Georg Ivanovas From Autism to Humanism - systems theory in medicine
As a human ability, patterns and states can be understood without any related theory. Therefore it comes to no surprise that nearly all systemic basics have been described in medicine in one way or another. A lot of such concepts and observations are found in historical medical systems or in outsider methods which belong to the so-called complementary and alternative medicine (CAM). The complexity management found there exceeds by far the reductionist approach and “the more scientists study CAM, the more surprises and challenges it throws up. It is forcing researchers to rethink some cherished ideas about medicine, from what makes an ideal drug and the design of clinical trials to the underlying causes of disease” (New Scientist 2001). Often physicians who cooperate with CAM proponents find new insights and enlarge their own understanding for the shifting states of patients (Ots et al 2001).
But the discourse between orthodox medicine and outsider methods is difficult, as CAM is not acknowledged by the mainstream medicine. Even the attempt for an open exchange between the orthodox and the CAM camp is mostly rejected, because this would assume a discussion among equals. This was, at least, the tenor of a discussion in the Deutsche Ärzteblatt (Deutsches Ärzteblatt 2004b) after such an initiative (Wilich et al 2004). The differences between the two sides are, in fact, enormous. Some methods as homeopathy or acupuncture even don’t define diseases and the attempt to discuss on the basis of a diagnosis only deepens the rift.
The stance of orthodox medicine can often be characterized by statements like CAM "ought to be as extinct as divination of the future by examination of a bird's entrails“ (BMJ 1980 cited in Carter).
This is in contrast to the importance of CAM in general practice. In Germany, for instance, no less than three quarters of the population use at least one complementary therapy (Ernst 2003a). In the US there were more visits at CAM proponents than at orthodox physicians (Ernst 1993). CAM has big shares all over the world, even in developing countries (Singh et al 2004).
This leads to the paradox situation that a lot of physicians against their fundamental beliefs use CAM methods. They prefer it in unclear and mild situations as something useless and harmless (Ring et al 2004), in order to satisfy the patient. This fulfils the classical definition of a placebo (lat. placebo = to please). As half of the English physicians uses also methods of CAM (Dobson 2003d) there will be many among them to practice such a kind of low standard medicine that has a bit of everything (Boon et al 2004). All this adds further to the bad picture CAM already has in the scientific community.
It is one of the paradoxes that a physician practicing low profile CAM, mainly as a placebo therapy, is better reputed than a physician practicing CAM out of conviction. Those are seen as quacks, independently of their personal integrity. A book on CAM with the title Quack, quack, quack (Helfand 2002) is programmatic. But the accusation of quackery is always delicate, as it implies a scientific and moral standard that is rarely obtained. Quackery is a typical phenomenon of all medical practice, ever since. Each kind of medicine has its own quacks. Also orthodox physicians and scientists make a lot of statements praising their therapies that often turn out to be wrong. Notorious became the sentence: “The war against infectious disease has been won” (US Surgeon General in 1967, cited in Morens et al 2004). Such misjudgements arise often and more modesty would be appropriate in every regard. It is a question of taste to call all the health promises often heard in modern medicine as quackery.
Lately many authors stressed that also CAM might produce serious side effects (except of withholding patients from the ‘correct therapy’). Such side effects include pain, fatigue and dizziness with manipulation treatments such as chiropractic and osteopathy; aggravation, needle trauma and mental effects with acupuncture; and digestive problems with homeopathy and herbal remedies (according to a poll of the Guardian, cited in Carter 1996). “Some alternative therapies have gone seriously wrong. A 40-year-old woman was killed in May last year when an acupuncture needle pierced her heart, and in September a 32-year-old Nottingham man died after taking Chinese herbal medicine. Other cases include a man who suffered a fatal stroke following spinal manipulation and two people who died from anaphylaxisa catastrophic allergic reactionafter taking royal jelly. Serious, nonfatal adverse effects have included miscarriages brought on by aromatherapy; autoimmune disease and kidney or liver failure associated with herbal concoctions; and dangerous interactions between patent remedies and prescription drugs“ (Carter 1996).
However, not every forgotten towel in the abdominal cavity is a proof against surgery. Generally, there is a tendency in standard medical journals to stress risks and side effects of CAM (Marcus/Grollman 2002; Smet 2002), although they tend to be less prominent than in orthodox therapy (Ernst 2003a).
The low rate of side effects in CAM is normally attributed to the fact (true or not) that most of the complaints treated by unorthodox methods are not diseases but 'states of reduced well-being' which are responsive to the placebo effect. Therefore little damage can be caused by treating such complaints with 'alternative' methods (Ernst 1993).
The controversy around CAM methods is generally characterized by an extreme low epistemological standard from all sides. Convictions are confused with proofs, arguments appear without context, etc. One reason is that the epistemological standard of medical discourse is freightingly low, in general. Words like placebo are used by persons ignoring all methodological difficulties of RCTs. Suggestibility is a favourite notion from critics ignoring the body/mind confusion (chap. 2.3) and who also do not believe in superstition, that is, that there is a power of ‘mind over matter’ (Bateson 1988: 59-60). There is a lot of inconsistencies in the argumentation on all sides, especially when it comes to efficacy control (chap. 5.7).
One thing, puzzling most scholars and common in many methods of CAM, is the vitalistic approach. In Chinese medicine it is called Chi in homeopathy dynamis. These are expressions for some sort of vital energy inherent in living beings. Vitalism has been regularly criticized and became a sort of an abuse in the scientific discourse.
When Bertalanffy introduced general systems theory, he was well aware that his concepts of equifinality and anamorphism are very close to vitalistic concepts (Bertalanffy 1968: 79). Therefore he stressed again and again that GST has nothing to do with vitalism, maintaining that the principles of GST “are accessible to exact formulation” (Bertalanffy: 86). But all these arguments miss the main point: There is no decisive theory of the living. There are different maps to describe certain processes and characteristics, but they are all of restricted use. Life as such remains an enigma.
Vitalistic concepts, as long as they are seen as a description of an observation, do not contradict any systemic or scientific finding. The problem arises only if the vital energy is seen as causal for living processes. However, neither in Chinese medicine, nor in Hippocratic medicine, nor in homeopathy such causal concepts prevail. It is one of the typical misunderstanding emerging from a linear point of view. Of course, there are a lot of authors who represent a ‘causal vitalism’. But they are already caught in a linear misunderstanding.
On the more general level, vitalism and systemic concepts are fairly similar. And such concepts are, at the moment, far the best we have to conceptualise living processes or processes of disease and health.
Another difficulty for orthodox medicine is that many CAM methods deal with archaic concepts in an unacceptable way. The empirical physiology of acupuncture is such an example. This ‘Chinese physiology’ does not coincide with Western anatomical and physiological knowledge (König/Wancura 1979: 183). And it is impossible to harmonize such different views due to the lack of epistemological tools in Western Medicine. That is, on the basis of a reductionist approach, medicine will not be able to understand other concepts. But it will also not be able to make predictable models of the living. It will not even be able to establish an individual prognosis on scientific grounds.
This section on CAM aims to
- provide better insights concerning current medical problems by translating the “archaic” models into modern concepts,
- demonstrate processes that cannot be conceptualised with the current methodology or are simply overlooked,
- contribute to a more complex and systemic science.
In order to do this. the first step is to use a clear definition of CAM. One definition normally used says that CAM consists of “medical practices which do not conform to the standards of the medical community” (Ernst 1993a). But this definitions creates a highly unsatisfactory situation. It could be a definition for quackery as well. Furthermore, it does not allow to investigate CAM scientifically.
More practical definitions are based on the regulatory principles of the body (Schimmel: 20-21): CAM or naturopathy are methods that influence the inner regulation of the organism, such that the organism is able to develop a better inner balance or a better robustness.
This definition creates a certain paradigm, different from the paradigm of orthodox medicine. Although it excludes some methods of CAM, it gives ground for systematic investigation. Different methods of CAM and orthodox medicine become comparable.
The following review does not aim to present, explain or justify these methods. It aims to demonstrate their epistemological and methodological basis as far as they contribute to the defined purpose.