JAMA Vol. 159 No. 18,
October 11, 1999

Is Integrative Medicine the Medicine of the Future?  
 
A Debate Between Arnold S. Relman, MD, and Andrew Weil, MD 

 

Editor's Note: I believe that many of our readers will be interested in the transcript of this debate, which was held at the Arizona Health Sciences Center, Tucson, on April 9, 1999. It pits Dr Andrew Weil, the leading proponent of integrative medicine, against a very distinguished adversary: Dr Arnold S. Relman, editor-in-chief emeritus of the New England Journal of Medicine.—James E. Dalen, MD, MPH

DALEN: Now it is my pleasure to introduce Dan Rutz, senior medical correspondent for CNN, who has graciously agreed to moderate this important debate.

RUTZ: Thank you, Dr Dalen. Good evening and welcome. The 18 years I have covered medical news for CNN have gone by quickly. It is because the field is so broad, the topics so compelling, and the pace so quick. It can be safely said there is never a dull moment. The part of the fascination that makes health and medical information the subject of such universal interest lies in its complexity and in the different perspectives the experts bring to their field. Indeed, the frequent admonition for patients to seek a second opinion is based on the premise that reasonable opposing arguments can often be made regarding how best to manage certain conditions or to prevent disease in the first place. This evening, we have an exciting opportunity for respected, reasonable experts to disagree. We will also find, I am sure, many areas of common ground between them. Let me introduce our debaters.

To my right, Dr Arnold Relman, who is editor-in-chief emeritus of theNew England Journal of Medicine, one of the most respected publications of its kind in the world. He is also professor emeritus of medicine and social medicine at Harvard Medical School, Boston, Mass. Dr Relman is a fellow of the American Academy of Arts and Sciences, a member of the Institute of Medicine of the National Academy of Sciences, and a former president of the American Federation for Clinical Research, the American Society of Clinical Investigation, and the Association of American Physicians. He is an outspoken critic of alternative, complementary, or the preferred term among proponents, integrative medicine.

Opposing Dr Relman is Dr Andrew Weil, director of the University of Arizona Program on Integrative Medicine. Dr Weil is an internationally established authority in the field. He is the author of 8 books and many scientific and popular articles on the incorporation of complementary interventions into modern medical practice for preventing and treating disease. So recognized is he in this area that in 1997 Time magazine named Dr Weil one of the nation's most influential people. His expertise includes the fields of drug and drug abuse, addiction, medicinal plants, and reforming medical education. Dr Weil holds advanced degrees in botany and medicine from Harvard University. He is very much an endorser of the concept of integrative medicine and is working to broaden its acceptance across the United States.

Our debate has been structured according to a mutually agreeable format. Both doctors will have 15 minutes for opening statements, followed by 5 minutes for a rebuttal from each one. After that, I will pose questions submitted by the participants but not shared with their opponent in advance. There will be 3 minutes allotted for each response. The debate will close with concluding remarks from both doctors, and I would remind the audience here in the studio to withhold their applause until the conclusion of the debate. We will begin with Dr Relman.

RELMAN: Thank you, Dan. Ladies and gentlemen. So-called alternative medicine, and its challenge to conventional medicine, is a large subject that cannot be adequately explored in a relatively brief debate of this kind. Instead, Dr Weil and I have agreed to concentrate primarily on the question of whether alternative medicine can and should be combined with conventional medicine to create a new entity called integrative medicine. He thinks such a step would be a major advance. He says, "Integrative medicine is the future and our healthcare institutions will not survive without it." I think he is seriously mistaken. In my view, integrating alternative medicine with mainstream medicine would not be an advance but a return to the past, an interruption of the remarkable progress achieved by science-based medicine over the past century. I can't see how such integration, even if it were possible, would improve medical care or further the cause of human health. What is more, considering all the dubious and disparate theories and practices gathered under the banner of alternative medicine, I don't see how our medical schools could make sense of such a hodgepodge, much less unify it with conventional medicine. Most alternative systems of treatment are based on irrational or fanciful thinking and false or unproven factual claims. Their theories often violate basic scientific principles and are at odds not only with each other, but with current knowledge of the structure and function of the human body as now taught in our medical schools. They could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests. Future advances in clinical practice will depend on the application of new developments in science, biotechnology, molecular pharmacology, and on the use of clinical epidemiology based on the analysis of objective clinical data. Indeed, it is hard to imagine any progress at all in the prevention, diagnosis, or treatment of disease without continued, even closer cooperation between modern science and evidence-based medical practice. With the promise of so many new breakthroughs in the offing, why on earth should we now want to drive a wedge between medicine and science? Alternative medicine stands apart from modern science, challenging many of its assumptions and methods and depending for its verification largely on personal belief and subjective experience. In sharp contrast to mainstream medicine, alternative medicine makes no distinction between objective phenomena and subjective experience or between the external world and human consciousness. This allows the practitioners of alternative medicine to believe in the power of mind and thought to change physical matter and heal organic diseases—a concept that basically contradicts the laws of physics in the modern scientific view of nature. Furthermore, since alternative practitioners also are convinced that individual subjective experience is the ultimate verification of truth, most of them do not see the need to obtain objective statistically significant data in order to test whether their methods really work. Medical science teaches practitioners to look for objective evidence before adopting a clinical method. But alternative medicine teaches that faith in a method will make it effective and that the strongest kind of evidence is the patient's belief that a treatment is working. How would the proposed new integrated curriculum deal with this wide philosophical gulf between alternative and conventional medicine? Dr Weil seems to be of two minds: On the one hand, he says that "good medicine must be consistent with good science" and he believes in basing clinical practice on clinical trials and other objective evidence. On the other hand, he often ignores medical science by supporting the concept of healing through the physical action of nonphysical forces, and by advocating the superiority of alternative treatments and herbs over conventional treatments and standard pharmaceuticals, based on little more than his own opinions and undocumented experience, or on the stories of others.

Here is just a very small but representative sample of the many unproven and often highly unlikely claims made by Dr Weil in his book:

1.       Improper breathing is a common cause of ill health and breathing exercises will cure disease and promote good health.

2.       Massive doses of intravenous vitamin C speed the healing of surgical wounds.

3.       Guided imagery, meditation, or hypnotherapy will reduce the frequency of recurrent attacks of herpes simplex.

4.       Topical application of human urine is effective treatment for athlete's foot.

5.       Two tablespoons of ground flaxseed daily reduces the risk of breast cancer.

6.       Cutting down on sugar intake decreases the frequency of urinary tract infections in nondiabetic women.

7.       Therapeutic touch and other forms of so-called energy medicine can heal disease through the manual transmission or adjustment of types of so-called energy that are simply too subtle to be detectable by instruments.

8.       Belief alone, without any physical intervention, can cure organic disease as "proven" by visits to miracle shrines, faith healers, and Christian Science practitioners. (Here, I might note in passing that, with respect to the investigation of claims of miraculous cures, the Catholic church lately seems to be doing a more thorough job than the apostles of alternative medicine.)

Would such teaching become part of Dr Weil's new curriculum?

When challenged about the scientific implausibility of many of his methods, particularly those based on the alleged healing power of thought, Dr Weil sometimes invokes quantum mechanics and other recent developments in theoretical physics. Like other gurus of alternative medicine (Deepak Chopra, for example), he apparently believes that quantum physics proves that human consciousness can change and even create external reality. Thus, he believes that the mind may be able to heal serious physical illnesses through mechanisms that classical physics can't explain or even test. This presumably is why he believes a new integrated medical curriculum should include recent developments in physics.

This idea cannot be taken seriously. It reflects a basic misunderstanding of science in general and of quantum theory in particular. As clearly stated by every distinguished physicist who has ever written about these matters, all physical theories, new or old, must be validated by objective data. Advocates of alternative medicine cannot avoid the need to test their methods simply by their vague allusions to "new scientific paradigms." Without objectively verifiable evidence, there is no reason to believe the claims of alternative medicine, particularly when there is no plausible biological mechanism by which many of its methods might work. Furthermore, as several leading physicists have written, quantum theory says nothing about human consciousness or its possible effects on the physical world, and it provides no support for the belief in so-called paranormal phenomena. Quantum theory is simply a mathematical tool for describing and predicting subatomic phenomena. It is not permission to believe in the kinds of magical cures claimed by Dr Weil in his books.

Before completing my argument, I want to say something very briefly about herbal therapy, which would be an important feature of Dr Weil's proposed new curriculum. In one sense, herbal therapy should not be in fundamental conflict with the conventional medical curriculum, because many plant-derived materials have important biological effects. We all know that many pharmaceuticals now in use were derived from plants, and doubtless many more will be discovered.

Unfortunately, however, herbal products are not regulated by the FDA [Food and Drug Administration], and so commercially marketed herbal preparations are highly variable in content, purity, and potency. What is more, they have passed no tests for therapeutic effectiveness or safety. Despite these facts, drugstore and supermarket shelves are filled with all kinds of herbal products and dietary supplements, and consumers are increasingly being bombarded by a confusing and misleading advertising blitz from the manufacturers.

Dr Weil says that the FDA "needs to create a new division of natural therapeutics to regulate herbs, vitamins, minerals, and other dietary supplements," but he hasn't said, that I am aware of, what kind of regulation he has in mind or whether and why the regulation should be different from the FDA's existing oversight of prescription pharmaceuticals. He ought to tell us what is special about these "natural" therapeutic substances that might require a different regulatory approach, if that is what he believes. Is it the fact that natural plant preparations contain many different kinds of active molecules rather than a single active molecule as in most prescription drugs? If so, these can and should be identified and tested, singly or in combination, for effectiveness and safety. We need to see many more controlled studies comparing standardized herbal preparations with conventional pharmaceuticals before concluding that herbs have any special advantage over conventional drugs and that herbal therapy should be taught in medical schools. The March 1990 issue, the last issue of Consumer Reports, has an excellent article on this subject that explains why today's over-the-counter herbals are not ready for prime-time medical use.

The paucity of good clinical studies of alternative methods and herbal therapy in the peer-reviewed medical literature is said by some to be explained by the biases of medical journal editors against such studies. As a former editor, I know that claim to be untrue. The fact is that there have been relatively few rigorous clinical studies of alternative methods submitted to the leading peer-reviewed journals. As Dr Weil correctly argues, this is partly due to lack of funds to support such studies, but I believe that the main explanation is that alternative practitioners, so far, have had very little use for the conventional scientific approach, preferring instead their own "person-friendly" version of "alternative science," which depends more on subjective experience and intuition than on objective quantitative evidence.

A new interest in alternative medicine is now generating support from government agencies and foundations for clinical trials of alternative methods, and that is all to the good. We should certainly reserve final judgment about the alternative methods presently undergoing, or slated soon to undergo, clinical trial. But why, in the name of common sense, should we now rush to bring most of what is called alternative medicine into the mainstream of medical education and practice, when the existing evidence to support its claims and theories is so weak and the probabilities of the validity so small?

If any alternative methods prove to be effective in treating disease, they should be integrated into the medical curriculum, and they will be. All clinical biases and preconceptions, whether in alternative medicine or conventional medical practice, must fall before the objective evidence, and we should all be assiduous in seeking such evidence to improve our practices. However, in the absence of evidence, it makes no sense to remodel our clinical training programs to include alternative medicine simply because many "customers," to use Dr Weil's term, seem to want it. If alternative medicine is considered a business, I suppose that would be sufficient reason, but I hold to the old-fashioned view that medicine is a profession and that physicians owe their patients something more than simply offering services that are currently popular. At the least, they owe patients their best professional advice, based on the most reliable information. By that standard, alternative medicine does not qualify for admission to the medical mainstream.

RUTZ: Thank you, Dr Relman. Now we will hear from Dr Weil.

WEIL: Thank you, Dan. In this country and throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help. This is a movement that has been building since the late 1960s, and it's now reached the point that visits to alternative practitioners exceed visits to primary care providers and the amount of money spent on these visits exceeds that spent on visits to primary care providers, so this is a very powerful social and cultural force that we're witnessing. Now, why are people doing this? Clearly, there is dissatisfaction with conventional medicine. I don't think it is simply with the recent impersonality and time constraints that have come with managed care, because this movement began long before that. In my experience—and I know this is a phrase that Dr Relman doesn't like, but I consider experience to be one valuable source of data—in my experience, many patients use alternative methods because they work. If a patient has tried a method and found that it works, that patient needs no further proof, does not need to read the reports of a randomized double-blind controlled trial in a medical journal to be convinced of the efficacy of treatment. So, I think large numbers of patients have found that there are treatments out there that their conventional physicians did not know about, did not advise them about, that have worked for them in some cases after conventional medicine has failed. One of the arguments that I hear from opponents of this movement is that patients in going this route are refusing or delaying real treatment from conventional medicine. That also goes against my experience of many years as a practitioner of this kind of medicine. The vast majority of patients who have come to me and the vast majority of patients who now come to the integrative medicine clinic in this institution are patients who have been through conventional medicine, often many times over, have been tested to death, have tried many conventional therapies, and have found that they haven't worked or have caused harm or both, and it is that which motivates them now to look for other kinds of treatments. We have to take this consumer movement seriously. It is not just that consumers want it. I think there are valid reasons why they want it and have found it to be useful, and furthermore, it is not just consumers who want a change in medical education. Significant numbers of medical students today are asking for this kind of instruction, as are physicians in training and physicians in practice. There is a large and growing gulf in this country between what patients expect of doctors and what medical schools are training them to do. Patients want physicians who have the time to sit down with them and listen and explain to them in language they can understand the nature of their problems, who are aware of nutritional influences on health, who will not just push drugs and surgery as the only approach to treating illness, who can intelligently answer questions about dietary supplements, who are sensitive to mind-body interactions, who will not laugh in your face if you ask questions about Chinese medicine, who are willing to look at you as more than just a physical body. I think those are reasonable requests, but that's not what we're training physicians to do. It is that widening gulf between patient expectations and physician realities that is leading so many patients to go elsewhere for treatment. One of the reasons that I feel passionate about bringing this kind of training into our medical schools is that I feel a very strong commitment to my profession, and I would like to see it better answer the needs of people. My impression is that many patients now going to alternative practitioners, if given a choice, would prefer to go to a physician who had basic medical training and was also knowledgeable about and open-minded about other treatment options, who could act as a guide or an advisor in making difficult treatment decisions. For example, our integrative medicine clinic has seen an enormous number of cancer patients over the past year and a half, and I must say I feel very sorry for many of them. I think they're left out in the cold. Their conventional oncologists give them standard treatments and tell them that there's nothing else to be done. They know that there are other things to be done, that there are remedies that can mitigate the toxicity of the standard therapies, can protect their immune systems from those therapies, can enhance general health. They go to alternative practitioners who tell them that if they use the conventional therapies they may as well not bother with the alternative treatments. So, it's the patient that suffers. How much better it would be if there were physicians trained to advise patients about the intelligent combination of the available therapies. This is what patients want, but they can't find that kind of service. By the way, I think it is interesting that some of our critics who don't really know what we do have accused us of taking all cancer patients off chemotherapy and putting them on herbs. We went back and looked at the records of cancer patients we have seen over the past year and a half. Of the first 60, none was taken off any kind of conventional therapy, and 11 who said that they would not do conventional therapies were persuaded by our integrative medicine fellows to do them in combination with other supportive measures.

I would like to say something about the issue of science-based medicine and evidence-based medicine. I consider myself a scientist. The word science comes from the root of a verb to know. There are various ways of knowing. One is paying attention to one's own experiences, as I have said. Another way is from the collective experience of other cultures. Here is an example from my own field of ethnobotany. If you are a pharmaceutical company looking for new drugs in the rain forest, you have a choice as to how you can go about the search. You can go into a geographical area, take every plant that grows in the area, bring it back, and screen it for biological activity, or you can target a particular plant family. But there is another way you can do things. You can go to the shamans in the cultures who live there, and you can ask them to show you the plants that they have learned work for certain conditions and take those back for testing. When you compare those 2 approaches, there is a significantly higher percentage of hits if you take the plants that have been brought into use by people over thousands of years of experimentation. Another aspect of this issue is the claim that conventional medicine is science supported by evidence. The Office of Technology Assessment of the US Congress has estimated that fewer than 30% of procedures currently used in conventional medicine have been rigorously tested, and I think there are many, many examples of procedures in common use today that are not backed up by the kind of evidence that Dr Relman would like to see. That includes the use of open heart surgery in general and coronary artery bypass grafting in patients where the evidence does not support its use. I am all for refining our medical practice and making it more consistent with scientific evidence, but as Dr Relman himself has pointed out in an editorial in the New England Journal of Medicine, medicine constantly operates in areas of uncertainty where the evidence has not yet come in. There is a great difference between being a researcher and being a practitioner. As a researcher, you have the luxury of insisting on rigorous scientific testing and you have the leisure to wait for results to come in. As a practitioner, you are in the trenches working with patients who have medical needs and you often have to guess to use your best medical judgment in the absence of definitive evidence. What do you do then? It seems to me that you do the best you can, and the first principle from which you operate, or should operate, is that you do no harm. That was Hippocrates' most famous teaching, and I fear that it is not sufficiently stressed in medical education today. As an example of what I mean, I would cite a lead article that was published in the Journal of the American Medical Association exactly a year ago entitled "The Incidence of Adverse Drug Reactions in Hospitalized Patients" that estimated that there are now 100,000 deaths a year in US hospitals directly caused by pharmaceutical drugs. In contrast to the few disasters that happen with herbal medication, these are the correct drugs, correctly prescribed for the correct condition. In herbal medicine, often a misidentified plant has gotten into commerce and caused a problem, but this article concerned the right drugs and the right doses being given to the right patients killing 100,000 patients a year, and this is now estimated to rank between the fourth and sixth leading cause of death in hospitals in this country. These drugs have come through the process of rigorous testing. They have come through the FDA's regulatory mechanisms, and nonetheless, they are producing this degree of harm. If integrative medicine did nothing other than reduce the incidence of this direct kind of iatrogenic harm, I think it would be very worth incorporating into our medical schools and teaching.

I would also like to comment on the kinds of bias that exist in conventional science, especially in medical journals, against the acceptance of novel ideas, and here again, let me just cite one example that also appeared a year ago. An article that was published in the Proceedings of the National Academy of Sciences described excellent research that used MRI [magnetic resonance imaging] scans of the living brain to show that stimulation of acupuncture points on the lateral aspect of the foot, points associated with vision in traditional Chinese medicine, caused activation of the visual cortex identical to the activation caused by stimulation of the retina by light. Stimulation of points a few centimeters off from these traditional acupuncture points did not cause visual cortex activation. That paper was rejected by the New England Journal of Medicine, and it was rejected by theJournal of the American Medical Association before it finally found a home in the Proceedings of the National Academy of Sciences. Despite what Dr Relman says, there is very strong prejudice against accepting ideas that run counter to preconceptions such as Chinese medicine being superstitious and on the face of it absurd; such attitudes lead journal editors and heads of medical institutions to ignore or at worst to suppress evidence that comes in contrary to expectations. I don't think you can have it both ways. You can't demand evidence, and then when evidence is presented that contradicts your preconceptions, say you aren't going to look at it. I am not so optimistic about resolving our differences because, while we do have common ground, I think there is a real difference in world view here. I feel strongly that integrative medicine is the future, not only because people want it, but because very powerful forces operating both within science and outside of science are moving us in this direction. Demand for it is not just coming from the customers. It is now beginning to come very strongly from practitioners and members of the profession. Large numbers of physicians in practice realize that they did not get the training required of them to satisfy the needs of patients today, and increasing numbers of medical students are asking why they aren't learning about botanicals, why they aren't learning about the role of phytoestrogens in flax and, say, as possible preventives of breast cancer, for example. So I think it is inevitable that we move in this direction. I feel very fortunate to be at a medical institution that recognizes this reality and supports the development of new curriculum as well as the studies that I strongly agree with Dr Relman are required to produce the kind of evidence that will lead to changes in how we practice medicine. Thank you.

RUTZ: Thank you very much, Dr Weil.