Chair’s Column June 2012

Some philosophical reflections on methods and evidence in medicine and mental health care

J. Lake

In this essay I provide a concise overview of important philosophical issues that
define and constrain research methods and evidence in biomedicine in general, and
conventional biomedical psychiatry in particular. These foundational issues should
be considered when reviewing research evidence for non-conventional treatment
modalities used in medicine and psychiatry. In general non-allopathic systems
of medicine neither require nor endorse empirical methodologies for verifying
the existence of a putative mechanism of action or validating treatment outcomes
because claims about mechanisms of action and outcomes are (often) regarded as
implicitly true by non-allopathic healing traditions. In other words, the conceptual
frameworks of many established World systems of medicine (eg, Chinese
medicine, Tibetan medicine, and Ayurveda) include apriori statements about about
the validity of modalities used by practitioners trained in those respective systems
of medicine.

It has been argued that claims that some non-conventional modalities (eg,
acupuncture, Reiki, qigong and other so-called “energy” healing modalities)
are efficacious cannot be adequately evaluated using contemporary scientific
methodology because mechanisms of action based on their postulated energetic
principles cannot be falsified or confirmed using these methods. This fundamental
disconnect between scientific research methods and non-allopathic healing
approaches is complicated by the fact that blinding and the use of placebos to
determine whether outcomes are closely coupled to treatment effects are relatively
recent innovations, and rest on disparate assumptions about the nature of causality
when used in Western style research designs vs studies conducted from the
perspectives of non-allopathic systems of medicine (Ernst 1996). Furthermore,
beliefs about the clinical efficacy of a particular modality are strongly influenced
by professional consensus and difficult to quantify economic and social factors.

Methodologies used in biomedical research studies to rank both quantitative and
qualitative data according to levels of evidence assume that certain kinds of
information are more relevant and certain explanatory models are more valid than
others. However, the validity of a particular epistemological approach (including,
for example, contemporary scientific method) rests on implicit assumptions about
phenomena that can have existence. Scientific method is based on empiricism in
which certain postulates are apriori assumed to be true, and implications of those
postulates are derived logically. In other words, assumptions about kinds of

phenomena that can exist, implicitly bias methodologies used to verify their
existence. As in all disciplines methodologies used in medicine and psychiatry to
verify efficacy claims rest on entrenched epistemological and ontological
assumptions about the nature of phenomenal reality. In the final analysis one is left
with the position of observing that disparate methodologies employed by disparate
systems of medicine provide different kinds of information regarded as relevant by
clinicians trained in different traditions. The rules of a particular methodological
approach in medicine can be rational, non-rational or both rational and non-
rational. Rational rules include analytical tests that verify the existence of putative
phenomena or characterize relationships between phenomena. The parameters and
goals of analytical tests are expressions of premises about phenomenal reality
embedded in disparate systems of medicine. The result is that tests which are
considered analytical and based on rational analysis in one system of medicine are
sometimes viewed as subjective and non-rational by practitioners of a disparate
system of medicine. Non-rational rules include propositions that define subjective
criteria incorporated in a specified methodology used to establish the existence or
properties of phenomena. This state of affairs is further complicated by the fact
that the same medical practice can be interpreted as rational or non-rational,
analytic or subjective, depending on the perspective from which it is viewed. For
example, conventionally trained allopathic physicians view pulse-taking in
Chinese medicine as completely subjective, while Chinese medical practitioners
would argue that they are following a rigorous and systematic algorithm that leads
to inferences about clinically relevant energetic imbalances manifesting as
symptoms. While the allopathic physician claims to measure and identify
phenomena in themselves in contrast, the Chinese medical practitioner claims to
measure and identify phenomena with respect to his or her subjective energetic
state, which, by definition, cannot be measured or empirically verified.

In view of the above discussion there may be no single, value-neutral or best
methodology for assessing evidence pertaining to both contemporary biomedical
treatments and the range of non-allopathic modalities, including Chinese medicine,
different schools of herbal medicine, homeopathy, and so-called “energy” healing
modalities.