Philosophy of Naturopathic Medicine seminar for advanced naturopathic students or practitioners David Nortman, N.D. © 2004-2005 David Nortman – www.metamedicine.com Motivation behind the project Personal background: Studied sciences, found them too specialised so switched to philosophy. Found philosophy courses much more relevant to life. I envisioned naturopathic medicine as a practically useful combination of philosophical thinking with scientific thinking. At CCNM many fellow students were excited about philosophical discussions and wished that more time were devoted to it. There were two reasons for the lack of philosophical discussion: Lack of time due to volume of „more important‟ material to be covered. Lack of structure to the philosophical discussion: typically, discussions had a promising start but stalled shortly after. The questions that life in the profession leads us to ask cannot be answered with the tools of the profession alone. The evolving nature of naturopathic medicine The philosophical questions arising in naturopathic medicine are very fundamental and require the tools of philosophy to address them. Early naturopathic philosophy was adequate for providing a world view to make sense of Nature Cure and the related hygienic approaches that characterised the profession 100 years ago. It has since become outdated, mainly but not exclusively because of: The growing application of modern research methods and scientific ideals. The inclusion of homeopathy and other psychological methods. The inclusion of TCM and other energetic methods. Naturopathic philosophy needs to be continually nurtured in order to remain a living aspect of clinical practice. Will studying philosophy make a difference? On the level of personal practice style, possibly not. On the level of the direction of the profession toward greater scientific rigor vs. greater methodological independence from scientific medicine, philosophy is a crucial undertaking. Its main contribution is in making what we do implicitly (intuitively) more verbally explicit and thus more easily communicable. The ephemeral nature of naturopathic medicine Insofar as we learn the basic principles of naturopathic medicine, we learn them as historical facts rather than as living ideas. This lack of creativity has consequences for the unity of the profession as well as for its future. If we rely on a naturopathic philosophy that, for all its strengths, is as lean as a corporate mission statement then our fate will be determined by outside forces. Specifically, the popularity or public support of naturopathic medicine will depend on fashion rather than on the intrinsic truth of the profession – unless we are able to describe our methods to others in our own terms. The popularity of naturopathic medicine We are currently riding on a wave of environmentalism (return to nature…vis medicatrix naturae), abandonment of traditional values (the status of the doctor in society… doctor as teacher), belief in complexity (chaos theory…discovering the fundamental causes of disease), individual expression and self-discovery (spiritual healing…individualisation). What if the resurgence of naturopathic medicine is simply a consequence of the popularity of these ideas in the public imagination? If so, what will happen when these ideas are no longer current? The current danger On the negative side, the popularity of evidence-based medicine and public accountability of the medical profession leaves our profession vulnerable to the influence of modern medicine and its methods. The profession‟s integrity, unique identity, clinical results, and very survival are at stake. At the same time we need to consider adopting some of those methods as part of a necessary drive toward increased standardization, due to the need to maintain the stability of the system as it grows. Because most scientists believe that they are automatically on good philosophical ground – science is, after all, an island of truth in a sea of error and superstition – it is now more important than ever to engage in independent philosophical thinking. The eclectic nature of naturopathic medicine Naturopathic medicine in actual clinical reality is an eclectic profession: On a practical level we have several systems. On the theoretical level we have several paradigms. The existing naturopathic principles provide an excellent framework for the formulation of more specific rules. These principles are like a nation‟s constitution: what I propose as the philosophy of naturopathic medicine is more like a nation‟s everyday rules and regulations. Currently the rules are vastly different in different spheres of the profession; greater unity is desirable. The fundamental question of the philosophy of naturopathic medicine Is there a unifying paradigm of naturopathic medicine, or is it rather an umbrella term for several systems, each with its own paradigm, which have come part way together through historical accident? If there is one, what is this paradigm? Possible answers “No, there isn‟t”: This reflects the present situation. It is easy to identify several contradictory paradigms within naturopathic medicine. “Yes, there is, and it is…”: Philosophical work is required in order to give substance to the answer. This is the goal of the project which I‟m proposing. The philosophical approach is idealistic: it assumes that naturopathic medicine should be not just a medical movement but the leading medical paradigm – that ultimately it is not alternative or complementary medicine, but medicine in the normative (prescriptive) sense. At the same time the paradigm must allow for diversity to adapt to the infinite variety of human situations encountered in medicine, or else it risks becoming triumphalist and exclusionary. Goals of the seminar To demonstrate that differences of opinion in naturopathic medicine can systematically be reduced to differences in basic philosophical outlook or world view. To provide critical philosophical tools that can be applied to the real world of naturopathic medicine and beyond. To show that philosophy is not an impersonal, dispassionate, and frustrating pursuit of questions which have no answers but is a rewarding and personally engaging search for knowable truth. Academic disciplines in pre-modern society Whatever its inadequacies, ancient thought was usually concerned with the whole of reality. Ancient thinkers and the great philosophers and scientists up until the Enlightenment almost invariably dealt with the perennial questions such as the nature of the physical universe, god(s), life after death, and morality. Universities first appeared in later medieval Europe as a place for studying the whole of reality through the then-current paradigm of Aristotelian Christianity. When this paradigm was challenged during the Renaissance the search for an alternate, allencompassing truth nevertheless continued. Major breakthroughs in mathematics, physics, and technology eventually persuaded people to adopt the methodology of those sciences to the investigation of reality at large. Academic disciplines in modern society By the early 19th century the ideal of specialisation became dominant. Universities were made up of many departments that didn‟t communicate with each other, and academics commonly believed that the methods of competing disciplines were invalid. Ever since then the university has been producing progressively more narrow-minded experts with an increasingly precise view of their subject matter but decreasing awareness that there is a whole to which their part belongs. Philosophy by its nature is concerned with the whole, with capturing the common denominator of all reality. But in the modern context philosophy has become a specialty just like any other, mostly ignored by other disciplines, and so its relevance has diminished accordingly. Structure of this seminar The seminar is based in structure and much content on a philosophy course I took in university: “Metaphysics and Epistemology” with Prof. Michael Vertin (St. Michael‟s College, University of Toronto). The course was premised on the notion that disagreement on the nature of truth in a wide range of academic disciplines – diverse fields such as physics, politics, and ethics – could be reduced to basic differences in philosophical outlook. These differences were in almost all cases implicit or unconscious: they had to do not with disagreement about observations (data, evidence) but with the inevitable philosophical baggage that the different parties brought to the discussion. Structure of this seminar Essentially, the parties to the dispute were talking in different languages. Philosophy is the lingua franca of rational thinking. It can be used in place of the language of the academic discipline where people find themselves talking in different languages. Philosophy can be used to make explicit the implicit pre-empirical presuppositions that structure people’s interpretation of data. The three basic questions of philosophy 1. 2. 3. „Cognitional theory‟: “What am I doing when I apparently come to know something?” „Epistemology’: “Does doing that ever constitute genuine knowledge?” ‘Metaphysics’: “What is the structure of the reality that I thereby apprehend?” (Bernard Lonergan) Data of sense vs. data of consciousness Western philosophy has traditionally relied on data of sense (evidence from the world around us) when investigating reality. The innovation in our methodology is in including the first question which forces each of us to ask oneself: “What am I doing when I apparently come to know something?” This involves accessing data of our own consciousness – somewhat like in Eastern philosophy – whenever making philosophical claims. Logical contradiction vs. behavioural selfcontradiction Traditionally philosophers used logic to determine whether a philosophical claim made sense. (Example: “This is a large square” vs. “This is a square circle.”) Attending to the data of our own consciousness allows us to use a new category of behavioural selfcontradiction to rule out impossible claims. This is not a (logical) contradiction in what I say contradiction but a contradiction between my claim and my behaviour while making the claim. (Example: “I am completely unconscious.”) The six basic families of world views F1: „Experiential Realism‟ F2: „Intuitive Realism‟ F3: „Subjective Agnosticism‟ F4: „Objective Relativism‟ F5: „Decisional Realism‟ F6: „Transcendental Realism‟ The two senses of ‘subjective’ and ‘objective’ These two terms are very commonly used in two senses: In the first sense „subjective‟ simply means „pertaining to a subject‟, „objective‟ means „pertaining to an object‟. In the second sense „subjective‟ is taken to mean „inadequate, possibly true, limited in perspective‟ and „objective‟ means „reliable, likely true, absolute‟. The two senses are often confounded, so that a subjective statement in the first sense is seen as inadequate, and an objective statement in the first sense is seen as valid. Applying philosophy to medicine Following is a sampling of the issues relevant to naturopathic medicine that can be addressed with the tools of philosophy. Many of the disagreements within the naturopathic profession are not new to it, but are simply yet another instance of age-old philosophical disagreements that can be addressed using the methods mentioned earlier. The philosophical complexity of naturopathic medicine There are two dominant streams in naturopathic medicine: the traditional and the scientific. There are additional broad divisions along the lines of energetic-hygienic, psychological-physiological, etc. Complicating matters is the fact that there are divisions within each modality along similar lines. Finally, it is often difficult to give generalised answers to questions about naturopathic medicine, because the clinical encounter is inevitably concrete and the number of variables indefinite. Example: The mind-body problem and the nature of pain The mind-body problem is a recurrent theme in western philosophy. In naturopathic medicine the same issue is often cast in terms of the existence and nature of the vital force. Most discussions of this problem are variations of the prevalent dualistic view of the physical and psychological realms of reality. There are, however, other relevant views. Our answer to the question has direct clinical relevance e.g. in the case of pain with no reasonable organic cause: Do we reject the reality of the pain: “It‟s only in your head!”? Do we keep looking for a physical cause (albeit taking a broader perspective than orthodox medicine), convinced that it must be there? Do we claim that the mind causes pain in the body? Do we regard the pain as real simply because the patient feels it? The mind-body problem and the nature of pain Descartes believed that pain was the result of bodily alterations mechanically communicated from the periphery to the mind („peripheralist‟ view). This view of pain permeates virtually all research into pain both in conventional and alternative medicine. The differences lies only in the methods used to subdue the pain. In contrast, a „centralist‟ view regards pain as formed in the mind with contributions from the person‟s overall makeup, including past, present, and possible-future perceptions of any sort. Under this model a physical pain is not fundamentally different from a psychological pain; the two may even be considered one and the same. We may therefore postulate a level at which the pain exists that lies beyond both the physical and the psychological realms. Empiricism and Hume’s ‘problem of induction’ We often say that naturopathic medicine has an empiricist orientation while orthodox medicine is rationalist. But it is important to know that empiricism is also associated with the notion of trusting only the evidence directly available from the senses, due to the impossibility of trusting induction to extrapolate from a limited set of data to a generalised law of nature (this is known as „Hume‟s problem of induction‟). This sort of empiricism unfortunately has little room for naturopathic medicine, with its reliance on concepts such as „vital force‟, „Qi‟, and on anecdotal evidence. Prominent 20th-century philosophies of science The following philosophies of science, dominant in the 20th century, represent the full spectrum of beliefs about scientific methodology: Logical positivism: That the only meaningful claims are ones that can be directly verified with the senses. Extreme yet very influential view. Popper‟s criterion of falsifiability: Scientific theories are ones that can be falsified rather than ones that can be proven true. Kuhn‟s paradigm concept: The most prominent „externalist‟ view describing influences beyond the scientific method on the practice of science. Sharp demarcation between competing world views with little chance of inter-paradigm dialogue. Feyerabend‟s anarchic „method‟: Iconoclastic view of science as strictly a product of who-knows-whom, who-sleeps-with-whom, whohas-power, who-is-popular. The scientific method is mere after-thefact storytelling made up to satisfy our desire for order and security. Statistical inference: applying group data to individuals Applying group data to individuals is valid only if we assume that the individual is identical in all relevant respects to the group. This is matter-of-course in a Platonist world view where concrete beings are real only insofar as they measure up to an abstract standard: there is fundamentally no difference between one case of colon cancer and the next – diagnosis is the same, treatment is the same, and all differences can safely be ignored. Other world views do not allow such simplification, and claim that statistical data provides only crude information: Diagnostically, statistics merely categorises and labels. Treatment-wise, it is inappropriate and irresponsible to apply statistical data to individuals. The nature of clinical skill Should naturopathic clinicians rely on their and others‟ experience, or learn to apply research data with expertise? Can a physician be successful acting strictly as physician (i.e. with only anecdotal evidence and experience)? Or is a good physician a good medical scientist who can be successful mainly through applying group (statistical) research data? This brings up the fundamental question of the nature of medicine: Is medicine a craft (autonomous discipline with its own principles, borrowing from outside itself when necessary) or a science (the skill of applying clinically the findings of the medical sciences)? Money and politics in medicine Is the expense of high-standard research a practical problem ideally to be overcome or a fundamental flaw? Can money, political clout, popularity of an approach, etc. be used to manufacture truth? If so, are methods requiring money, political and public support, etc. contrary to the spirit of medicine? Further, if medicine is properly to be concerned with achieving freedom and self-sustaining vitality for the planet‟s population at large, should expensive methods be encouraged because of their benefits (which are at times undeniable) or shunned because they are fundamentally contrary to the long-term goals of medicine? This has direct implications on evidence-based medicine and on the vaccination debate: Can evidence for and against vaccines be compared on even ground? Are we talking evidence-based medicine or biased-evidence medicine? The Randomised Controlled Trial as the ‘gold-standard’ of evidence Is it in principle possible or desirable to have such a standard? Why is anecdotal evidence considered inferior to research data? A proposed way of combining the virtues of large studies with the virtues of anecdotal evidence: Clinical outcome studies: the new gold-standard of evidence? But this overturns the rationalist mentality of orthodox medicine on its head, as placebo healing can no longer be distinguished from scientifically explicable phenomena. Worse, it is accepted as a medically valid mechanism of action! Whatever standard we choose, is it cheap enough or will it be subject to the rules of the game imposed by money, politics, etc.? Defining the placebo effect There are several distinct notions of the placebo effect, which should not be mixed up: Medical anomaly: Any case of healing that doesn‟t fit into the current paradigm is considered to be „due to placebo‟. (So can clinical evidence ever challenge medical theories?) Therapeutic effect produced by a biomedically inert substance. (But what is a „biomedically active‟ substance?) Non-specific effect of therapy – i.e. not corresponding with the mechanism of action. (But is the validity of a proposed mechanism of action relevant to evaluating the clinical results?) What all treatments have in common. (So should we harness the effect or dismiss it as trivial?) The value of laboratory investigation The use of results from laboratory tests is a fastgrowing part of both orthodox and naturopathic medicine. Apart from the obvious advantage of gathering data otherwise unavailable, some problems include: Decline in clinical diagnostic skills due to reliance on technology. (This is already happening in orthodox medicine.) What are we treating: the person as living being or the person as biochemical mechanism? Is it necessary to know information that will not influence the choice of treatment? This depends on whether or not we think physicians should double as medical scientists. Classification of disease This is arguably the single most important issue in medicine, because the way disease is conceptualised influences all subsequent thinking and treatment. Even in naturopathic medicine we usually accept the western classification of disease uncritically: we have Grand Rounds about Hypertension, studies about Heart Disease, etc. But why not study „Liver Qi stagnation‟, „Phosphorus state‟, „xenoestrogen disease‟, „chlorinated-water bowel dysbiosis‟? Whether we accept such alternative classifications will depend on our beliefs about the nature of categories: are they absolute, determinable by scientific methods, or do they depend on clinical perspective? Can categories exist outside to the clinical encounter or do they take form and exist only within the clinical encounter? Sharpening the definitions of existing naturopathic terms Much of the criticism of naturopathic medicine is a result of vague definitions of the major concepts: „Natural‟: „of natural origin‟ or „in line with the natural laws of healing‟? The two senses sometimes correspond but this doesn‟t warrant fudging them in case they don‟t. „Holistic‟: is a vague and trivial concept in its current form. Every health-care practitioner will claim to be treating the whole person as conceived within a certain paradigm. The underlying question is: What is a (human) being? …so a definition of „holistic‟ is of little use unless it is coupled with a clear definition of (human) nature. Do we want to maintain the current notion of science and claim that naturopathic medicine is not a science but an art/craft; or: Do we want to expand the notion of what is science in order to be able to maintain that naturopathic medicine is scientific? „Scientific‟: Causality in medicine Usually people talk of causes in terms of „necessary‟ and „sufficient‟. This is useful when we are looking for a single cause among a few possibilities, but insufficient when dealing with multiple concurrent causes as in virtually all disease. In such a scenario a better way of analysing causes is to choose the „most relevant cause‟ (relative to given clinical situation) from a within „causal matrix‟. Determining this is the most important step of diagnosis. Developing naturopathic methods Finally, we can use the tools of philosophy to come up with methods to guide us through history taking, diagnosis, and treatment. Most importantly, these methods can be used to help us decide which modality to apply under which conditions. These methods should be checked for validity by using the tools of philosophy. Example 1: Therapeutic order of the healing process (according to Jared Zeff, ND) 1. Identify and moderate disturbing factors: Spiritual (interaction with the person); Mental/emotional; Physical (principally toxemia). 2. 3. Correct regimen (diet, exercise, etc.). Stimulate vital force (homeopathy, exercise, constitutional hydrotherapy). Most people start feeling better by this point. 4. 5. 6. Address specific systems (often with botanicals). Correct structural imbalances. Address pathology directly if still necessary (i.e. if the body hasn‟t healed itself by now). Biggest mistake is to begin here instead of doing 1-5 above first. 7. May need to suppress the pathology in order to save life of organs/systems. Example 2: The levels of experience of disease (according to Rajan Sankaran) Patients and practitioners perceive disease on one or more of several levels: Name of disease (Western diagnosis) Signs and symptoms Emotions Delusions, symbols, metaphors „Vital sensation‟ Non-verbal manifestations of energy (body movement, qi flow, shen, chakras, etc.) It is useful to diagnose the patient on all levels. The naturopathic modalities can be mapped on this spectrum. Each has its strengths and weaknesses, and it is possible that greatest therapeutic benefit will occur whenever patient experience and the primary perspective of the modality line up. Participating in the seminar As a regular participant you will need to prepare by reading the assigned material weekly. You can also access the material by referring to the website www.metamedicine.com. I intend to post lecture notes alongside the readings at some point, possibly this summer, though I will likely have at least an outline available soon after each session.
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