I. 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 disenfranchisement. "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.

Nineteenth-Century Alternative Medicine

THE THOMSONIAN SYSTEM. One of the first challenges to the orthodoxy of "regular physicians" occurred in the early 1800s. Samuel Thomson (1769–1843) was a poor New Hampshire farmer whose mother and wife had suffered from the bleedings and mercurial drugs forced upon them by regular physicians. Thomson believed that better treatments must be available, and he began studying the therapeutic value of herbs. He soon developed his own system of botanical medicine predicated upon the assumption that there is only one cause of disease, cold, and one cure, heat. Thomson believed that by restoring heat to his patients' systems, he could cure any ailment. Using botanics such as cayenne pepper, supplemented with steam baths, Thomson sought cures without the incessant bloodletting or mercurial drugs utilized by the era's orthodox physicians.

The Thomsonian system reached the height of its popularity in the 1820s and 1830s. Some estimate that its methods were employed in varying degrees by as many as a million Americans. One obvious reason for its appeal was that its treatments were generally more benign than the aggressive arsenal of bloodletting, alcohol, opium, mercury, arsenic, and strychnine that many regular physicians used to stimulate their patient's systems. Perhaps more important, Thomsonianism could be studied relatively inexpensively (although the official price for the right to use his methods was a substantial $20) and practiced by family members. During the days of medical professionalization in the United States, Thomsonianism strengthened the role of parents, and especially mothers, in caring for family members. Thomsonianism also fit nicely with the period's moral and religious climate, which urged individuals to take responsibility for their own moral and spiritual regeneration. It endeavored "to make every man his own physician" and encouraged individuals to take responsibility for restoring their rightful relationship to the divinely decreed laws of nature. Of lasting significance is the fact that Thomsonianism was the first system to take on the issue of licensing of medical practitioners, and to assert the public's right to free choice of healers. Thomsonians led the successful campaign to repeal medical licensing legislation in the mid-1800s and drew public attention to the somewhat predatory tactics with which orthodox physicians sought to restrict the right of would-be healers to practice whatever system they wanted.

HOMEOPATHY. A second form of sectarian medicine, homeopathy, emerged more or less concurrently with the public's gradual loss of enthusiasm for the Thomsonian system. The homeopathic system of medicine was the creation of the German physician Samuel Christian Hahnemann (1755–1843), who grew increasingly critical of the indiscriminate prescription of drugs by contemporary physicians. He coined the term allopathic to refer to orthodox medicine's alleged overreliance upon invasive therapeutic treatments (e.g., bloodletting, surgery, or the administration of strong pharmacological agents). In contrast to allopathic medicine, Hahnemann enunciated a medical theory that he thought relied more upon the body's natural powers to bring about recovery. The first principle of homeopathic medicine is "like cured by like." By this Hahnemann meant that physicians should treat symptoms by prescribing drugs that produce similar symptoms in a healthy individual. The second fundamental principle of homeopathic medicine is the doctrine of infinitesimals. It was Hahnemann's conviction that the greatest therapeutic benefit was to be achieved by administering diluted doses of a drug, sometimes only 1/1,000,000 of a gram. Although homeopathic physicians' use of infinitesimal doses undoubtedly negated any therapeutic value their drugs might have had, at least these small doses had the virtue of not assaulting the patient's recuperative powers. It is thus not surprising that many turned to homeopathy as a viable alternative to orthodox medicine.

Homeopathy spread quite rapidly in the United States. It was introduced by Hans Gram, who opened an office in New York after studying the homeopathic system in Europe. By 1835 a homeopathic college had been formed, and in 1844 the American Institute of Homeopathy was organized. Throughout the 1800s, 10 to 12 percent of the country's medical schools and medical school graduates were adherents to homeopathy. In contrast to Thomsonianism, which was practiced by nonprofessionals, homeopathic practitioners were educated professionals who often came from the ranks of regular physicians. Moreover, while those who received Thomsonian treatment tended to be rural and poor, there is evidence to suggest that homeopathy thrived among the urban upper and middle classes. This latter fact led to direct economic competition with the regular system and proved an important catalyst in the formation and success of the American Medical Association as economic motives joined with scientific ones to rally regular physicians in opposition to their irregular competitors. As the most popular of the century's alternative systems, homeopathy raised a number of important ethical questions. For example, could allopathic physicians consult with "unscientific" practitioners? (The AMA's original code of ethics included a consultation clause that prohibited such interactions.) Or should homeopathic physicians be allowed to practice in publicly supported hospitals or in the military? Even in the late twentieth century there was some debate about whether pharmacies should be required to stock homeopathic medicines.

HYDROPATHY AND DIETARY REGIMENS. In the mid-1840s another alternative therapy, hydropathy (water cure), began to attract a following in the United States. Based on the theories of Vincent Priessnitz of Austria, hydropathy was based on enhancing the body's inherent vitality and purity. Priessnitz believed that pure water could be used to flush out bodily impurities and stimulate the body's inherent tendencies toward health. Water-cure treatments emphasized drinking large amounts of water and applying water externally through baths, showers, or wrapping wet sheets around the body. Most American adherents of water cure advocated an eclectic approach to health based on the curative powers of fresh air, diet, sleep, exercise, and proper clothing. The philosophy of water cure also had a decidedly moral tone. As one anonymous American enthusiast put it, "We regard Man, in his primitive and natural condition as the perfect work of God, and consider his present degenerated physical state as only the natural and inevitable result of thousands of years of debauchery and excess, of constant and wilful perversions of his better nature, and the simple penalty of outraged physical law, which is just and more severe than any other" ("Water-Cure World," 1860).

Hydropathy thus equated disregard of the laws of healthful living with defiance of God's will. Systematic efforts to promote healthful living were not only the means to physical well-being but also the key to the spiritual renovation of Earth. The hydropathic cause naturally attracted many of the period's moral and religious reformers. William Alcott, Lucy Stone, Amelia Bloomer, Susan B. Anthony, and Horace Greeley visited major hydropathic retreat centers, where they circulated reformist agendas ranging from vegetarianism to utopian socialism. Critical of the alleged superiority of "official" medical authorities, advocates of hydropathy had a natural affinity with the feminist thought of the time. Hydropathy looked to nature, not credentialed male physicians, as the ultimate source of healing, and in so doing, it provided a vehicle for those seeking to redress what they thought were faulty notions of social and political authority.

Another nineteenth-century forebear of contemporary alternative therapy in the United States was Sylvester Graham (1794–1851), who combined conservative religious beliefs with zealous concern for health reform. An ordained Presbyterian minister and itinerant evangelist, Graham believed that human physical, moral, and spiritual well-being required scrupulous adherence to the natural order established by God. Graham admonished his followers that avoiding alcohol and the overstimulation of the sexual organs could help them maintain moral and physical health. His advice for a healthful diet included a coarse bread, later produced in the form of a cracker that still carries his name. Graham's dietary principles, widely circulated throughout the nineteenth century, served the cause of keeping the soul's "bodily temple" free from impurities.

Ellen White (1827–1915) occasionally visited a hydropathic resort in Dansville, New York, where she became a convert to Graham's dietary gospel. White thereafter had a series of mystical visions in which God revealed to her that he expected humans to follow the divinely given laws governing health and diet as faithfully as his moral laws. The Seventh-Day Adventist denomination founded by White has since then adopted Grahamite principles and a vegetarian diet as essential parts of purifying themselves in expectation of the Second Coming of Christ. Seventh-Day Adventists, one of the largest religious groups to originate in the United States, support a number of health sanatoriums and combine their evangelical religious faith with a strong emphasis on healthy dietary practices. This emphasis upon a healthful diet does not in and of itself constitute an alternative medical practice. Their dietary concerns are, however, closely connected with their belief in the efficacy of petitionary prayer.

The Rise of Mental Healing Practices

MESMERISM. The introduction of Franz Anton Mesmer's "science of animal magnetism," commonly known as mesmerism, in the 1830s and 1840s popularized a belief in the power of the unconscious mind to draw upon an invisible healing energy. Mesmer (1734–1815), a Viennese physician, believed that he had detected the existence of an almost ethereal fluid that permeates the universe. This fluid, called animal magnetism, flows continuously into, and is evenly distributed throughout, a healthy human body. If for any reason an individual's supply of animal magnetism is thrown out of equilibrium, one or more bodily organs will begin to falter. Mesmer proclaimed, "There is only one illness and one healing." The science of animal magnetism revolved around the identification of techniques for restoring a patient's inner receptivity to this mysterious, life-giving energy.

Mesmer held magnets in his hands and repeatedly passed them over the heads and bodies of his patients in an effort to induce the flow of animal magnetism into their systems. His followers later dispensed with the magnets, finding that verbal suggestions from the healer could induce patients into a trance, ostensibly heightening their receptivity to the influx of this metaphysical healing agent. Mesmerized patients claimed to feel prickly sensations running up and down their bodies that they attributed to the influx and movement of animal magnetism. Awaking from their sleeplike trance, they reported feeling refreshed, invigorated, and healed of such disorders as arthritis, nervousness, digestive problems, liver ailments, stammering, insomnia, and the abuse of coffee, tea, or alcohol. Some patients even claimed that the mesmerizing process enabled them to open up the mind's latent powers for telepathy, clairvoyance, and precognition. These claims contributed as much, or even more, to mesmerism's growing popularity than its reputation for healing.

A good many of those drawn to mesmerism were middle- and upper-class individuals who styled themselves progressive thinkers and were interested in uniting science and religion in a single philosophical account of human nature. Mesmerism struck them as an important step in this direction. The phenomena surrounding mesmeric trances were thought to provide empirical proof that each human is inwardly connected with higher, metaphysical planes of reality. Adherents of mesmerism believed that under certain conditions of psychological receptivity, humans are able to open themselves to an influx of energy or guidance from these higher realms. American mesmerists borrowed terminology from transcendentalism, spiritualism, and Theosophy to provide their middle-class reading audience with a new vocabulary for understanding the interconnection of their physical, mental, and spiritual natures.

MIND CURE AND CHRISTIAN SCIENCE. A popular philosophy known as the mind-cure or New Thought movement grew out of the mesmerists' healing practices. Mind-cure writers in the United States published books and pamphlets describing how thought controls the extent to which we are able to become inwardly receptive to spiritual energies. From Phineas P. Quimby and Warren Felt Evans in the late 1800s to Norman Vincent Peale, Norman Cousins, and Bernie Siegel in the late 1900s, Americans have displayed a remarkable enthusiasm for this "power of positive thinking" literature. The mind-cure movement gave rise to a novel form of religious piety based on the belief that the deeper powers of our mind control our access to a metaphysical power that can instantly help us to achieve peace of mind, improved health, and a never-ceasing flow of energy. The holistic health movement of the 1960s and 1970s relied heavily upon this cluster of metaphysical ideas.

Mesmerism was also instrumental in the formation of Christian Science. In 1862 Mary Baker Eddy, in great physical and emotional distress, arrived on the doorstep of the famous mesmerist healer Phineas P. Quimby. Quimby's treatments gradually cured her of her ailments; they also gave her a new outlook on life, based upon the principle that our thoughts determine whether we are inwardly open to, or closed off from, the creative activity of a spiritual energy (animal magnetism). Soon after Quimby's death, Eddy transformed his mesmerist teachings into the foundational principles of Christian Science. Her principal text, Science and Health with Key to the Scriptures (1875), reveals her intention to shift the science of mental healing away from the categories of mesmerism to those that bear more resemblance to Christian Scripture, albeit her own unique interpretation of it. The basic theological postulate of Christian Science is that God creates all that is, and all that God creates is good. Sickness, pain, and evil are not creations of God, and therefore they do not truly exist. They are simply the delusions produced in an erring, mortal mind that has lost a firm hold on the belief that only those things created by God have true existence. For Christian Scientists the universe is spiritual. What we call matter (e.g., bacteria, viruses, etc.) consequently does not really exist and therefore has no causal power. Christian Science healers, known as practitioners, help individuals to overcome their faulty thinking and to elevate their mental attitudes above the delusions of the senses. Healing occurs as the individual learns to function on a metaphysical, rather than a physical plane. Healings are understood not as miracles or faith healings but as the lawful consequence of exchanging false conceptions for true ones, which center solely on the higher laws of God's spiritual presence.

Both Christian Science and the "holistic health" philosophies that emerged from the mind-cure tradition teach that our thoughts control the degree to which we avail ourselves of the higher spiritual source from which health proceeds. As a consequence, illness or disease is understood as something the sufferer has brought upon himself or herself through failure to sustain a "correct" mental posture toward life. Any ethical analysis of these forms of alternative therapy must take seriously their built-in skepticism about whether a medical system really needs to attend to material causes of illness (bacteria, viruses, etc.). The issue is not quite so acute for holistic healing practices that teach that the mind can draw upon a higher energy capable of invigorating matter but do not teach that matter itself is unreal. In other words, most holistic health systems do not deny that there are physical and material causes of illness. They simply maintain that mental and spiritual factors are entailed in the etiology of most illnesses and must be taken into account in any comprehensive medical system. And thus, although they insist that a patient's mental outlook often is a significant factor in the creation and cure of illness, they do not espouse a medical theory that puts all the "blame" for illness or "credit" for recovery upon the patient.

Christian Science, by contrast, goes much further in challenging the empirical and rational foundations of Western science. By denying the ontological reality of matter, and hence the causal power of viruses or bacteria, Christian Science is clearly at philosophical loggerheads with both medical orthodoxy and the legal systems of most Western, democratic nations. For example, the Christian Scientists' belief system is opposed to immunization. The courts have understandably become concerned over the medical wellbeing of the children of Christian Science practitioners, as well as other students with whom they attend school; this has led to legal restrictions on the right of Christian Scientists to practice their form of religious healing. In 1990 the U.S. courts decided that two Christian Science parents were guilty of child neglect when their sole reliance on Christian Science methods was deemed responsible for their child's death (Hodgeson v. Minnesota). Such cases draw attention to the important ethical distinction between "private" religious belief and actions that have consequences in the "public" domain regulated by the legal system.

Christian Science healing practices, fundamentalist faith healing, and outright quackery have prompted strong responses from practitioners of orthodox medicine. The American Medical Association, emerging as a powerful national organization early in the twentieth century, set itself the task of prompting state and federal agencies to enact stricter licensing regulations. Its efforts to restrict medical practice to graduates of AMA-accredited medical schools surely furthered the cause of scientific medicine and protected the public from potentially harmful forms of quackery. It also tended, however, to force out of the medical marketplace those whose approaches to healing utilized a nonscientific worldview or whose medical services did not fit with dominant approaches to medical care.

Chiropractic and Osteopathic Medicine

Osteopathic and chiropractic medicine provide interesting examples of the fate of alternative philosophical, religious, and ethical interpretations of healing in an age dominated by scientific medicine. Osteopathic medicine emerged from the healing philosophy of Andrew Taylor Still (1828–1917). A former spiritualist and mesmeric healer, Still developed techniques for manipulating vertebrae along the spine in ways that he thought removed obstructions to the free flow of "the life-giving current" that promotes health throughout the body. Still explained the healing principles of osteopathy (a term derived from two Greek words meaning "suffering of the bones") in overtly metaphysical terms that described the origin and nature of "the life-giving current" ultimately responsible for human well-being. His followers largely discarded the occult-sounding dimensions of Still's philosophy and instead insisted that osteopathic medical education be grounded in anatomy and scientific physiology. Thus, although osteopaths originally relied only upon manual manipulations of the spine as a means of restoring health, they soon added surgery and eventually drug therapy to their medical practice.

By the 1950s, so few differences existed in the training or practice of osteopaths and M.D.s that their two national organizations agreed to cease the rivalry that had existed for several decades and to cooperate in such matters as access to hospitals, residency programs, and professional recognition. Having jettisoned the alternative worldview of its founder, osteopathy no longer bore any overt signs of unorthodoxy and finally found itself within the medical mainstream. Interestingly, during the 1960s many osteopaths were concerned about being absorbed into allopathic medicine and gave renewed focus to osteopathy's philosophical origins. Their commitment to osteopathy's historical concern with enhancing the body's natural powers for recuperation made them champions of holistic medicine long before the term holistic became commonplace among alternative healers. As of 1990, over 24,000 physicians practiced osteopathic medicine, collectively treating over 20 million patients per year.

The case of chiropractic medicine is more complex. Chiropractic originated in the work of Daniel David Palmer (1845–1913), a mesmerism-inspired magnetic healer in Iowa. Palmer, who knew of Still's osteopathic techniques, theorized that dislocations of the spine are able to block the free flow of the life force, which he called Innate (his nomenclature for animal magnetism). Palmer and his son, B. J. Palmer, explained that Innate is a part of the Divine Intelligence that fills the universe, bringing full physical health whenever it flows freely through the human body. Chiropractic medicine represents the Palmers' art and science of adjusting the spine in ways that remove obstructions to the free flow of Innate within the body.

Over the years, chiropractic physicians began downplaying the movement's metaphysical origins and emphasized its scientific approach to the treatment of musculoskeletal disorders. In this way, they minimized their theoretical unorthodoxy and identified an area of medical practice largely ignored by most medical doctors. Chiropractic physicians' sustained attention to this void in the "orthodox" medical system has earned them a viable niche in the medical marketplace; as of 1990, more than 19,000 chiropractic physicians were treating more than 3 million patients annually. Even though most medical insurance companies have come to recognize the medical functions performed by chiropractic medicine, M.D.s are still largely wary of chiropractic medicine because it has failed to elucidate an empirically validated theory that would substantiate its therapeutic claims. This professional tension provides a fascinating example of a continuing theme in the history of alternative medicine: the clash between orthodox medicine's rationalism (its insistence on an acceptable scientific explanation for all methods) and alternative medicine's pragmatism (discovery of therapies that produce results regardless of whether they are "proved" with rational theories).

Holistic, New Age, and Folk Medicine

During the last few decades of the twentieth century, the holistic healing movement led a surge of popular interest in therapies based on an explicitly religious, or quasi-religious, interpretation of the healing process. The precise meaning of the term holistic medicine varies among healing systems. Among its meanings are emphasis upon "natural" therapies, patient education and responsibility, prevention, and treating patients as "whole" people. Also common to holistic healing is the basic assumption that, as one handbook put it, "every human being is a unique, wholistic, interdependent relationship of body, mind, emotions, and spirit." The term spirit, alongside body, mind, and emotions, carries holistic healing beyond psychosomatic medical models; it also represents commitment to a belief in the interpenetration of physical and nonphysical spheres of causality. Even holistic healing's exhortations concerning reliance upon the body's own regenerative and reparative processes are typically laden with references to opening individuals up to the inflow of a divine healing energy. Persons who call themselves holistic health practitioners typically operate according to a worldview that is incompatible with the naturalistic framework of the modern Western scientific heritage.

One example of such a holistically oriented healing movement is Alcoholics Anonymous (AA), and its Twelve-Step program, which has influenced many other "selfregenerative" therapies. Founded in the 1930s, Alcoholics Anonymous has well over one million members, with about 35,000 groups meeting weekly in over ninety countries. The principal founder of the movement, Bill Wilson, was an alcoholic who became acutely aware of his inability to overcome his addiction. A mystical experience of "a great white light" convinced him that a loving Presence surrounds us and is capable of healing our broken inner lives. Wilson maintained that we need only to cease relying upon our own willpower and surrender to this Higher Power. Wilson was extremely wary of institutional religion, especially the moralism associated with biblical religion. From psychologists such as William James and Carl Jung, he pieced together a form of spirituality based upon opening the unconscious mind to a higher metaphysical reality. AA counsels its members that "in order to recover, they must acquire an immediate and overwhelming 'God-consciousness' followed at once by a vast change in feeling and outlook" (Alcoholics Anonymous, p. 569). AA's mystical, nonscriptural approach to personal regeneration sets its doctrines apart from most of America's religious establishment; its denunciation of both material and psychological/attitudinal factors in favor of an overtly spiritual view of healing sets its practices apart from the American medical and psychological establishments. But its open-minded and eclectic sense of the presence of spiritual forces in the determination of human well-being makes it one of the most powerful mediators of wholeness in America in the late twentieth century.

The various religious and healing groups that comprise the New Age movement endorse a holistic approach to health and medicine; they envision every human being as a unique combination of body, mind, emotions, and spirit. Central to New Age piety is the conviction that each person exists simultaneously in both the physical and the metaphysical (i.e., the astral and etheric) planes of reality. New Age therapies such as the use of crystals, therapeutic touch, and psychic healing seek to channel healing energies from higher metaphysical planes into the physical body. New Age crystal healing, for example, maintains that illness in the physical body is frequently caused by a disruption or disharmony of energies in what is called the etheric body (the portion of the self that extends into the astral and etheric planes). Healing consequently requires techniques to achieve harmony between the physical and subtle or etheric bodies. Crystals are thought to have unique properties that enable them to serve as receptors and capacitors of energies that emanate from the astral and etheric planes. Used properly, crystals are assumed to be capable of transmitting these energies in ways that bring the individual's physical, moral, and spiritual natures back into harmony. To this extent, New Age adherents do not reject the therapeutic efficacy of established medical science (though they do condemn what they perceive to be an overreliance on drugs and invasive surgical techniques) so much as its secularist and materialistic worldview, which fails to take into account our spiritual nature or potentials. Healing, for New Agers, is a by-product of the more fundamental goal of attaining an expanded spiritual awareness.

New Age healers are especially drawn to Eastern religious systems that involve entering into meditative states that heighten receptivity to the inflow of a higher spiritual energy, variously referred to as ch'i, prana, kundalini, animal magnetism, or divine white light. Yoga, t'ai chi ch'uan, Ayurvedic medicine, shiatsu, acupuncture, and various Eastern massage systems are studied for their advocacy of attitudes and lifestyles geared to the renovation of our moral and spiritual lives. Although each of these healing systems has its own philosophical basis and history, Americans tend to approach them with agendas left over from such nineteenth-century movements as mesmerism, spiritualism, and Theosophy. Even acupuncture, whose ability to alleviate pain and promote healing is more or less recognized—though poorly understood—by medical science, is embraced by many Americans not only for its obvious physical benefits but also for its connections with Eastern mystical philosophies.

A wide variety of folk and ethnic remedies exist alongside medical science. Botanical and herbal remedies, while ordinarily aimed at promoting health rather than curing illness, represent a noninvasive approach to physical wellbeing. Rural Pennsylvania Dutch still practice variations of powwow, an eclectic tradition using charms, prayers, and rituals, to prevent and cure disease. In the American Southwest, curanderismo still flourishes in Mexican-American communities, and recent immigration to the continental United States from the Caribbean has rekindled folk medicine practices (e.g., charms, herbs, incantations) peculiar to the African-American heritage. Immigration from Southeast Asia has brought Hindu and Buddhist medical practices like Ayurvedic medicine and prayers to the heavenly saints (bodhisattvas), who reward the faithful with their healing powers. Far East Asian immigrants have included dedicated practitioners of such religiomedical systems as t'ai chi ch'uan, shiatsu, and acupuncture. The continued presence of such folk or ethnic medical treatments may represent a form of preserving cultural identity, economic disenfranchisement from the nation's more expensive established medical system, or the seeds of a new era of genuine medical pluralism. In any case, both legal and economic attitudes toward alternative therapies must be philosophically and culturally nuanced.

The Challenge to Bioethics

Persons with life-threatening diseases who have not been helped by conventional treatments understandably become interested in pursuing alternative therapeutic strategies. The highly publicized debate over the effectiveness of laetrile for retarding cancer, for example, drew attention to the potential risks of the regulation of medicine by the U.S. Food and Drug Administration (FDA). At stake was the unresolved issue of whether a drug should be restricted only when it is known to cause harm or only when laboratory testing has failed to reveal measurable physical benefits. This debate continues in the controversy over various treatments for AIDS. Persons given a bleak prognosis by medical doctors seek immediate access to experimental drugs that have just entered the slow and laborious regulatory processes mandated by U.S. federal law. Although much has been done to try to speed up the evaluation of experimental AIDS-related treatments, a growing number of persons find themselves barred from access to innovative scientific treatment.

The central ethical question raised by alternative therapies is whether genuine medical treatment can be distinguished from various forms of quackery. Except for isolated instances in which individuals engage in deliberate medical fraud, quackery is difficult to identify or prove. Any reliable definition of therapeutic benefit requires being able to define the factors "known" to affect human well-being and what optimal health consists of. The practitioners of many forms of alternative medicine criticize the assumptions they believe underlie contemporary medical science. They argue that alternative therapies better understand human well-being and are cognizant of mental, moral, and spiritual factors that go well beyond the physiological considerations on which scientific medicine relies. To those who say that their practices or those who utilize them are "irrational," they respond that every therapy is rational insofar as its methods of treatment are logically entailed by its fundamental premises or its assumptions about the nature of disease.

Establishing criteria with which to mediate between competing medical systems is complicated by the fact that the plausibility of the beliefs or assumptions that underlie them are every bit as dependent on sociological factors as on intellectual "proofs." What we consider valid evidence, whom we consider expert authorities, and how we should go about separating relevant from irrelevant information turn not on objective, rational criteria but on the ways we were socialized into one belief system or another. Who, then, is in a position to decide what is an "irrational" medical choice? With what degree of confidence or philosophical integrity can orthodox physicians seek to dissuade persons from seeking alternative treatments? Do persons have a right to what seems to be an utterly ineffective therapy simply because it conforms to their personal belief system?

Alternative therapies may reasonably be expected to demonstrate their benefits to patients and to substantiate the claim that their distinctive healing practices directly cause these therapeutic results. Medical ethics is concerned with protecting persons from intended or inadvertent harm. Well-intentioned tolerance of alternative therapies should not preclude their undergoing rigorous scrutiny. Governmental agencies, healthcare facilities, and insurance companies are forced to allocate limited resources and to ensure the welfare of the general public. They must be prepared to make reasonable assessments of alternative medical systems that are based upon belief systems at considerable variance with modern Western science.

Because of the inherent threat that quackery poses to both personal and public well-being, ethical and policy-related judgments must exercise caution and strive for the unrelenting application of "public" (openly demonstrable and subject to empirical scrutiny) standards of evidence. The scientific study of psychosomatic interaction (e.g., of the role of psychological variables in the etiology of ulcers) promises to help practitioners of alternative therapies justify their practices in ways that are more amenable to these standards of evidence. Because psychosomatic medicine has expanded scientific appreciation of the roles nonmaterial factors play in the etiology of illness, alternative medicines have access to a set of medical categories that will potentially enable them to argue for the therapeutic efficacy of treatments that focus on such nonmaterial factors.

Cases involving patients' desire to be permitted to use drugs before they have received FDA approval testify to the conflict between private needs and the regulation of public well-being. Unlike alternative therapies that are based on different belief systems, unvalidated drug therapies are usually discussed using medically orthodox terms and logic. The ethical concerns here are more frequently about the speed with which regulatory agencies arrive at decisions on potentially lifesaving drugs or the possible collusion of powerful pharmaceutical companies with regulatory agencies to keep competitors from the marketplace. Perhaps the most important consideration in assessing unvalidated therapies is that contemporary medicine differs from its predecessors not because we have become more rational but because we have learned to use the controlled trial to determine the relative merits of competing medical treatments.

Medical systems that are labeled unorthodox because their concerns or treatments are at the periphery of mainstream medicine are reminders that dominant professional groups tend over time to employ predatory tactics to ensure their continued supremacy and keep potential competitors at a distance. These "medically peripheral" systems alert us to the fact that medical science has philosophical and institutional blinders that may close off, rather than open, innovative approaches to human health. The presence of alternative health professionals in the wider system of healthcare helps safeguard against the kinds of complacency and narrowness of vision that frequently creep into economically entrenched professions. By providing a range of services that address both curative and preventive issues typically neglected by allopathic physicians, many of these alternative therapies contribute to a comprehensive understanding of human health and well-being.

robert c. fuller (1995)

bibliography revised

SEE ALSO: Healing; Health and Disease: Anthropological Perspectives; Medicine, Anthropology of; Medicine, Philosophy of; Medical Ethics, History of the Americas; and other Alternative Therapies subentries

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