Social History

Healing is a profoundly cultural activity. The very act of labeling a disease and prescribing treatment expresses a healer's commitment to a particular set of assumptions about the nature and structure of reality. These assumptions not only help specify the agents thought to cause disease but also contain implicit understandings of what health optimally or normatively enables humans to do. Because rival medical systems typically subscribe to differing philosophical and cultural outlooks, the notion of orthodoxy pertains to medicine as surely as it does to religion or politics. What makes a therapy "orthodox" is its adherence to a belief system that, for intellectual and sociological reasons, informs the practice of the dominant members of a culture's medical delivery system. A therapy is therefore "unorthodox" to the extent that its diagnoses and treatments are not deemed legitimate by the dominant belief system.

The philosophical and professional differences that separate orthodox and unorthodox therapies give rise to complex ethical questions. How, for example, are we to understand medical "legitimacy," when this notion is the product of ever-changing philosophical, cultural, and social factors? What does it mean for a medical treatment to be unethical? Must it in some way bring about negative results, or is it unethical even if it is—such as vitamin placebo treatment—merely a harmless fraud? What constitutes a therapeutic benefit? Is it an improvement in physical, mental, or spiritual well-being?

First, the sheer diversity of alternative therapies hampers attempts to generalize about the kinds of ethical issues that unorthodox treatments present. There is an almost bewildering array of alternative therapies, ranging from chiropractic, osteopathy, and acupuncture, to shiatsu, herbal medicine, and religious faith healing. Further complicating this task is the fact that these alternative therapies find themselves labeled unorthodox for quite different reasons. Some, for example, are practiced by healers committed to an alternative belief system or worldview that grants reality to causal forces that differ greatly from those specified by medical orthodoxy. Such is the case with various "faith healing" traditions and New Age medical systems. Religious therapies such as these invoke an overtly metaphysical explanation of the causes of physical illness and depict human health in terms of adherence to specific spiritual or ethical outlooks on life.

Second, healing systems may become unorthodox when they employ therapies that, although predicated upon the consensus worldview, have not yet been validated or confirmed as efficacious by orthodox medical standards. Many of the treatments suggested for combating cancer or acquired immunodeficiency syndrome (AIDS) are considered unorthodox for this reason. Third, healers find themselves outside the medical mainstream when they provide services that are typically ignored or deemed of secondary importance by a culture's dominant medical practitioners. This has been the case, for example, with dentists in the nineteenth century, podiatrists in the early twentieth century, and midwives throughout most of modern history. The case of midwifery is instructive. While never as widespread in the United States as in other parts of the world, the use of midwives provided the only obstetrical assistance available to many women until early in the twentieth century. As obstetrics became a recognized medical specialty, primarily under the control of male physicians, hospitals equipped with surgical facilities supplanted the home as the normal site for giving birth. Increasingly the last resort of those who could not afford hospital births, midwifery generally fell into disrepute. Midwifery, then, became an "unorthodox" form of medical care not because it employed an alternative worldview or because it could not be validated as a treatment, but because the dominant providers of medical services decided that the home and the assistance of other women at childbirth were not of primary importance. Interestingly, midwifery has witnessed a modest resurgence in recent decades as part of a general cultural trend toward "natural" medicine and woman-centered healthcare. Nurse-midwives perform about 2 percent of all deliveries in the United States, and more than a dozen universities offer certification programs for midwives.

What alternative therapies have in common is economic, legal, and cultural disenfranchisement from the socially empowered institution of scientific medicine. Any attempt to reflect upon the ethical questions raised by these "alternative" approaches to healing requires sensitivity to the historical and philosophical roots of this disenfranchise-ment. "Regular" physicians coalesced into state and local medical societies during the nineteenth century, securing an institutional power base for what was to become medical orthodoxy in the United States. This emerging corps of physicians shared a more or less common approach to medical practice and were eventually able to "institutionalize" this approach through the influence they exerted over licensure laws enacted by state and federal governments, the accreditation of medical schools, and access to technologically equipped hospitals. The American Medical Association (AMA) (founded in 1847, but lacking strong organization and sufficient membership until the early twentieth century) eventually succeeded in organizing and promoting the interests of the nation's dominant medical practitioners on a national level.

Medical orthodoxy aligned itself with the worldview spawned by the Western scientific tradition. Its approach to therapeutic intervention has been firmly rooted in the evolving body of information that has emerged from advances in physiology, chemistry, and pharmacology. Accompanying this reliance upon the Western scientific tradition has been an implicit endorsement of a secularist and rationalist ontology (i.e., a worldview skeptical of claims concerning the supernatural or other unquantifiable influences). What has given scientific medicine its "public" character is its insistence that theories concerning the etiology and treatment of disease specify physical, as opposed to spiritual or metaphysical, causal forces. Its theories and strategies for therapeutic intervention are thus more susceptible to empirical verification, and disputes can at least potentially be resolved by an appeal to observable and quantifiable sets of data. This is also why scientific medicine found itself more amenable than many of its alternative counterparts to the economic and legal institutions of modern Western governments. Rejecting the "private" claims to truth made in religious arguments, Western democracies have required that all civic discourse be advanced according to rational and public grounds of argumentation.

To the extent that scientific medicine's academic and experimental foundations facilitate such "public" argumentation, it has largely merited its enfranchisement within the legal and economic institutions that make judgments about the allocation of medical resources. Any consideration of the ethical status of these judgments and their effect upon the practice of alternative medical systems must take into account the important role that such rational and public discourse has had in the development of Western culture.

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