alternative medicine, what should we think about it? (1/3)

If you already think you know everything about alternative medicine, this three-part survey may surprise you. Let's dive together into the wonderful world of these particular therapies. First step: knowing how to differentiate between conventional and alternative medicine. Is it that simple? Nothing is less sure…

The notes indicated by a number in brackets are to be found at the end of the article.

Do you really know how to differentiate the so-called alternative medicine from scientific medicine? Do you really know why individuals consult these so-called alternative therapists and the problems that these practices can pose? We will try to answer all these questions in the first and second part of the survey. Also, in the third and last part we will ask ourselves what place can they have within our society.

But before we start, a few clarifications. This investigation is not written in order to be hostile to therapies say alternatives or be complacent with so-called conventional medicine (1). Its main objective is to transmit elements of understanding to all those who want to know more about it. As a precaution, we wish you a good read.

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Any practice that treats any disease is part of medicine. The problem is therefore posed on the nature of care. "What is healing? Allows defining medicine. © chamillew, Adobe Stock

Are there several medicines?

The idea of ​​alternative medicine suggests that there are several medicines. But this medical plurality can quickly be undermined by a simple argument: what is the aim of the discipline called medicine? Treat. Therefore, any practice that treats any disease is part of medicine. Thus, the debate takes root on how do we know that a practice heals. Here, the problem is therefore posed on the nature of the treatment. "What is healing? Allows defining medicine.

Treat, as the oath ofHippocrates that any doctor swears to respect is first of all to do no harm or according to the Latin formula "Primum non nocere". A medical care is defined in several ways according to the affection of the individual and our knowledge.

  • If we know the cause that causes a condition pathological, the aim will be to remove the cause which causes symptoms. A bacterial infection treated with antibiotics, for example. We note that this supposes that we have therapeutic methods (medicinal, behavioral, surgical, etc.) which we know do more good than harm. This is called the benefit-risk balance.

  • If only the symptoms are known to us, the aim of the treatment will be to reduce the occurrence and / or intensity of the symptoms by gauging the benefit-risk balance of the care provided. For example, anti-inflammatory during painful periods. Obviously in parallel, medical research will continue to ask what are the possible causes of symptoms to better respond to the disease in the future.

Roughly and in a worry to generalize the subject, the care must bring as much as possible, the return of the pathological state to the normal state (2). Therefore, to treat, one must already identify what a pathological condition is. Then, it is necessary to find an adequate method which allows the return to the normal state by bringing to the patients more benefits than risks. The benefit-risk balance is essential in the act of treatment. Without carefully measuring it (3), the doctor potentially exposes his patient to a risk greater than the benefit he wishes to bring to him.

How do we know that we are treating?

Intuition and feeling are bad compasses to tell us if we are really sick (4) and if a therapeutic practice confers more benefits than risks. We will not dwell on the definition of the pathological state starting from the postulate that there is consensus in its definition in scientific medicine as an alternative, which in reality is not exactly the case. This is to better focus on the evidence required to identify if a practice can be qualified as therapeutic care.

To produce such evidence, we need as objective evidence and facts as possible, which support the safety (or dangerousness) and effectiveness (or ineffectiveness) of a treatment. This reflection gradually led to the creation ofEvidence Based Medicine (EBM) or evidence-based medicine (5), of which an article of the magazine The Lancet dating from 2017 gives a good definition: “The first principle of EBM is that not all evidence is created equal and that the practice of medicine must be based on the best available evidence. The second principle subscribes to the philosophical view that the search for the truth is best done by assessing the totality of the evidence and not by selecting evidence that favors a particular claim. However, evidence is necessary but not sufficient for effective decision making, which must address the important consequences for the decision maker in the given environment and context. Thus, the third principle of EBM is that clinical decision-making requires taking into account patients' values ​​and preferences ”. This definition is, to our knowledge, unanimous in the world of modern medicine (6).

How to differentiate modern medicine and alternative medicine?

If there is consensus on the definition of scientific medicine, we all have, in the corner of our heads, one or more criteria that differentiate between what comes under modern medicine and what comes under alternative medicine. Here are some testimonials that we have collected. They are to be taken as such and only reflect the thoughts of the individuals interviewed.

"For me, these are non-Western medical practices to treat", says Sébastien. The geographic criterion can serve as a distinction in the minds of individuals. However, thehomeopathy, which is considered an alternative medicine, is a doctrine of European origin. It is therefore not a good criterion for discrimination.

"It is a person who dispenses an action for therapeutic purposes who has no legal medical training", says Manuel. The legislative Review can also serve as a distinction within the general population. However, there are homeopathic doctors, acupuncturists and osteopaths. People with legal medical training therefore provide care considered as alternative. So it's not a good criteria either.

Other interviewees believe that these are "Practices that are not recognized by the Academy of Medicine" or "Not recognized by the Ministry of Health" or "Whose diplomas allowing to practice are not recognized by the State". The authority criterion allows individuals to classify therapies in the “alternative” box. It is a fairly good criterion of distinction in absolute terms. However, he suffers from a major problem; it does not make it possible to understand why a practice X is considered to be conventional while a practice Y is considered to be an alternative.

The reimbursement criterion is also present in the collective imagination. Some believe that alternative therapy is "A practice that uses care not reimbursed by Social Security". From then on, we remember that homeopathy is always reimbursed up to 15% until 2021 (even if, at the outset, its reimbursement is a political decision more than health), while consultations on dietetics or clinical psychology are not. This criterion is therefore not a good differentiation criterion.

Finally, some interviewees consider that “Alternative therapies are practices that are based on a non-scientific theoretical corpus and whose effectiveness has never been demonstrated scientifically”.

The two major distinction criteria

These are the two criteria that Albin Guillaud, author of a thesis titled "Describe and explain the use of alternative therapists in France", selected to distinguish between conventional and alternative therapies. These two pillars are fundamental to distinguish an alternative therapy from a scientific therapy. The rest being just clues heuristics (7). In the majority of cases, these intuitive criteria work, but as we have just seen, they are not foolproof. The questions therefore arise: what is valid proof of clinical efficacy and what is a scientific theoretical corpus? Because to start well, this is where we must center the debate, at the risk of getting lost in unnecessary considerations later.

Draw me…

  • evidence of clinical efficacy

Let’s start with valid clinical efficacy evidence as we will need it to define the theoretical corpus. The idea when you want to know the effectiveness of a therapy is to rule out anything that could have a negative or beneficial effect on the patient in addition to the therapy you are testing. Thanks to the study of the human psyche, we know that contextual effects (which include the effect placebo and thenocebo effect) play a role in the healing / worsening and feeling of well-being / ill-being of patients. Likewise, with the help of our knowledge in human biology, we know that our organism has the capacity to fight itself against diseases and sometimes to heal without treatment. Finally, we also know that factors specific to individuals such as age, sex, lifestyle, etc. have an important place in theequation healing / worsening or perceived well-being / discomfort.

When one understands this, one can then sketch out what will be a valid proof of clinical efficacy. A valid proof of clinical efficacy is when several experiments measure (using clinical criteria, markers diagnostic, Scales of feelings, etc.), thanks to a methodology of their own (8), that the care provided to the patient brings more benefits than risks – that is to say, that he treats – which cannot be explained neither by contextual effects nor by the healing spontaneous, nor by individual factors. It is easy to understand why the personal experiences of a patient or a doctor, often brandished by practitioners and supporters of alternative medicine, cannot be considered as evidence. solid. Simply because what follows a phenomenon is not necessarily the cause of the latter in an uncontrolled complex environment. It goes without saying that we would all like a more individualized medicine which could measure all the factors specific to the patient (its genetic, his microbiota, all of the interactions betweenhost and the environment, etc.). For the time being, modern medicine does not have sufficiently powerful tools to achieve this. And contrary to what they try to make believe, it is not the case of the alternative therapies either. Their only tools are intuition and " natural laws " devoid of scientific theoretical corpus erected in dogmas.

  • a scientific theoretical corpus

This leads us to wonder what a scientific theoretical corpus is. We could define it as a set of laws, hypotheses and experiences that represents knowledge, because they have proven themselves over time and have generally made it possible to produce other knowledge. Very roughly, in medicine, the scientific theoretical corpus, this will be all that we know in the field of physical, of the chemistry, biology,anatomy, physiopathology, etc. All these fields include statements about the real world which are, for the moment, the best representation we have of the latter.

When a therapy is supposed to act on a cellular receptor, we know what we are talking about and we know how to Review and measure this action. Conversely, when a therapy is supposed to act on energetic points we do what is called a metaphysical postulate (9). This goes completely against the principle of intellectual parsimony that we seek to respect in science. The idea is that as little as you need to explain the most with the least. It is when we can no longer explain a phenomenon with all that we already know, that we can try to build other theoretical scientific corpora and that we generally witness scientific revolutions (10).

To conclude

To summarize and conclude on this first part, a therapy which is not based on what we currently know about physics, chemistry and biology (homeopathy, magnetism, acupuncture, etc.) and which, on top of that, does not show any specific efficacy (homeopathy) or a mixed efficacy which can be explained by what is already known (contextual effects, confounding factors, spontaneous healing) and which for as much needs to add metaphysical entities (the energies in acupuncture), can be considered an alternative medicine.

Finally, we will specify, for the sake of impartiality, that modern medicine, if it is based only on well-established scientific corpora, is not totally devoid of practices which have no inherent efficacy or which lead to patients more risks than benefits. This is what gives rise to health scandals. It is also, until recently, the use of antibiotics to treat viral infections or over-medication. All this does not enter into our concept of alternative medicine, even if it would be desirable to integrate it. After all, having an alternative use of data acquired from science does not respect the rules of EBM. It is the role of the doctor to scrupulously respect these data for treatment (11). These problems are at the heart of major health issues. However, unlike its alternative counterparts, scientific medicine generally has no preference for one treatment or another. Also, she knows how to say that she does not know and integrates into her practice what heals as we defined it at the light evidence she has. In short, she tries at best to clean up in front of her door.

We will meet again Wednesday for the second part of this survey where we will talk about the numbers of attendance at alternative therapies, the causes that push individuals to use these therapies and the problems, sometimes serious, that this can cause.

Notes and sources:

(1): Modern, conventional or classical medicine will be the terms used as synonyms in the article.

(2): On this subject the curious reader will get the work of Georges Canguilhem: "Normal and pathological", which deals specifically with the definition of these two states.

(3): Here, there remains a problem of definition from which we extract ourselves by taking the return from the normal state to the pathological state as absolute criterion. Benefit and risk are to be defined individually and collectively. This therefore changes according to the values ​​that we set at the start. But let's leave this reflection aside.

(4): We are not talking about the feeling of symptoms, which is the basis of a medical consultation, but rather the feeling of a disease or an imbalance without symptoms or diagnostic marker established by a patient or a practitioner.

(5): Care must be taken not to understand the word proof as a fixed and definitive base. The sciences and therefore by association, the medical sciences, are constantly evolving in the face of new "evidence".

(6): Scientific medicine echoes an ideal of modern medicine. Modern medicine tends to want to be always more scientific and based on the best evidence that the scientific method allows us to acquire.

(7): That is to say useful information for our mental shortcuts which work by association of ideas, in order to identify what belongs to modern / alternative medicine more quickly than by making the effort of us address the substance of the matter.

(8): The methodology of clinical tests whose explanation you can find in text or in video series.

(9): There is no measurable physical evidence of the existence of energies. The latter are ill-defined (not to say not defined) in the context of alternative medicines. Therefore, to consider their existence is to bet on the existence of an entity beyond the physical world known until then. Conversely, the exercise of science is based on a methodological materialism.

(10): On this subject, the curious reader will be able to obtain the work of the philosopher of sciences Thomas Khun " The structure of scientific revolutions ".

(11): Article 8 of the medical code of ethics (article R.4127-8 of the public health code): " Within the limits set by law and taking into account the data acquired from science, the doctor is free to prescribe which will be those which he considers most appropriate in the circumstances. He must, without neglecting his duty of moral assistance, limit his prescriptions and his acts to what is necessary for the quality, safety and efficiency of care. He must take into account the advantages, disadvantages and consequences of the various possible investigations and therapies. "

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