David & Goliath: Putting Naturopathic Medical Education to the Test
David J. Schleich, PhD
The Philistines assembled their army at Sokoh in Judah. On the other side of the valley of Elah, the Israelites took up their position. The Philistines proffered Goliath, formidable in his bronze helmet and armor, and otherwise armed to the teeth with the latest weapons. The Israelites eventually came up with David, a shepherd. He chose 5 stones and a sling – unorthodox weapons for such a battle. The latter prevailed, but not without controversy before, afterward, and during. Such is the lot of natural medicine providers facing down the monolith of allopathic medicine, the pharmaceutical industry, and decades of regulatory imbalance. Not dissimilar, then, is the confrontation in our time between the orthodox biomedicine industry and the expanding community of heterodox providers, especially naturopathic physicians, whose tools and skills differ from the goliath of pharma and regulatory entitlement.
In any case, people in both camps are increasingly upset with biomedicine’s assumptions of hegemony. We in the naturopathic medicine sector undulate through the skirmishes, dreading the bigger showdowns when they manifest, because the odds are in favor of those who control the turnstiles of healthcare services. Nevertheless, there are many reasons for all this bilateral consternation. We also have to contend with our own habits of deference and temerity. Even so, the confrontations with the biomedicine industry continue to escalate, especially given the alarming data about chronic disease, costs, and market segmentation.
Pellegrino & Bioethics
The orthodox medical establishment has “ignored and thus tolerated the promotion of junk food, industries producing dangerous by-products, hazardous work practices, urban planning that reduces incentives and opportunities for exercise, and many other unhealthy aspects of everyday life, not to mention the massive level of iatrogenic disease.” (Martin, 2004, p.716) The work of Edmund D. Pellegrino can reassure us in the face of these philosophically and ethically odd behaviors (biomedicine professionals, after all, are supposed to be as committed to healing as we are), not to mention the willful marginalizing of the naturopathic profession, its values, and its successes.
Pellegrino has been a scholar of bioethics and the philosophy of medicine for several decades. He writes about familiar topics whose intended audiences are his own academic colleagues and the status quo allopathic world. Even so, his ideas and themes ricochet through our eclectic conversations about naturopathic medicine too. As a case in point, Pellegrino’s original work on the healing relationship is a key component in his larger goal of placing humanism into the standard allopathic medical curriculum. In this regard, Pellegrino also writes about the “patient’s good.” Essentially, his lifetime scholarship is about “virtue-based normative ethics for health care.” His abundant writings and the journal he founded, The Journal of Medicine and Philosophy, are a rich resource for reflective natural medicine professionals.
What is valuable for those of us in naturopathic medicine, particularly the educational and professional preparation portion, is to take note that what has happened to the biomedicine profession has also affected the accredited professions in natural medicine. At one extreme we may even be concerned that, in Pellegrino’s words, “the profession of medicine [has] [already] transformed from a guild to a trade” (p.5). The symptoms of this transformation are echoed in what the early naturopaths and contemporary naturopathic physicians consider to be true of the dominant, orthodox biomedicine profession and the industry which has grown up around it. Among many others, Pellegrino identifies 7 particular challenges to the biomedicine profession (Pellegrino, 2008, p.6). They are familiar territory for us too: 1) overspecialization and over-professionalization; 2) insensitivity to personal and sociocultural values; 3) too narrow a construal of the doctor’s role; 4) too much “curing” rather than “caring”; 5) not enough emphasis on prevention, patient participation, and patient education; 6) insensitivity to the poor and socially disadvantaged; and 7) overmedicalization of everyday life.
Virtue as a Professional
Despite these blemishes to sustainable, ethical professional formation, Pellegrino feels that the doctor – allopathic, naturopathic, TCM, or Ayurvedic, to name the main groups – nevertheless has a continuing obligation to relationship, and only in relating can there be what he calls “the possibility for virtue as a professional.” For him, the professional healer simply has to “maintain … autonomy over political and socio-economic pressures.” We may wonder to what extent the natural medicine professions are cognizant of Pellegrino’s list, at the same time as we wonder about mainstream allopathic medicine and its subsidiary professions. We may worry that our beliefs and preoccupations (always catalysts for what we teach our students), via the framework of curricular materials we keep re-engineering, tinkering with, and delivering, are inevitably propelling the profession in the same direction.
On balance, I think not. One marker of our differing path is that the philosophers in the naturopathic medicine profession do not hesitate in a landscape where evidence-based medicine is a mantra, and where presenting our therapies, modalities, and research outcomes in scientific packages are important strategies for acceptance, to challenge at times the validity and utility of the science behind medicine. These same colleagues continue to present a counter to the day-to-day practice of research and clinical work defined by scientific inquiry. Their voices still live in many of the students who found their way to our programs, seeking to heal people and a planet hungry for holism without drugs and invasive protocols.
In defense of this perspective, one could have a look at Peter Medawar’s argument in “Is the scientific paper a fraud?” (1993) or at the still-famous 1979 Herbert Spencer lectures (Heath, 1981), to be reminded that philosophy and science are perhaps no more compatible with regard to medicine these days than they were a century ago. In fact, some claim that as we build the profession, we must not let the philosophical basis of contemporary naturopathic practice become shredded by a compelling need to move from the status of a heterodox medical system to an orthodox one, as occurred, say, for the osteopaths. The biomedicine lobbyists in state legislatures formally assault naturopathic doctors as clinically heretical because we hang on to values and modalities that they find unacceptable, and they couch their claims in the jargon of science.
Dissent in Medicine
What some say is “dissent and heresy in medicine” (Martin, 2004, p.713) is really about the domination of the marginalized by the orthodox players who don’t want to let their privilege and power slip. They can’t imagine cooperation in the landscape of primary care. Even when the scientific method is utilized to announce an important finding in defense of some aspect of our medicine, those conclusions are invariably dismissed as unscientific and heretical. An example is Benveniste’s remarkable conclusion that very dilute solutions “can have biological activity” (Davenas et al, 1988), in support of the field of homeopathy; such conclusions are flung into the land of heresy by orthodox biomedicine authorities, many of whom cannot imagine a reality or framework different than their own.
Some of our colleagues are exasperated by the unrelenting opposition to licensing by MD and DO lobby teams in state legislatures, not understanding why well-educated healthcare professional bodies cannot tolerate, in their own philosophies and political entitlements, multiple truths about the potential of different modalities and paradigms of health promotion, even when a particular therapy is shown to be effective. Martin suggests, about such a “market of modalities,” that patients are less inclined these days to hold some a priori assumption that “any single modality provides a universal answer.” (Martin, 2004, p.714) What is happening, Dollemore insists, is that the increasing role of markets in health and medicine “means that modalities compete with each other in a market in which claims to exclusive truth are less persuasive than in the past, with consumers’ demands for ‘choice’ fostering a tolerance for diverse truths.” (Dollemore, 1997, p.37)
What we need instead is an assumption of a “plurality of truths” (Martin, 2004, p.715) in which “researchers and practitioners would be happy to help each other develop greater insights on a range of perspectives.” (Martin, 2004, p.715) Alas, in the real world of biomedicine, research and practice are characterized by rivalries and power plays (Boffey, 1975; Dickson, 1984; Greenberg, 1967). In such a world, we diminish ourselves by adopting strategies designed simply to defeat biomedicine politically and to gain inherent advantage and control.
Despite our best intentions and tactics, it will take more than, say, publishing outstanding research within the same epistemological sector that Baer calls the “dominative, orthodox medical system” (Baer, 2001, p.43), to make a dent and carve out a safe place. Perhaps, as Martin suggests, we would be more successful by “competing for more market share” (Martin, 2004, p.716), and in lieu of “trying to compete on epistemological grounds, namely tackling orthodoxy on its own terms, to examine instead each of the methods by which orthodoxy maintains its position.” (Martin, p.716) We have been doing some or a lot of this, for decades, state by state, research article by research article, and agency by agency (eg, regional accreditation for our standalone schools, loan forgiveness, media and public forum presence, corporate funding for research).
Alas, some scholars remind us that by cooperating with the dominant orthodox medical establishment in order to gain their recognition and their neutrality is, in the end, just a widespread myth. (Collins & Pinch, 1998; Feyerabend, 1975; Mitroff, 1974).
Our best strategy is likely to seek, build, and call to the attention of beleaguered consumers of health our very real clinical and healing successes. Results touch lives by referral, reputation, and reach. Our training must include not only the best didactic and clinical education possible, but also consciously avoid those top 7 challenges along the path of professional formation that Pellegrino points out as diluters of professional integrity and effectiveness in the world.
Baer, H. (2001). Biomedicine and Alternative Healing Systems in America. Madison, WI: The University of Wisconsin Press.
Boffey, P. M. (1975). The Brain Bank of America: An Inquiry into the Politics of Science. New York, NY: McGraw-Hill.
Collins, H. M., Pinch, T. (1998). The Golem: What You Should Know About Science. (2nd edition). Cambridge, MA: Cambridge University Press.
Davenas, E., Beauvais, F., Amara, J., et al. (1988). Human basophil degranulation triggered by very dilute antiserum against IgE. Nature, 333 (6176), 816-818.
Dickson, D. (1984). The New Politics of Science. New York, NY: Pantheon.
Dollemore, D. (1997). New Choices in Natural Healing. New York, NY: Rodale Press.
Feyerabend, P. (1975). Against Method: Outline of an Anarchistic Theory of Knowledge. London, England: New Left Books.
Greenberg, D. S. (1967). The Politics of Pure Science. New York, NY: New American Library.
Heath, A. E., Ed. (1981) Scientific Explanation. Herbert Spencer Lecture. Oxford, England: Clarendon Press.
Martin, B. (2004). Dissent and heresy in medicine: models, methods, and strategies. Soc Sci Med. 58 (4), 713-725.
Medawar, P. (1993). Is the scientific paper a fraud? In: The Strange Case of the Spotted Mice. Oxford, England: Oxford University Press: 33-39.
Mitroff, I. I. (1974) The Subjective Side of Science: A Philosophical Inquiry into the Psychology of the Apollo Moon Scientists. Amsterdam, Netherlands: Elsevier.
Pellegrino, E. D. (2008) The Philosophy of Medicine Reborn: A Pellegrino Reader. Engelhardt, H. T., Jr., & Jotterand, F., Eds. Notre Dame, IN: University of Notre Dame Press.
Image Copyright: <a href=’https://www.123rf.com/profile_lakhesis’>lakhesis / 123RF Stock Photo</a>
David J. Schleich, PhD, is president and CEO of the National University of Natural Medicine (NUNM), former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).