Conventional and non-conventional medicine and the Placebo Paradox

Alternative medicine is a trendy topic to discuss – both by despising and praising it in a contradictory manner. But there is something controversial in the categorical critique towards it. The controversies and fallacies in the categorical praise are much elaborated and I will mostly leave aside that part.

Firstly, the term “alternative medicine” is very vague in the popular discussion.  The sharpest point in the discussion concerns mostly homeopathy, which is based on the idea of “like cures likes” and preparing remedies by diluting a chosen substance in alcohol or distilled water (a very brief definition). Homeopathy has been repeatedly proven to be a non-scientific method and not having actual effects on patients – for example according to the recent NHMRC review. The review received some critique which is answered for example here.

However, it seems that the discussion about “homeopathy” is often not limited to the “like cures like -diluting” method. Instead, this method, based on a very implausible scientific theory, is mixed with many other categories that belong to the vague area of “alternative medicine”. The latter term is much broader. It can be defined as any practice that is put forward as having the healing effects of medicine, but is not founded on evidence gathered using the scientific method. When looked at the list what can be included to alternative medicine (or complementary medicine, if used together with conventional medical treatment), we find a long list. Examples include -in addition to homeopathy- massage, herbal remedies, exercise, lifestyle counseling, meditation, relaxation, acupuncture, and art therapy.

Labeling exercise, lifestyle counseling, any herbs, relaxation, and massage under the same topic with treatment paradigms based on utmost implausible theoretical backgrounds is problematic. Altogether, criticizing “alternative medicine” in the broad meaning can be seen to imply that any other than strictly biomedical treatment with drugs having clear pharmacological pathways is ineffective pseudoscience. When discussed in the context where homeopathic remedies are offered as the primary answer to severe diseases, the argument is in place. However, used like a blanket, it is problematic.

The critique of alternative medicine, thus, slams – or at least it contributes to a discourse that slams – treatments that have no effective biomedical pathways. However, meanwhile, there is a growing literature on the importance of other than strict biomedical mechanisms in conventional medicine. These effects, that are often called the placebo effect, are brought by a wide range of practices: for example pills, tablets, injections, touch, words, and gestures. There is, for example, strong scientific evidence that cough medicines are not clinically effective, but people still use them and find them effective. “The physician or the patient believes that the treatment is effective, although all available evidence is against it.”

According to physicians Pekka Louhiala and Raimo Puustinen, these psychosomatic effects originating from, for example, good faith, should be strictly separated from the term “placebo” which should be reserved for controls in medical research. Instead, they prefer the term care effect:

When we refer to the phenomena that take place during the consultation and lead to beneficial therapeutic results while the treatment given has no apparent causal connection to the outcome, we suggest that that phenomenon be called, not a placebo effect, but a care effect … A care effect is necessarily present in any therapeutic encounter, providing the patient is not unconscious. Whatever the treatment, the patient is being treated. Thus, when a patient reports subjective responses that cannot be fully explained in terms of the supposed mechanisms of the treatment given, that may be considered to be the effect of being treated or cared for.

And here is the apparent connection with alternative medicine, which often operates with a very holistic approach: “Scientific or no, alternative practitioners tend to express empathy, to allow for unhurried silences, and to ask what meaning patients make of their pain.”

As Louhiala and Puustinen put it,

That is, for all of us, just being acknowledged, heard, understood, assured and comforted can be very alleviating in itself. This can be considered, ultimately, a substantial part of any treatment, irrespective of the care giver’s frame of reference, be it that of a scientifically educated physician, an alternative therapist or an indigenous healer.

As Louhiala and Puustinen maintain, the term placebo has harmful connotations – it is common to refer to these effects as “mere placebo effects” when important psychosomatic effects are at hand, as if these “other” than “biomedical” effects didn’t matter. In other words: it is said that diseases should not be treated with a simplistic and reductionist disease models, and more holistic approaches are needed.

Thus, it seems, that on the on hand, alternative medicine is accused of being based on outcomes without clear biomedical effects, and on the other hand, conventional medicine is being accused of not taking sufficiently account for the outcomes without clear biomedical effects.

How to proceed from this controversy? Surely, the immediate problem is if the proponents of alternative medicine deny that care effect is important in these treatments, argue that conventional treatments to severe diseases should be altogether abandoned, and their methods were as efficient as biomedical means with scientific evidence. Admitting this should not undermine the healing experience that many find from alternative medicine. (By the way: there is something absurd in that western medicine, continuously going more high-tech, is “conventional”, whereas herbs and acupuncture are “non-conventional”)

What comes to (at least to the popular discussion about) “conventional” medicine, better acknowledgement of the care effect is clearly needed. It seems that the power of, for example homeopathy, is not so much in homeopathy, but in the limitations of conventional medicine and health care system with such scarce resources. What if the GP gave an hour to the patient asking questions about her life, mood, and feelings? It might be that if practitioners of homeopathy were put under the same pressure of efficiency that GPs are, homeopathy would work no longer for anyone.

Furthermore, it could be said that drugs based on mostly care effect (that have no harmful side effects, of course) are unproblematic. If cough medicine or many other drugs are needed to create the psychosomatic effect, we should have them if needed. Who cares where the effect came if it works? (And why do we think that taking cough medicine is rational but “alternative” herbs irrational?) However, there is something disturbing about the idea of pharmaceutical companies making huge profits out of care effect. But then again, pharmaceutical companies are hardly the only companies that profit from psychosomatic feelings. Would the important care effect work if the pill was not made by pharmaceutical industry? Furthermore, harmful side effects are often present.

Maybe the important point is that all treatments that are “alternative medicine” should not be straightforwardly labelled as humbug. The care effect that is produced by any treatment is valuable and might have significant meaning to many patients. Still, yet perhaps even more important is to keep in mind that the care effect is only a part of treatment. It might be possible that some alternative treatments might have the “real effect”, or at least that cannot be falsified. Just as some pills are not better because they are “natural”, they are not better if they are synthetical. However, offering herbs or baking soda to cancer patients as the primary treatment and encouraging patients away from biomedical treatments is just irresponsible.

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