- Barbara Prainsack
Department of Political Science, University of Vienna
Waehringerstra§e 28, 1090 Vienna, Austria
Eubios Journal of Asian and International Bioethics 12 (2002), 128-132.
The search for meaning in human suffering is as old as humanity itself. Being convinced that our pains and illnesses bear a certain meaning for us and do not beset us "by accident", facilitates the process of accepting our suffering. Additionally, throughout history, phenomena that seemed to be inexplicable or inevitable have always been somehow attributed to higher sources. In pre-modern societies, references to heavenly powers in matters of disease and human suffering were articulated explicitly and became part of the dominant narratives. Those heavenly powers were thought to affect someone with a disease for a particular reason and health would then be restored as soon as the disease had served its purpose (1). A sick person would therefore \ through prayers, offerings or other means, depending on the culture \ turn to her god(s) in order to try to convince them to release her from her suffering. "Healing" as such was perceived as a process much more complex than its modern notion that focuses on the treatment of physical malfunctions (2). It meant overcoming a crisis, with the help of higher powers and in submission to them. "Health" and "healing" were concepts that existed on various levels besides the one that we would today label as the level of the material body.
Medieval Christian Europe embraced this perception. According to the Christian Bible, "health" is a condition of spiritual and physical harmony with God. Faith was a prerequisite for achieving "health"; the connection between religious faith and healing is manifested in various places in the New Testament (3). Soteria, "spiritual salvation", and therapeia, the process of physical healing, were insepararable categories (4). In early Roman Catholic doctrine, God himself was regarded as the only legitimate source of healing. Whoever claimed to be a healer must have received this power from God. Profane medicine, which restricted itself to curing the somatic aspect of an illness, was seen as an illegitimate rivalry to divine healing and thus sometimes even defamed as a piece of devilry. Particular clerics claimed that the use of medical remedies was a reprehensible thing to do for Christians (5).
However, church doctrines are one thing and people's observance is another. The harsh battle that the church fought against profane healing was not able to thwart the people's demand for healing methods and healers that were not in accordance with the Christian worldview. In addition to the academic medical profession (who was small in number in medieval Europe, and whose advise was usually unaffordable for the majority of the population), the use of medical herbs and magical practices were popular (6). Nevertheless, in Christian medieval Europe the notion of human suffering and healing was inseparably connected to the path of spiritual salvation as the destiny of human beings. Illness was regarded as an integral part of a divine design, bearing a certain meaning and serving a certain cause for the individual suffering from it. The interpretation of physical suffering as either a divine punishment, a "test" of oneLs faith - like it was the case with the biblical Job -, or a blessing, despite all the painful aspects, was able to lend valuable assistance to the sick person in accepting her illness as a meaningful event, including the hope for an release (7). Conceptualizing disease as divine punishment was the dominant narrative in this context; it is not a coincidence that the word "pain" stems from the Latin term poena, "punishment". This mechanism also served as a means for disciplining people, urging the suffering person to examine his conduct for possible moral faults that may have caused the illness.
While the Roman Catholic church opposed purely profane methods of healing, it also harshly criticized competing narratives of the cause and the meaning of suffering. The old discipline of astrology, for example, was condemned severely by the church not only because of its origin in pagan cultures but also because of the un-Christian determinism it implied (8). How could believers be kept adhering to the conviction that their suffering was a matter of divine fate and connected to their conduct, if they were able to blame the stars?
What Giacomo Marramao called "the Christian monopoly of interpretation" (9) serves well in characterizing the medieval Christian perception of human life as a process that strictly follows a religious teleology and is deeply embedded in the context of sin and guilt. The subsequent process of Secularization can be seen arising with the decreased willingness of people to lead their lives within the narrow boundaries of the restrictive Christian worldview.
As the British anthropologist Bronislaw Malinowski has plausibly shown at the beginning of the 20th century, the main function of religion and the magic in premodern societies was to institutionalize hope. People turned to higher powers, gave offerings and performed spells, in order to compensate for their own helplessness and fear (10). Assuming a close relationship between the feeling of human weakness and the need for direct transcendental assistance, we can conclude that Secularization also meant an increasing level of human self confidence. In addition to recognizing the fact that the rise in "empirical" and technical knowledge at those times contributed greatly to the human ability to understand and control the world, Keith Thomas has demonstrated that the decline in importance of the traditional institutions of religion and magic had taken place prior to the discovery of new remedies to fill the gap: "The difference between the eighteenth and the sixteenth century lies not in achievment but in aspiration" (11). This claim is particularly true for the field of medicine. Highly effective pharmaceuticals were mainly invented over the course of the 19th and 20th century, literally centuries after the decline of magic and the beginning of Secularization.
The Reformation movement, which radically changed the character of the whole continent during the 16th and 17th centuries, placed additional focus on the postulate of human self reliance. Protestantism uncompromisingly disapproved of all forms of superstition, and \ in contrast to the Catholic church, which answered the disaster by imitating the magical in many ways \ relied on the principle of rational reflection and the belief in human abilities. People were told not to rely solely on God, but also to work hard in order to achieve their goals. Prayers would help, but they would not be sufficient.
Hand in hand with the retreat of the Christian monopoly of interpretation came a change in the perception of the human body. It increasingly lost its purely negative connotation and gained importance as a separate category (12). A long and healthy life emerged as a legitimate desirable scenario (13), thus placing the material body within the focus of medicine.
The Cartesian approach towards the human body soon turned out to become the foundation of what developed into modern medicine. Descartes (1596-1650) regarded the body as a machine, constructed by God like a watchmaker builds a watch. The new feature in DescartesL thinking was not his attribution of mechanistic qualities to natural phenomena (14) but his application of the mechanistic pattern not only to inanimate nature but also to living creatures. Even emotional feelings he conceptualized as mere automatic processes (with the only exception being what he called the intellectus purus, "pure intellect"), physiological mechanisms designed to support the frictionless functioning of the organism. Descartes imagined emotional feelings as being caused by nervous stimuli. The basis of the Cartesian concept was a rigid dualism of mind/soul. Focussing on the material body became the determining factor for medicine in the age of rationalism. Human intellect was regarded as a means to understand and manipulate the body-machine.
These developments resulted in a number of additional separations. Not only was the body separated categorically from the spiritual and mental sphere, but the healing profession was split up into the physici, physicians and other medical professions concerned with physical wellbeing, and the theologici, who were entrusted with spiritual needs. The founding of numerous universities from the 14th century onwards advanced the establishment of a profane medical canon of medical knowledge that could be obtained independently of the approval of religious authorities. The separation between profane and religious healing found its peak in the prohibition for clerics to obtain medical knowledge in secular institutions (15).
Rationalism, scientific objectivity and the striving for clear categories and boundaries became the core values of modern medicine (16). Anything not directly referring to visible and measurable categories, anything that was incapable of being understood by human intellect, was labeled "irrational" and was banned into the sphere of the "unthinkable". For the meaning applied to human suffering, the impact of the new paradigm was twofold. On the one hand, in light of the categorical separation of the material human body from the mental and spiritual sphere, disease and illness were unable to be easily traced back to moral faults of individuals anymore. Suffering lost its moral connotation to a large extent. God was banned into the heavens. On the other hand, this "relief" was not achieved without losing the alleviating merits of attributing meaning to suffering. Within the context of modern medicine, illnesses "just happen", like a flat tire or a sudden rain. Not many things are as humiliating for the human ego as being a victim of coincidence (17).
The boom of alternative and holistic approaches within medicine can be interpreted in the context of the need to reconnect meaning to human suffering. The well known characterization of postmodernism as the end of the grand meta-narratives, a phrase coined by the French philosopher Francois Lyotard, brought along the decline of uncontroversial authoritative knowledge. The diffusing of clear boundaries, the heterogenization of categories and the possibility of different truths existing simultaneously, extended the range of what is perceived as reality (or should I say realities?), as well as legitimate means to understand and interpret it. Western medicine appears to be standing at the doorstep from modernism to postmodernism, in its mainstream still relying on positivistic "scientific" approaches, but increasingly being "completed" by healing practices and outlooks that transcend traditional modern boundaries. The body does not necessarily end with our skin; suffering is regarded as not only taking place on the visible and material level; and categories like illness and death experience a shift in interpretation from purely negative events to necessary steps in a process.
Let me defend this claim with the examples of acupuncture and homeopathy, two increasingly popular complementary and alternative healing approaches in the United States (18). Acupuncture is a branch of the larger field of Traditional Chinese Medicine (TCM). It is based on a concept of health as the state of well balanced energies. If the flow of energy through the body is interrupted or imbalanced, the balance of yin and yang is disturbed, and disease can be the outcome. Acupuncture therapy manipulates the points where the so-called meridians, the "channels" of the energy, come to the surface of the skin. The most common form of manipulation is the application of needles, aimed at rebalancing the energies and restoring the undisturbed flow of energy through the body (19).
It is obvious that an approach based on categories as "unscientific" as "energies" does not draw its boundaries at the same points as Western biomedicine in other aspects either. The rigid Western body-mind-spirit distinction cannot be found in Chinese medicine. Diagnosis is formulated by the practitioner through asking, feeling, seeing and hearing, and the notion of wellbeing is based on a holistic model, encompassing physical as well as mental and spiritual aspects. The distinction between health and sickness is not a sharp line, but a field of flowing passages. Emphasis is not only put on restoring health but on preventing sickness, and "recovery" is not only the result of a single therapeutic intervention, but conceptualized as a meaningful process dependent on various aspects of both the healer and the patient, and the circumstances they live in.
This holistic approach can be found not only in acupuncture but is common ground for many complementary and alternative healing approaches. Homeopathy, for example, does not treat diseases, but individuals. A cough is not simply a cough; the decision on what remedy to prescribe depends on various additional parameters connected to the person. How does the patient feel, what does her skin look like? A healthy person, in the approach that is based on the teachings of Samuel Hahnemann (1755-1843), is a person that is free from constraints on all levels; mental, physical and spiritual. Healing means to stimulate the person to heal himself. The medicines used are based on the principle similia similibus curentur; the like cures the like (20). A person suffering from various symptoms can be cured by a medicine that causes the same symptoms in a healthy person. These medicines are obtained through a process called succession. A substance is diluted to such extents that, "scientifically", the outcome does not contain any significant amounts of the healing substance anymore. "Paradoxically", the less substance the tincture or the globules contain, the more effective they are supposed to be.
This opens the question of "proving" efficacy of alternative medicines. As a matter of fact, the popularity of complementary and alternative healing approaches are steadily increasing in the Western world. In 1997, an estimated 44% of the U.S. population used at least one form of alternative medicine (21). Is this proof enough? Certainly not - in the opinion of those who claim that "there is no alternative medicine. There is only scientifically proven evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking" (22). It has been argued that although randomized controlled trials are not immune to being based on false assumptions or imperfect performances, they are still the best means for measuring treatment efficacy - regardless of the belief systems underlying a healing approach, whether they be biomedical or spiritual or otherwise (23). But traditional biomedical instruments for measuring treatment effects have been questioned from various sides. Constructivist thought has addressed the relativity of truth and rejected the concept of absolute and objective criteria of knowledge. Scientific truth is to be regarded as a manifestation of a particular thinking style by a group of scientists, or so-called "thought collective", sharing the same a prioris of thinking (24). Even on a less theoretical level, valid objections to the integrity of controlled trials can be made when it is found out that the qualification, the position or the motivation of the individuals performing the tests are possible parameters to affect the outcome (25).
Taking into consideration the particular characteristics of complementary and alternative medicine, it has been argued that they are in large part incompatible with the principles of evidence based medicine (26). First, the categories are not the same. "Health", "disease", and other terms connected to healing are what postmodern theorists call "empty signifiers"; "a sign only means that it means" (27). Particular terms get their specific meaning only through their embeddedness in a specific system of knowledge. Biomedical knowledge provides a coherent system of thought, thereby producing clear-cut categories that bear the same meaning for almost anyone and almost everywhere. Alternative medicines, on the contrary, lack uniformity. An acupuncturist may associate other things with "health" than a chiropractor does, and it definitely has different notions for both than it does for a traditional physician. In addition to that, alternative medicines tend to perceive healing as a process with no definite starting and ending point, and as bearing a meaning as such. Each system defines its terms of measuring progress. Alternative medicines do not operate with cause-effect models that are compatible with the cause-effect system of biomedicine.
The problems arising from these incompatibilities are obvious. The neatly defined definitions that evidence based medicine relies upon may work in the context of alternative medicine, but only to a certain extent. I argue that the attempt to quantify progress "scientifically" in alternative healing approaches is a paradox as such. It is like asking experienced beauty contest jurors who shall be Miss Oklahoma: Peter or David. Certain parameters may apply; but the outcome will not be very meaningful. As biomedicine as a form of modern knowledge is a one-stage system that can only be sustained and legitimated from within itself, alternative medicines are multi-level systems, and sometimes bricolages. Dr. James Gordon of the U.S. National Institutes of Health (NIH) was quoted in 1995 by CNN stating that "what we're doing is that we're creating a larger whole. We're creating a new medicine which combines what we know of traditional bio-scientific medicine, and which brings in many other traditions from the world's healing cultures" (28). In the long run, systems of measuring efficacy of this "larger whole" will have to incorporate approaches that are not purely biomedical, even at the price of losing an universally applicable mode of trial. If this does not happen, there will be a widening gap between what people opt for with their feet, and what "scientific" medicine accepts as rational treatment options.
For patients, the benefits of alternative healing approaches are various. First of all, healing approaches not solely based on "rational" and positivist patterns of diagnosis and therapy open up the possibility to interpret one's illness according to individual creeds and convictions, enabling the suffering person to develop a meaningful illness-narrative that serves as a means of orientation and guidance. Additionally, the rejection of a strict cause-and-effect paradigm releases the patient from being forced into an idealized role as the well-informed and responsible patient whose societal duty it is to respond to the illness in the very way that the medical profession prescribes as appropriate, thereby putting the onus of responsibility for a proper recovery on a rigid notion of the patient's compliance (29). Alternative, holistic medicine is therefore able to function as a "shelter of spirituality" for the patient, with the leading question being what is wrong with her life rather than where exactly does it hurt (30).
The keyword here is spirituality, not religion. We are not experiencing a religious awakening inside the field of medicine. In contrast to hegemonical religious narratives that determine how life events are to be interpreted, thus universalizing certain understandings of truths and normalizing people in a Foucauldian sense, the phenomenon of respiritualizing medicine consists of a mosaic of possible creeds and convictions. Those convictions \ may they be transcendental or not \ exist next to each other, overlap and sometimes even contradict one another.
H. Schipperges, E. Seidler and P. Unschuld (eds), Krankheit, Heilkunst, Heilung. Freiburg: Verlag Karl Alber, 1978.
By using the phrase _modern understanding of healing" I intend to allude to the rather mechanistic approach characterizing the era of _heroic medicine", which was based on the Cartesian concept of the body and the conviction that there is absolute truth and pure, objective science that enables us to find the scientifically "correct" and suitable solution for every medical problem if we just try hard enough.
Luke, 5,20; 8,48; 18; Mark, 5,34; 9, 14-29; Matthew, 8,1-13; 9,2. For a comprehensive analysis see O. Temkin, Hippocrates in a world of pagans and Christians. Baltimore: The John Hopkins University Press, 1991.
O. K_hler, "Die Utopie der absoluten Gesundheit". In: H. Schipperges, E. Seidler and P. Unschuld (eds), Krankheit, Heilkunst, Heilung. Freiburg: Verlag Karl Alber, 1975. Pp. 619-52.
R. J_tte, Geschichte der alternativen Medizin: von der Volksmedizin zu den unkonventionellen Therapien von heute. M_nchen: Beck, 1996. P. 68.
The difference between magical practices, including sorcery, and religious practices is not always easy to determine. Both include the use of higher powers. In theory, the main distinction can be described as follows: whereas magic spells are regarded as having the ability to cause the desired effect directly, prayers are a plea to God to make the desired effect happen. Within the sphere of the magical, power is attributed to the magician himself; within religion, the person performing the prayers or the religious rites is aware of her weakness and subjugates herself to God, who is the real actor (see B. Malinowski, Magic, Science and Religion and Other Essays. Waveland Press, 1992). We cannot assume that in daily life in medieval Europe people were always aware of this difference. The mechanical recitation of prayers especially resembles the act of casting spells in a way.
An example of the interpretation of illness as a divine blessing can be found in the New Testament, John, 9, 1-4: "And when he went on his way, he saw a man blind from birth. And his disciples put a question to him, saying, Master, was it because of this man's sin, or the sin of his father and mother, that he has been blind from birth? Jesus said in answer, It was not because of his sin, or because of his father's or mother's; it was so that the works of God might be seen openly in him."
See K. Thomas, Religion and the Decline of the Magic. Studies in popular beliefs in sixteenth century England. London: Weidenfeld & Nicolson, 1997.
G. Marramao, Die S_kularisierung der westlichen Welt. Frankfurt am Main: Insel Verlag, 1999.
B. Malinowski, Magic, Science and Religion and Other Essays. Waveland Press, 1992.
K. Thomas, Religion and the Decline of the Magic. Studies in popular beliefs in sixteenth century England. London: Weidenfeld & Nicolson, 1997. P. 658.
For an example of the traditional Christian view of the body as a troublesome entity see Romans, 8,3-8. See also O. Temkin, Hippocrates in a world of pagans and Christians. Baltimore: The John Hopkins University Press, 1991.
A. Labisch and R. Spree (eds), Medizinische Deutungsmacht im sozialen Wandel des 19. und fr_hen 20. Jahrhunderts. Bonn: Psychiatrie Verlag, 1989.
Mechanistic theories can be found throughout the history of philosophy. The teaching on atoms by Leukipp (5th century BCE) and his disciple Demokrit (460-370 BCE) included the assumption that atoms where moved mechanically, by physical pressures and shoves.
See R. J_tte, Geschichte der alternativen Medizin: von der Volksmedizin zu den unkonventionellen Therapien von heute. M_nchen: Beck, 1996; S. Fl_gge, Hebammen und heilkundige Frauen. Recht und Rechtswirklichkeit im 15. und 16. Jahrhundert. Frankfurt am Main: Stroemfeld Verlag, 1998.
As Barbara Katz Rothman stated in 1982, despite the fact that modern medicine has of course ceased adhering to a purely mechanical approach, it has never given up the perception of the body as a machine. "The earliest models in medicine were largely mechanical; later models worked more with chemistry, and newer, more sophisticated medical writing describes computer-like programming, but the basic point remains the same. Problems in the body are problems requiring technical solutions, whether it is a mechanical repair, a chemical rebalancing, or a `debuggingL of the system." B. Katz Rothman, In Labor: Women and Power in the Birthplace. New York: Norton, 1982. P. 34.
Siti Nurami Mohamed Nor in EJAIB 11 (2001), pp. 52-4, is also addressing the failure of modern medicine to "incorporate an element of moral and spiritual guidance". For my examples, there is a fine distinction to add: when our car has a flat tire, or when we are experiencing a sudden rain, we usually perceive these events as being something happening outside ourselves. When we are sick, on the contrary, we have an illness, and we are sick at the same time. Suffering undoubtedly affects our understanding of ourselves as such.
Two things need clarification at this point. First, I am aware of the complexities inherent in the expression "complementary and alternative medicine". Recent articles tend to refer to Eisenberg and colleaguesL understanding of "unconventional" medicine as those practices "neither taught widely in U.S. medical schools nor generally available in U.S. hospitals" (D.M. Eisenberg, R.C. Kessler, C. Foster, F.E. Norlock, D.R. Calkins, and T.L. Delbanco, "Unconventional medicine in the United States \ prevalence, costs, and patterns of use". In: New England Journal of Medicine 1993, 328, pp. 246-52). This definition is of course not uncontroversial and loses its validity as soon as we step out of the homelands of Western biomedicine. Due to my conviction that the level of complexity and confusion increases when we try to categorize medicines along other rationales, I stick to this definition for the purpose of this paper. Second, I want to put emphasis on the distinction between alternative healing approaches and alternative healing techniques. Physicians practicing traditional medicine may use certain alternative healing techniques (mostly because they have "proven" efficient for particular disorders) but do thereby not transcend the boundaries of the biomedical paradigm of the body-machine. For other healers, alternative healing "techniques" must be seen as a manifestation and a result of an approach that differs from the hegemonical biomedical narratives, hence losing their characteristic as a mere technique and becoming part of a worldview. It is characteristic for traditional biomedical treatments to be "used" as a means to achieve a certain end, without being conceptualized as embedded in - and dependent on - the context of its use. For alternative medicines, it is not. See also the KimLs (et al) distinction between complementary and alternative medicine, which focuses on the question whether a treatment is offered in addition to traditional standard treatment or in lieu of it. Y.-H. Kim, G. Liechtenstein, and J. Waalen, _Distinguishing Complementary Medicine From Alternative Medicine". In: Achives of Internal Medicine 2002, 162, p. 943. Correspondence.
See, for example, M. Nightingale, The Healing Power of Acupuncture. New York: Sterling Publishing Co. Inc, 1986; A. Hicks, Principles of Acupuncture. London: Thorsons Publishers, 1998.
The term "homeopathy" stems from the Greek expressions homoios, "similar", and pathos, "state (of suffering)". See, for example, W.B. Jonas, and J. Jacobs, Healing with Homeopathy. New York: Warner, 1996; P. Bellavite and A. Signorini, Homeopathy: A Frontier in Medical Science. Berkeley: North Atlantic, 1995.
And from 1990 to 1997, alternative medicine visits increased from an estimated 427 million to 629 million. See P.M. Wolsko, D.M. Eisenberg, R.B. Davis, S.L. Ettner, and R.S. Phillips, "Insurance Coverage, Medical Conditions, and Visits to Alternative Medicine Providers." In: Archives of Internal Medicine 2002, 162, pp. 281-7.
P.B. Fontanarosa and G.D. Lundberg, "Alternative medicine meets science." JAMA 1998, 280, pp. 1618-9.
B.S. Bloom, "What Is This Nonsense That Complementary and Alternative Medicine Is Not Amenable to Controlled Investigation of Population Effects?" In: Academic Medicine 2001, 76 (12), pp. 1221-3.
L. Fleck, Genesis and development of a scientific fact. Chicago: University of Chicago Press, 1977; T. Kuhn, Structure of scientific revolutions. Chicago, University of Chicago Press, 1962.
See, for example, K. Dickersin, "The existence of publication bias and risk factors for its occurrence." In: Journal of the American Medical Association 1990, 263, pp. 1385-9. For a recent example, see Anonymous, "Doctors accused of cancer trial bias". In: BBC News online, Wednesday, 13 March, 2002.
M.R. Tonelli and T.C. Callahan, "Why Alternative Medicine Cannot be Evidence-based". In: Academic Medicine 2001, 76 (12), pp. 1213-20.
R. Goldman and S. Papson, "Advertising in the Age of Hypersignification". In: Theory, Culture & Society 11, August 1994, p 23-54. Quote p 50.
Anonymous, "Alternative medicine: Hope or hype?" CNN online, September 24, 1995.
For example, let us think for a moment about the revealing character of the expression "I failed therapy".
See R. Davis-Floyd and G. St.John, From Doctor to Healer: The Transformative Journey. New Brunswick, NJ: Rutgers University Press, 1998. P. 119.
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