation lead to poor physical health among primates, and it is generally thought to operate similarly in humans. Recently, a large study of nine hundred forty-two Finnish men found that feelings of hostility, hopelessness, and cynicism sharply accelerated atherosclerosis in carotid arteries, a major precursor to stroke.

		Since the 1960s a large body of rigorous research has demonstrated how job-related stress can adversely affect one's health. In 1973, Work in America: Report of a Special Task Force to the Secretary of Health, Education and Welfare found that dissatisfaction with one's work was the single best predictor of a heart attack—superior to blood pressure, cholesterol, or any other traditional "risk factor." Subsequent research has been able to specify those particular job characteristics that lead to especially high risk, such as limited decision-making ability coupled with high job demands. Researchers have also identified certain job characteristics that are protective against heart attacks, such as feelings of control and commitment. Large epidemiologic studies, carried out in Britain, have clearly shown the relationship of the type of job one holds in the occupational hierarchy to be related to most major causes of death, independent of risk factors like smoking and blood pressure, or of access to medical care.

		This research has not primarily focused on the health of individuals in a clinical context. Rather, these studies have dealt with the health of populations and groups. However, the findings from these population-based community studies suggest associations that are similar to the results of the more individually-focused psychological work on social isolation described earlier. Common to both approaches is an emphasis on the interpenetration of the mental and the physical realms of life. Social relationships and events can either create distress and literally make someone sick, or relieve distress and make someone well. Health and illness exist as points on a continuum, in a constantly changing relationship to each other. Resources for maintaining health or fighting illness may exist in an individual's environment, but they must be perceived as beneficial if they are to be effective. It is perceived meaning, our thoughts, derived from the sum total of our life experience that determines our propensity to be healthy or ill. The implication of all this work is clear: the communal environment, which includes our relationships with other people, enters our bodies via the symbols and categories in our minds. As in the development of social psychology and in the studies of the placebo effect, the essence of this research is that the line between our selves and those around us is blurred. Thus, a basic tenet of the "medical" view of illness is undermined. As in the case of the placebo effect, despite having been conducted under the auspices of medical institutions, this research has had only a minimal impact on clinical practice. Regardless of conventional medicine's neglect of these ideas about the interpenetration of mind, body, and the community, such notions are quite compatible with the views held by most forms of Judeo-Christian religion, as well as various types of Eastern, "new age," and humanistic spiritual groups. The former have always been an important force within American life. The latter have come to play an increasingly significant role as the population has become more ethnically diverse, more highly educated, and more secular. Although the major religions have been very receptive towards mainstream scientific medicine, each encompasses a tradition that stresses the potential of body-mind interaction and the importance of the relationship between the suffering patient and healer, along with the connection between the individual and the community as both a source of sickness and healing. To the extent that religion and spirituality have provided a counterpoint to the dominant American values of scientific rationalism, they have also offered an alternative to scientific biomedicine for understanding health and healing. The recent ascendancy of charismatic, Pentecostal, and "born again" movements within American Christianity has greatly enlarged the number of people who know about and accept some alternative views of how healing may occur. Many Americans have become familiar with a quasi-religious perspective on healing through their contact with 12-step programs and other self-help groups. Modeled on the premises of Alcoholics Anonymous, 12-step programs require turning oneself over to a "higher power" as a condition of help or healing. Robert Wuthnow, a professor of sociology at Princeton University, estimates that there are approximately three million spiritually oriented self-help groups in the United States, many in churches and others based on the 12-step framework. The twenty-year-old New Age movement has also had a significant impact on Americans' spiritual beliefs. Respected public opinion polls repeatedly find that belief in various forms of "alternative realities" is common and positively associated with education. At least half the adult population admits to a belief in the existence of angels, and in the period between 1990 and 1995, over two hundred books concerned with the topic of angels have been published. The World Wide Web boasts approximately three thousand mystically-oriented sites. Even physicians are joining the ranks of those who believe that there is a role for spirituality in healing. According to a 1996 statement released by the Harvard Medical School, over 99 percent of the three hundred family physicians interviewed by an independent research firm reported that they "believe in the ability of religious beliefs to contribute positively to the healing process." Additionally, 80 percent of the surveyed physicians believe in the "palliative powers of meditation and prayer," and 55 percent reported that they use relaxation and meditation techniques in their practice. This widespread prevalence of groups proclaiming and promoting a spiritual or religious dimension to healing as well as the rise and ubiquity of 12-step programs reflects and reinforces beliefs about health and illness that are fundamentally at odds with the traditional biomedical worldview. Prevention versus Curing Since its earliest days, Western medicine has encompassed a range of views about how a state of health is best achieved. Dubos describes the "competition" between the Greek gods Hygeia and Asclepius. Hygeia represented the possibility of preventing or forestalling illness by living in a healthy manner, what today would be called "health promotion." Asclepius, the first physician according to Greek legend, achieved fame not by teaching wisdom but by "the use of the knife and the bandage of curative plants." There is little doubt that Asclepius's approach became the dominant view of medicine. Today his image and name are frequently represented on medical institutions. However, the views of Hygeia did not disappear completely. Those seeking the ''laws" of a healthy life, the prevention of illness, and the building of healthy communities maintained a presence within medicine, most commonly under the rubric of "public health." Although this catchall term has, for many, become synonymous with the units of state and local government that bear the name, the field is much broader. As seen in schools of public health (which originally were restricted to the post-graduate training of physicians and other health professionals), public health includes the assessment and measurement of community health, prevention of illness, and effects of environmental factors on human health, along with the administrative dimension of health care. In many respects public health schools and agencies have served as a refuge on the border of mainstream medicine for health providers working to improve the health of communities. Despite its marginalized status, public health research has consistently documented the limited role that clinical medicine and medical technology have played in reducing mortality in industrialized nations. Public health research has also provided evidence of the crucial roles played by social status, working conditions, the physical environment, and social relationships in promoting health. Removed from its bureaucratic and professional "home" in public health schools and agencies, the underlying message of public health is strikingly similar to the views held by other critics of mainstream medicine: Health is a product of community life which reflects social distinctions and hierarchies and is modifiable by environmental change and alteration in the way in which people relate to each other. Aggressive calls for the primacy of a "public health paradigm"—or a "biopsychosocial model"—over the dominant biomedical model have recently become relatively common among public health leadership. After-the-fact clinical interventions are seen as a diversion from the goal of preventing illness. In the case of problems such as chronic illness, substance abuse, and mental illness, prevention is heavily dependent upon changes in the consciousness, or the ''empowerment" of people and groups. The congruencies and convergence among public health advocates, psychologists documenting mind-body interaction, and social scientists charting the influence of the community on health are striking. Although many commentators such as Rick Carlson, Ivan Illich, and Irving Zola noted the intersecting lines of thought and saw the potential affinity between them, these critics of conventional biomedicine have carried on their work independently of each other. Yet despite their relative infrequency and isolation, these criticisms of mainstream medicine have become increasingly influential. The heightened prominence, synergy, and impact of these critiques have not been due to any newfound validity as much as to their affinity with a wholly distinct set of changes in the mainstream medical care system.

Changing Views of Health and Illness

		Mind and Body

		A central tenet of views critical of "scientific medicine" has been the overriding importance of the interconnectedness of mind and body. Scientific medicine's roots in the dualism of Descartes has precluded it from viewing the human being as an organic whole. This has led to the neglect, minimizing, and denial of the mind's ability to produce and remove symptoms, if not create and cure illness. The opposing "holistic" view starts with the assumption that an organism (the whole) is more than the sum of its parts. According to this perspective, the nature of the parts is determined by the whole with each part understandable only as an interdependent part of the whole. While the dominant views in medical education and practice since Flexner have given short shrift to holism, developments in psychology, laboratory science, epidemiology, physics, and many other fields did not.

		The development of psychology as a field of inquiry and clinical practice exemplifies this gap with medicine. The work of many notable psychologists from John Dewey to Freud and the gestalt psychologists such as Wolfgang Kohler and Kurt Koffka, as well as the "human potential" psychologists such as Abraham Maslow, all viewed the human being as an indivisible unit of mind and body. The essence of living, and in particular the potential or overall goal-directed nature of the organism, could not be understood unless one comprehended this unity. While each of their perspectives influenced the development of American psychology, their work extended beyond the academic and clinical realms. This has been especially true of Maslow's theories, which directly led to the development of the "human potential movement" by Carl Rogers and others. The human potential movement was instrumental in carrying the message of holism to the fields of education, management, and organizational development, as well as to the worlds of art and music during the 1960s. Thus, psychology has been influential in contributing to holistic ideas about the interpenetration of mind and body and establishing them among the public, especially among the most educated and accomplished. The growing recognition and understanding of the "placebo effect" has contradicted views that proclaim the mind and body as fundamentally separate. The placebo effect occurs when substances lacking intrinsic actions produce cures, distinguishing them from the results of "real" treatments. Although many mainstream clinicians had long recognized that part of their power to heal people derived from the symbolism and expectations both patients and practitioners brought to the therapeutic encounter, the formal recognition of that fact by medical educators and organized medicine was consistently downplayed. Remission of symptoms and cures lacking a "scientific" rationale could be dismissed as being "only the placebo effect." Mainstream practitioners have often trivialized the placebo effect, not because a suffering patient would reject being cured on that basis, but because it undermines the rational scientific approach of Western medicine. As Linnie Price put it, ''The implications of the placebo effect for medicine, then, is that it relocates healing in the realm of the irrational. . . . If the pharmaceutical industry were able to produce a drug which was as reliable, of such wide-ranging applicability, and with a record of efficacy as impressive as that of the placebo effect, it would no doubt be proclaimed as a miracle panacea and attributed to the wonders of science." Despite scientific medicine's ideological discomfort with the placebo effect, it has been the subject of much cross-cultural research as well as a topic of interest to a small number of physicians, who have described its omnipresence in every sort of medical encounter from psychotherapy to surgery. Placebos have been shown to effectively treat a wide variety of conditions, including mood changes, angina pectoris, headache, seasickness, anxiety, hypertension, depression, and the common cold. Placebos can work for years, reducing symptoms as long as the patient believes them to be "real." Additionally, placebos have been shown to mimic the effect of active pharmacological agents and to be capable of producing many of the formal traits of drug dependency. Moreover, several studies have chronicled negative side effects in patients being treated with placebos and indicated that "just as a belief that a placebo is a 'real' drug produced a 'real' effect, belief that a real drug is a placebo produces a lack of effect." These studies provide evidence that the placebo effect remains as powerful as ever in the age of "scientific medicine." Ironically, it was the cumulative efforts of medical researchers, most of whom wished to demonstrate the efficacy of a new drug or technique, that provided the strongest testimony of the prominence and prevalence of the placebo effect. According to the standards of Western scientific medicine, "proof" of the efficacy of a new drug or technique requires the use of socalled "double blind" randomized controlled trails. By using random assignment to determine whether study participants will receive either a treatment drug or a placebo, and keeping both the participant and the clinician ignorant of which subjects have received which treatments, this type of study design is considered the most rigorous means of ascertaining the "true" effect of the drug being evaluated. This approach to medical research explicitly minimized the usefulness of clinical reports of success. The entire methodology was based upon the premise that if either the doctor or the patient (no less both) knew which treatment was "supposed to'' work, it would indeed succeed. The working assumption in medical research was that the placebo effect was an overriding presence, in constant need of being excluded if any sense was to be made of proposed innovations. Yet despite this omnipresent acknowledgment of the placebo effect's ubiquity and power, little attention was given to how its impact might be enhanced for the benefit of patients, much less what it implied about the underlying assumptions concerning the relation of body and mind. In like fashion, the critique of classical physics arising from the development of "the new physics" has raised questions about the adequacy of the current scientific biomedical model. The new physics refers to the theories of quantum mechanics, based on Max Planck's theory of quanta in 1900, and relativity, which began with Albert Einstein's special theory of relativity in 1905. According to the new physics, a complete understanding of reality lies beyond the capabilities of rational thought, and, at best, physics can merely describe the statistical behavior of systems and predict probabilities. That is to say, the new physics contravenes positivism, disputing the possibility of a detached and objective science in pursuit of "absolute truth." Indeed, Bell's Theorem, a keystone of the new physics, posits that ''underneath" ordinary space-time phenomena, there lies a deep nonlocal reality in which none of the "laws" of classical physics apply. Moreover, the new physics insists that it is not possible to observe reality without changing it; there is no objective reality apart from our experience. Therefore, our experience of the event occurs at the moment we observe the event. This implies that our experience of reality is determined by our own consciousness. Thus, these developments in physics question the validity of the assumptions upon which conventional scientific medicine is based. Additionally, they transcend traditional views which hold that mental and physical phenomena are functionally different.