Policing the Boundaries of Medicine

To hear some of my scientist friends explain it, contemporary medicine is threatened by a tidal wave of pseudoscientific, quackish alternative practices. That narrative has always struck me as a bit of an overreaction. Even though a non-negligible percentage of people have forgone vaccines for their children and many regularly use supplements that run the gamut from the relatively harmless to the risky, the vast majority of people go see a regular doctor when they're ill. So what has some advocates of mainstream medicine in a dither? Why are they so intent on making mountains out of these molehills? 

Consider a recent article "Acupuncture Still Doesn't Work." Its author, a self-identified epidemiologist named Gid M-K, exerts considerable effort in order to try to twist a recent study into yet another mark against the ostensible scourge of acupuncturists. His argument is, in turn, based on a recent study evaluating the benefits of acupuncture for acute pain: namely,  that of people coming to an emergency room for low back pain, ankle sprains, and migraines. Despite the fact that the authors of that study themselves conclude that acupuncture is comparable in efficacy to drugs, except for migraines, and also cite studies that conclude that acupuncture is more effective than sham treatments, Gid ends his piece with the claim that "acupuncture works no better than placebo. This has been shown time and again in studies from all over the world. There’s no reason to believe that it should work, and when you test it with robust evidence, it doesn’t."

One doesn't have to be scientist themselves to recognize that such a large discrepancy between the evidence an author cites and their conclusions is demonstrative of something other than solid scientific thinking. Yet such flaws in reasoning are quite common among those, including scientists, involved in the science-pseudoscience debate. One should not be surprised that they are so common, however, for these debates are not really (or perhaps not completely) about the conduct of science but rather the politics of expertise.

Certainly the question of therapeutic efficacy remains important; these debates do exhibit some of the qualities associated with science. Nevertheless, the political dimensions of the debate are revealed by how critical questions about efficacy are selectively applied. If advocates for mainstream medicine were really just concerned about the harms of scientifically questionable medical interventions they would devote more attention to the mainstream doctors and surgeons who routinely administer treatments that are out-of-date, not in line with research findings, or have not been proven effective in a clinical trial. The fact that some mainstream doctors' behavior may be no more based on the weight of evidence than an acupuncturist, however, receives scant attention. 

Hence, it becomes clear that the debate is not just about the efficacy or the scientific backing of different treatments but rather is a battle over who is permitted to treat illness. While there are institutions that try to combine mainstream medicine with alternative approaches, most acupuncturists are trained at different schools and are steeped in a very different medical paradigm. As a result, many in mainstream medicine appear to feel threatened by people going to see alternative practitioners: it is likely seen as a threat to their standing as the preeminent experts on human health. Therefore, they engage in what science and technology studies scholars call "boundary-work": they mobilize political rhetoric aimed at keeping practices like acupuncture outside of the sphere of accepted medicine in order to maintain their own relative autonomy.

That is, acupuncture is viewed as a problem not simply because of its uncertain therapeutic value but because acupuncturists are viewed as competing with mainstream doctors. Medicine, just like science itself, is not just about knowledge but about resources and power: Who gets to decide what treatment a patient is to receive? Who gets what support in the form of research dollars and in terms of being covered by insurance? Insofar as the situation is or appears to be zero-sum--the more support and acceptance for acupuncture, the less for mainstream medicine--than advocates of mainstream medicine can be expected to react fanatically, no differently than any other interest group.

Because the source of the dispute is not so much scientific or empirical but political, so is the solution. The problem lies in the way we categorize medicine and health, which in turn is a result of the zeal of early champions of science-based medicine, who threw the baby out with the bathwater of pre-20th century medicine (much of which was no doubt harmful). Medicine became only that which could be reduced to biological mechanism. Consequently the pyschosocial facets of human health and wellness became neglected. Consider how 20th century doctors thought it more convenient to restrain and induce a zombie-like state in pregnant women, relying on episiotomies and forceps to birth babies. At its worst, mainstream medicine doesn't see people, only bodies needing fixing.

This is why efforts toward integrative medicine are so important. Reconceptualizing patients as multifaceted persons who should be treated in mind and body eliminates the ostensible incommensurability of evidence-based medicine and treatments like acupuncture. Personally I have little faith in the Qi-based explanations for acupuncture's efficacy. I only know that few other treatments leave me feeling as relaxed as acupuncture; few others are so good at relieving painful muscle tension without side-effects. Given the risks of opioid addiction, efforts to eliminate the option of acupuncture for pain relief seem callous. No doubt other alternative treatments are riskier than they are worth, but their following won't be diminished by advocates of mainstream medicine only further entrenching themselves in the mechanistic model of 20th century medicine and stepping up their boundary-work efforts. Indeed, that move only exposes them to be more interested in their own political autonomy than patients' well-being. 

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