Sara Murray Jordan

In the history of medicine, there has never been a time when one methodology, one paradigm, one hierarchical classification of healing has been uniformly accepted. Different approaches to healing have continually found themselves in conflict over methods and even over the basic tenets of their profession. Samuel J. Melzer, the first president of the American Society for Clinical Investigation, founded in 1908, argued that clinical medicine has two components-science and art-and that they are separate, antagonistic, and incompatible. He warned his fellow physicians that "the simultaneous cultivation of both is detrimental to the progress of either" [1].

We are currently experiencing a health care revolution that is, arguably, less about health and more about money [2, 3]. We are also observing a growing interest in alternative medicine. A frequently quoted survey published in 1993 in The New England Journal of Medicine reported on the alternative health care practices of 1500 U.S. adults. Thirty-our percent of those surveyed had used at least one unconventional therapy in the preceding year [4].

On the level of national policy, the use of alternative methods is of increasing interest to the U.S. Congress. In the 1992 National Institutes of Health (NIH) Appropriation Bill, the language of the Congressional Appropriations Committee is clear:

"The Committee is not satisfied that the conventional medical community as symbolized by NIH has fully explored the potential that exists in unconventional medical practices. Many routine and effective medical procedures now considered commonplace were once considered unconventional and counter indicated ... In order to more adequately explore these unconventional medical practices the Committee request that NIH establish within the Office of the Director an office to fully investigate and validate these practices."

Congress added $2 million to the NIH's $10 billion budget in order to fund this office (the first director of the office, Dr. Joseph J. Jacobs, called the amount "homeopathic" [5]). Because Congress is willing to mandate an office to explore alternative practices and because people are willing to spend so much for these practices out of pocket, future health care planners may need to discuss alternative health care in the same breath with "regular" medicine.

In such discussions, the license to name brings with it the power to control ideas. All participants in the healing professions pejoratively label those not like themselves. They do this, in equal measure, to better define themselves and to gain a competitive edge. For this reason, the nomenclature used to describe competing healing practices is reviewed here.

The Name Game

"What's in a name? That which we call a rose By any other name would smell as sweet."

William Shakespeare

As the term alternative medicine is popularly understood, it represents a wide spectrum of healing and health tactics, including acupuncture, acupressure, biofeedback, Chinese medicine, chiropractic, folk medicine, herbalism, holistic medicine, homeopathy, hypnosis, massage, naturopathy, psychic healing, relaxation, and reflexology. In fact, the term alternative has widely differing connotations for the very people who use it. Does it simply mean anything not taught in traditional western medical schools? Do the words alternative, complementary, holistic, natural, and fringe describe similar or different activities? It has been noted that alternative medicine defines itself by exclusion and that the term is no more helpful than the similar catch-all term foreign [6]:

"An Englishman setting out to comment on "foreigners" would be as accurate in his description of foreigners as most doctors are in their understanding of alternative therapies, and the Englishman's commentaries ... would tell us more about the prejudices of being English than the characteristics of non-English people."

Alternative, as it is commonly used, may imply an equal choice between two things or may suggest a choice that, if taken, leaves the other behind. It suggests an order of choices, starting with the first and best and proceeding to those of less value. "Naturally," we cannot forget the culturally popular concept of alternative lifestyles and the controversial social baggage that alternative carries in that context. Once again, depending on your politics and values, alternative can suggest a positively nurturing or a negatively hedonistic viewpoint, a warm fuzzy feeling springing from one's romantic youth or a stern reproach from a conservative superego.

A closely related word, a relic of methodologies and concepts now extinct, may have given rise to (and been replaced by) the phrase alternative medicine. The definition of alternative, as in alternative medicine is, according to Zell's Popular Encyclopedia of 1886 [7]: "Alternative ... (Med) Such medicines as induce a favorable change in the system, without any manifest operation or evacuation. The principal therapeutic employment of the Alternatives is as antiphlogistics or resolvents."

Antiphlogistic is another dated medical term that, according to Zell's, refers to agents "that counteract burning heat, or inflammation." Resolvent makes reference to an extinct

"... class of medicines used by surgeons to dissolve or dissipate impacted humors, swelling, tumors, &c ... however, such remedies are more fanciful than real; for though mercury, lead, and ammonia are considered among the best of the class, there is one agent of more value than twenty such combined ... and that is the human hand. Friction with a soft hand-with or without lard, or oil-is the only reliable [resolvent] ... in the whole catalogue [7]."

This is an interesting and prescient comment on competing techniques, the caustic drug therapeutics of the 19th-century "regulars" versus the laying on of gentle hands in a massage-like therapy. Alternative medicine lacked a visible assault on the patient, such as that seen with blistering, emetics, or purges, and it was a practice in sharp contrast to the "heroic" therapies of the time. (Early crude efforts to reduce fever and inflammation with these harsh techniques were referred to as heroic therapy [8]. In retrospect, what earned the label heroics-the therapeutics as applied by the physician or the effort to survive them by the patient-is debatable. The term has since evolved, thankfully, as have the techniques.)

Names and naming were among the earliest issues tackled in the first NIH Working Group on Unconventional Medical Practices. Unconventional was simply unacceptable. Although they agreed that the public did have a good understanding of the term alternative, many participants were still unhappy with it. These representative practitioners felt that the term negatively implied a last resort. Many preferred the term complementary, but others found issue with that. Not able to agree among themselves, they came up with the following tentative names for their new organization: "The Office of ... complementary and traditional, holistic and complementary, complementary, alternative and complementary, alternative and holistic and complementary, traditional ways, and integrated ... Medicine (or Medical Practice)" (Meeting of the Working Group on Unconventional Medical Practices, 14-16 September 1992. National Institutes of Health Office of Science Policy and Legislation). Yet, regardless of what these leaders may choose, the public and the lay press have already settled the issue, and alternative they shall remain.

The "Other"

"The art of medicine is my discovery. I am called Help-Bringer throughout the world, and all the potency of herbs is known to me."

Ovid (Publius Ovidiou Naso, 43 BC-17 AD)

Alternative medicine or alternative health care has come to be the term generally used by both the supporters (including Congress and the NIH) and the detractors of this type of medicine, but this is not the case for the name of the "other" medical discipline practiced by the more than 660 000 licensed physicians in the United States. Many terms are used for this method of healing; this probably reflects the continuing evolution of the practice itself.

Scientific medicine is one term accepted by these physicians [9]. This name lays exclusive claim to a "scientific" foundation on a body of knowledge, derived from both research and observation, that is chronicled in peer-reviewed journals. It has a history of controlled, clinical studies; has a strong tradition of basic laboratory science; and is closely affiliated with medical schools and hospital research centers. But alternative practitioners, short on laboratory science but long on case reports, can also point to a historic collection of observations and data. With the NIH now enrolled as a sponsor, they will be soon publishing the results of more rigorous clinical studies, whatever their outcome, and may establish a stronger scientific foundation for their work.

The term scientific medicine implies that other healing practices are not grounded in reality. It suggests, in a not so subtle manner, that alternative practices have no scientific or technological underpinnings, no systematization of facts, methods, or principles. It insinuates that alternative health care offers an alternative to the scientific laws that exist in the natural world. (This belief may indeed be held by those who support alternative medicine as well as those who attack it, but it belittles the legitimate debate that the subject demands.) The mantle of "science" cannot be claimed or exclusively worn by any one field of medicine.

If not scientific, then what should we call the alternative to alternative medicine? Traditional cannot be used, because both types of medicine have long traditions and the actual historic edge goes to the alternative practitioners. Conservative? This term, also, carries too much political baggage, and its use is completely dependent on one's viewpoint. After all, conservative management in a hospital may mean noninvasive management, and alternative practitioners are certainly less invasive than most surgeons. Regular medicine implies that the alternative is irregular and imperfect and is extremely prejudicial.

Allopathic medicine has historically been defined as ordinary medicine [7]. It was, in fact, a term first coined by Samuel Hahnemann, founder of homeopathy [10, 11]. Politically, Hahnemann thus positioned "regular" physicians as merely one type of doctor representing only a single doctrine who practiced curing with agents that produced symptoms or conditions opposite to those of the disease being treated [10-13]. This practice was in sharp contrast to that of homeopaths, who used small doses of agents to produce symptoms similar to those of the disease being treated (a "like cures like" model). This practice was based on the observations of John Hunter, an 18th-century Scottish surgeon [14]. (Hunter hypothesized that an organism cannot be diseased in two ways simultaneously. If a body cannot have two simultaneous fevers, it follows that one illness can drive out the other.) In contrast to "allopathic" practitioners, followers of homeopathy use small doses of preparations based on provings, the results of Hahnemann's experiments on himself and his family, that in higher doses would recreate symptoms similar to those of the patient [10, 11]. The term allopathy, however, is not applicable to the modern practice of "nonhomeopathic" medicine. Whole drug classes, such as antibiotics, do not act in the manner of "opposites." Furthermore, the botanical schools of the 19th century used allopathy as a disagreeable term of contrast. They claimed the captured warmth and life-sustaining properties of the botanicals that they administered, whereas allopathy carried all of the derogatory implications associated with its use of cold minerals from the dark earth (such as mercurial agents) [10, 15, 16]. This, too, has now lost its applicability in a world that uses agents created by bioengineers and genetic manipulation.

Organized medicine does a good job of describing the U.S. health industry. Licensed physicians are separated into guild-like societies, each with their own apprenticeships and licensure examinations. Organized also accurately describes the industrial-medical complex, the relatively new industry that provides health care and related services for profit [17]. In a broad sense, this industry includes insurance companies, claim processors, consultants, pharmaceutical manufacturers, laboratory suppliers, and equipment manufacturers, as well as the employees of hospitals and other health care delivery organizations. Organized medicine certainly allows alternative medicine to represent an alternative to the highly capitalized, politically empowered, and legally codified model that currently exists. But some practitioners in the alternative health care system, such as chiropractors, are also developing political strength, lobbying skills, societies, licensure requirements, and examination requirements. Organizationally, they may be years behind, but they are determined to catch up. And, finally, organized medicine is not without its cultural baggage: Some wags are sure to make allusions to organized crime.

Conventional medicine is also a misnomer. It is hard to accept advanced technologies, such as high-energy proton beams used to treat cerebral aneurysms, as conventional. This term also implies that alternative health care practices, such as the use of herbal teas, are unconventional; most grandmothers would take issue with this idea.

The veracity of the cultural term mainstream medicine depends on one's point of view. This term ignores the history and traditions of many alternative health practices that existed long before our regulated and legislated system was in place. Furthermore, many "mainstream" ideas (such as breast feeding) were once dismissed, only to return years later, vindicated; this shows that the term better represents fashion than it does fact.

One thing that distinguishes regular, traditional, mainstream, organized, conventional, and scientific medicine from alternative medicine is its considerable economic and political power. This system of health care commands an overwhelming authority by being the largest and fastest-growing sector of the economy ($389.7 billion was spent on health care in 1984; this Figure increased to $949.4 billion in 1994 [18]). It is big business and "big medicine." At more than $1 trillion and still growing, it is outstripping even the military-industrial complex [18, 19]. This single fact, more than any other, distinguishes this type of medicine from the rest. Its rigid hierarchical structure, complex regulations, licensure standards, organizational monitoring, self enforcement, protocol, and standard-of-care guidelines now dictate how practitioners may serve in it. It is an authoritarian medicine, as in "Authoritarian, a. [from authority, and -arian.] ... believing in, relating to, or characterized by unquestioning obedience to authority rather than individual freedom of judgment and action" [20].

The term authoritarian medicine promotes the power of medical autonomy, the belief that physicians possess such special knowledge that nonprofessionals cannot properly evaluate them, the belief that physicians are conscientious and do not require supervision, the belief that the profession can be trusted to supervise and discipline itself, and the belief that peer review is the highest moral authority in the profession [21].

Authoritarianism is itself a medical subject heading (MeSH) term in MEDLINE, which indexes more than 3600 major medical journals. It describes the attitudes of physicians toward their patients and society and describes their sense of professional control. Authoritarianism is nurtured early and is developed by the exposure of medical students to medical faculty and housestaff [22]. It represents a broadly based hierarchy that seeks to control the tiniest details of health care delivery and all of its participants. Nurses, for example, since the time of Florence Nightingale, are not allowed to provide any service that is not ordered by a physician. Like most other health care providers in this system, they are dedicated to serving others on the orders of others, thus becoming extensions of physicians and being legitimized by laws that restrict the practice of medicine to physicians [23].

In Roman mythology, Aesculapius was the god of medicine, the son of Apollo and the nymph Coronis. He could prevent the death of the living and recall the dead to life. Aesculapian authority refers to the physician's acknowledged, legitimate power based on knowledge, a power that has a mystical connection with the unknown and the spiritual, maintains a superior morality based on the Hippocratic oath, and demands submission of those who are ill to an authority greater than any other earthly power [24, 25].

It is easy to show how Aesculapian's authority, authoritarianism, or authoritarian medicine could describe "big" medicine. It jealously guards its hegemony over the healing arts. It restricts, by licensure, the eligibility of those who can practice it. It makes the regulations, monitors their compliance, polices those who fail its standards, judges, and determines punishment. It organizes and lobbies for its own empowerment. It restricts professional association with other healers. It forces the incorporation of new ideas when convincing evidence is produced or is agreed to by peer review, overruling individual perspectives and subjective beliefs. This is unlike alternative medicine, in which charismatic healers and cult followings may maintain unwavering loyalty to ideas or theories despite conflicting evidence.

However, although the American Medical Association adopted the staff of Aesculapius, the single serpent entwined about a wooden staff, as its official insignia in 1910, it never adopted the notion of its authority or the idea of a totalitarian profession. In addition, the modern politics of medicine now reflect the growing powers vested in the patient as consumer, as well as the relinquishing of control of the profession to business management techniques. Indeed, authoritarian medicine is becoming a very cautious, self-conscious, medicine.

Criticism of authoritarianism in medicine by the peers of those who practice it is similarly old and established. Maimonides (1135 to 1204 AD), the philosopher-physician-scientist, counseled physicians to use individual judgment rather than relying on authorities. He warned that the practice of medicine was too often guided by the opinions of those famous in the field instead of on the testing of "accepted" theories [26].

Finally, alternative medicine has authoritarian tendencies, too: It now competitively markets itself in conformity with ideas and trends based on its own idiosyncratic presumptions. However, the individual practitioners of alternative health care still remain just that-alternatively and individually free of authority, minimally restricted, and enjoying a methodologic freedom that will never again exist for the licensed, highly regulated physicians of the United States.

Conclusions

"Perjuria ridet amantium Jupiter (Jupiter laughs at the perjuries of lovers.)"

Albius Tibullus III

Healing methodologies, patterns, and paradigms forever claim new names and classifications for their changing views of disease and therapeutics. Historical perspective and cultural and academic prejudices have rendered many of these descriptors moot or inflammatory. Our health care system, the largest sector of the U.S. economy, will continue to evoke new terms as it evolves, constantly redefining itself against successive practices. At the close of the 20th century, however, it still lacks an appropriate, all-encompassing title. Frequently used terms such as scientific, regular, mainstream, conventional, organized, allopathic, or conservative fail to describe adequately what licensed physicians do in our society. Authoritarian medicine, arguably a better designation, also has its shortcomings, the least of which are its existential, democratic constraints.

Competing healing methods find reasonable accommodation in their freedom as alternative health care. Yet within their own societies, dogmatic attendance to their own prejudices renders the faithful captive to similar authoritarian hierarchies. From Hahnemann, who counseled that once a patient had been treated by a "regular" physician, the alteration in his natural state would forever prevent a cure by homeopathic methods and that this cure should not even be attempted [27], to our modern "alternative subculture represent[ing] a population that has lost its faith in medical reassurance ... [and] seeks its knowledge of the body from the media" [28], alternative methodologies can be equally at fault in dictating how both practitioner and patient must act and think.

Alternative approaches to health are present, have always been present, and will always be present. Alternative health care practices will continue to evolve and will never be static, persevering in their historic role as challengers to the preeminent medical thinking of the day. At the same time, the "other" medicine will forever be rediscovering the alternatives, exploring their databases and paradigms, and publishing news of their "resurgences." Together, the systems are healer twins, a medical Gemini, like the two mythical brothers who were good companions and protectors of the brave. And, just like those mythologic twins who were set in the night sky by Jupiter, they may never appear together. They alternate forever before us, appearing in turn when we look to the heavens in our time of need, whatever we choose to call them.