Journal of Bioethical Inquiry
March 2019, Volume 16, Issue 1, pp 99–112
Medicine is Patriarchal, But Alternative Medicine is Not the AnswerArianne Shahvisi
Lecturer in Ethics and Medical Humanities, Brighton & Sussex Medical School University of Sussex, Falmer UK
Abstract
Women are over-represented within alternative medicine, both as consumers and as service providers. In this paper, I show that the appeal of alternative medicine to women relates to the neglect of women’s health needs within scientific medicine. This is concerning because alternative medicine is severely limited in its therapeutic effects; therefore, those who choose alternative therapies are liable to experience inadequate healthcare. I argue that while many patients seek greater autonomy in alternative medicine, the absence of an evidence base and plausible mechanisms of action leaves patients unable to realize meaningful autonomy. This seems morally troubling, especially given that the neglect of women’s needs within scientific medicine seems to contribute to preferences for alternative medicine. I conclude that the liberatory credentials of alternative medicine should be questioned and make recommendations to render scientific medicine better able to meet the needs of typical alternative medicine consumers.
Free full text:
https://link.springer.com/article/10.1007%2Fs11673-018-9890-5Excerpts:
“Women dominate alternative medicine (AM), both as consumers...and as service providers. In this paper I analyse the gender differential in AM consumption and provision against the context of two facts.
First, AM use is driven by
(a) dissatisfaction with scientific medicine (SM) (McIntosh and Ogunbanjo 2008),
(b) the favouring of a more equitable patient–provider dynamic which centres patient autonomy (Gollschewski et al. 2008; Hall et al. 2012),
(c) its association with particular ideologies, notably feminism (Astin 1998; Scott 1998).
Second, SM does not adequately serve women’s health needs, which are often under-researched (e.g., Mikhail 2005; Holdcroft 2007) and under-treated (Annandale and Hunt 2000; Hoffmann and Tarzian 2001), while women’s bodies are over-medicalized (e.g., Drew 2003; Leidy Sievert 2003). I argue that we should combine these facts and take seriously the idea that women’s attraction to AM is related to the fact that SM neglects women’s needs.”
“Complementary medicine therefore comprises all therapies or heuristics which complement SM but do not attempt to replace it. These are therapies which may be related to one’s lifestyle or obtained through one’s social relations: a healthy diet, exercise, massage, relaxation techniques, group or individual counselling. In other words, complementary medicine tends to involve engagement with determinants of health problems, rather than health problems themselves.
[Comment: I disagree. Many complementary methods deal with relief of symptoms.]
“These interventions generally have an evidence base, even though their effects are often incremental and long-term. For example, massage therapy has been shown to reduce pain, anxiety, and blood pressure (Moyer et al. 2004), while the breathing techniques used in yoga have also been shown to reduce blood pressure (Grossman et al. 2001). Complementary therapies do not generally require medical supervision or facilitation, yet their benefits may be straightforwardly rationalized in line with SM, albeit generally in indirect terms.
“AM, on the other hand, departs dramatically from the paradigms of science. AM is used as a replacement for SM, in part or in whole; that is, it sets out to treat ailments that would generally be considered to be medical in nature. Drawing on recent work by Shahvisi (2016), AM1 may be defined as intended treatment that:
1. Does not have any proven effect beyond placebo, and;
2. Either:
(a) does not posit any mechanism;
(b) posits a physical mechanism that is implausible with respect to known science;
(c) posits a mechanism that is not physical.”
[Comment: some alternative methods, such as herbs and supplements, may propose mechanisms that are plausible (provision of nutrients or antioxidants). The key is whether there is evidence in support.]
“Homeopathy is perhaps the most famed variant of AM and serves as an expository archetype. Its ostensible mechanism of action is elaborate and internally consistent. It imbues water with a “memory” which outlasts multiple dilutions of an infinitesimal amount of active ingredient. However, not only does this mechanism fail to cohere with the remainder of our vast scientific knowledge but its claims are directly contradicted by that body of knowledge.”
“Consider also chiropractic, which claims that a range of health conditions can be treated through manipulation of the spine. Whilst the details of the proposed underlying mechanisms vary, the central claim of chiropractic is that misalignments or displacement of the vertebrae, known as “subluxations” (which are not necessarily detectable using medical imaging, e.g., X-rays (WHO 2005)), affect the nervous system in such a way as to bring about a range of health conditions, including musculoskeletal pain, headache, asthma, and gastrointestinal problems (Posadzki and Ernst 2011). Chiropractors manually manipulate the spine in ways that are alleged to rectify the subluxations and thereby remedy the associated health conditions. There is no evidence for the existence of chiropractic subluxations (Homola 2010), no scientifically acceptable mechanism for the way in which subluxations cause ill health (Mirtz et al. 2009), and no scientific evidence for the efficacy of chiropractic for the treatment of any medical issue (Posadzki and Ernst 2011).
“Likewise, other AM modalities are ineffective beyond placebo and lack mechanisms that are consistent with the remainder of our science, for example, energy medicine (Stenger 1999; Ernst 2006), naturopathic medicine (Atwood 2003), and faith healing (American Cancer Society 2013). Importantly, what all these therapies have in common is the absence of a plausible mechanism, that is, one that fits in with the remainder of our collective knowledge and can therefore be verified. As such, their method of action or the reason for their selection cannot be explained to patients, because there is no objective sense in which these facts are knowable by the practitioner, let alone the patient (Shahvisi 2016).”
“Drawing on studies across populations in Global North contexts (Australia, Austria, Canada, Denmark, Germany, Italy, the Netherlands, Switzerland, the United Kingdom, and the United States), the profile of a typical AM user is a woman (MacLennan et al. 1996; Verheij et al. 1999; Ernst and White 2000; Stein et al. 2009; Frass et al. 2012) who is more highly educated (MacLennan et al. 1996; Blais et al. 1997; Verheij et al. 1999; Ernst and White 2000; Stein et al. 2009; Frass et al. 2012), relatively affluent2 (Blais et al. 1997; Ernst and White 2000; Stein et al. 2009), and often suffering from a long-term health condition (Blais et al. 1997; Busato et al. 2005; Stein et al. 2009; Ernst 2010; Frass et al. 2012).
“Empirical research reveals a range of motivations for AM use. Unsurprisingly, users believe that AM is effective in alleviating medical problems (Ernst and White 2000). Amongst other positive motivations, or ‘pull factors,’ are the presumed ‘naturalness’ of AM treatments...the control they are believed to offer over illness/health (Stein et al. 2009), and the contention that they are person-centred and holistic (Ernst 2010). Negative factors, or “push factors,” also abound: dissatisfaction with SM and the doctor–patient relationship or the clinical encounter (Moore et al. 1985; Mitzdorf et al. 1999; Stein et al. 2009; Ernst 2010) and doubts about the efficacy of treatments within SM (MacLennan et al. 1996; Stein et al. 2009)...others (e.g., Astin 1998) determine that a commitment to feminism, environmentalism, or another value-system is most pertinent to AM use...reasons why people choose AM (Bakx 1991; Astin 1998; Siahpush 1998), which include a desire for greater autonomy, a desire to reduce the power differential between patient and practitioner, and an attempt to access therapies which better fit the patient’s personal philosophy or value system.
“Importantly, AM use is associated with greater numbers of encounters with general practitioners and negative associations with SM as a result of iatrogenic effects of long-term medication (Murray and Shepherd 1993; Al-Windi 2004). Further, the relatively high level of education and income amongst service-users indicates that AM is likely to be a considered decision amid multiple options, rather than a last resort. This suggests that patients are preferentially seeking AM where SM is accessible..a tacit critique of SM.
“In an empirical study, Siahpush (1998) finds that patients ‘turn away from orthodoxy not because of its failure to deliver the promise of good health, but because of the way they are treated by doctors’.”
“AM is seen as being more personalized, and to its users it stands in contrast to SM in that it ‘does not marginalize or deny human experience; rather, it affirms patients’ real-life worlds’” (Kaptchuk and Eisenberg 1998, 1062).”
“AM is thought to overcome the ontological dualism and one-size-fits-all model that typifies SM.”
“The preponderance of women clients is only half of the story: AM is also dominated by women practitioners (Andrews et al. 2003; Cant and Sharma 2004; Nissen 2010; Nissen 2011; Keshet and Simchai 2014).”
“Further, there is evidence of a gendered difference in attitude towards AM amongst medical students across different contexts, with women students more likely to view alternative therapies positively (Furnham and McGill 2003; Lie and Boker 2004; Greenfield et al. 2006; Akan et al. 2012).
“Women’s dominance as users and service-providers within AM can be contextualized within a broader trend of women’s greater interest in spirituality and the holistic milieu (Houtman and Aupers 2008)...The holistic approach typified by many AM modalities is theorized to be attractive to women because it is coherent with, and legitimizes, the relationality that women are socialized to embody in their care-giving but at the same time validates notions of self-care which subvert the stereotypical care role and recognize the importance of a woman ‘thinking about her own well-being rather than that of her dependents’ (Sointu and Woodhead 2008).”
“In short, AM is valued both for pragmatic medical reasons—because it is believed to be effective, it is assumed to have few or no side effects, it is deemed to be more ‘natural’—and for ideological reasons—because it is believed to offer control over health, be non-authoritarian, and improve patient autonomy by avoiding paternalism and universalism.”
“Within medical settings, healthcare professionals endeavour to avoid paternalism by securing informed consent from all patients before issuing any treatment.”
“By contrast, AM therapies cannot deliver on the demand for ideal informed consent, and this limitation is a matter of principle, not practice. It seems that AM is therefore necessarily paternalistic. The inescapability of this paternalism operates in two independent ways. First, no scientifically acceptable explanation can be given for the mechanism of the therapy, which means that exemplary informed consent is ruled out. Second, should too much information be given about the therapy, its nominal positive effect—which relies on the placebo effect, which in turn relies on belief that a therapy is efficacious—may be threatened.”
“AM therapies cannot be recommended to patients by reference to their mechanisms without asking patients to accept explanations which are not consistent with the vast body of knowledge we collectively accept. Nor can they be recommended on the strength of their evidence base, since none has been shown to be effective beyond placebo.
“To approach this argument another way, consider O’Neill’s suggestion that genuine informed consent requires that a patient is ‘neither coerced nor deceived, and can judge that they are not coerced or deceived,’ and that patients are offered ‘extendable information,’ which is to say, ‘easy access to more specific information that lies behind an initial, or second, or third layer of information provided’ (2003, 6)...Yet the claims made within AM are not consistent with our most basic auxiliary assumptions about the world...It is therefore not possible for patients to verify their likely truth unless they already hold the proposition ‘this practitioner’s treatments will work’ within their set of auxiliary assumptions, in which case limitless deceit is possible. Second, extendable information is not possible for AM, precisely because it is not founded on the scientific principles which guarantee an extendable information base for all other medical queries.”
“Unable to rely on the persuasive power of conventional explanations or bodies of evidence, practitioners must pre-emptively buttress their credibility through careful management of the therapeutic encounter."
“It seems that patients must simply believe in the proffered AM therapy, because they trust either the practitioner or the paradigm...Yet trust without informed consent is patently a violation of autonomy..”
“In short, AM’s lack of engagement with plausible mechanisms of action, and ipso facto, with explanations and informed consent, leads to a situation in which there is a therapeutic free-for-all in which all manner of (potentially contradictory) claims may be made, and in which patient autonomy drops off the agenda, leaving those who are marginalized by SM with neither effective treatment nor meaningful autonomy.”
“Whilst it may be argued that AM offers personalization and a satisfactory therapeutic encounter, it must also be noted that forfeiting an evidence base, plausible mechanisms, and the ability to make autonomous decisions is a heavy loss to patients and one for which SM must take some responsibility.”
“Those who begin with a sense of dissatisfaction with SM...end up with healthcare that is on many counts less adequate.”
“As Ernst (2010) has noted, concentrating on the therapeutic relationship within SM seems like the most constructive way forward. Although patients often look to SM for the ‘science of medicine’ clearly many are turning to AM for the ‘art of medicine’ (Ernst 2010, 1473)—for a compassionate clinical encounter in which patients are humanized and power differentials are flattened.”
“Focusing on the U.K. healthcare system, I therefore recommend that general practitioners...make efforts to address the inadequacies in the clinical encounter, specifically for those with long-term health conditions or medically unexplained symptoms.”
“That women may be less likely to benefit from medicine and therefore more likely to spend time and money seeking therapies whose claims are questionable, whose benefits are negligible, and whose potential for exploitation is considerable, is a grave matter. Researchers and clinicians must take responsibility by consciously modernizing biomedicine to ensure that its goods are accessible to all and that the benefits of a positive therapeutic encounter are acknowledged and prioritized in the delivery of care.”
