Anthroposofie Anhang 3
[Christof Schnuerer]
Anthroposophic Medicine - An Attempt to Present the Clinical Practice
Anthroposophic medicine - unreasonable?
Dr. Kiene has given an outline of the epistemologic background to the
difference between conventional and anthroposophic medicine.
Conventional medicine claims to seek exact scientific methods and sees
anthroposophic medicine as a medicine based on faith, at most granting it a
basis in the science of the spirit but generally believing it to arise from a
mythical, self-contained conception of the world that is not open to critical
examination.
Such a philosophy carries the risk of losing sight of the man's
different dimensions in scientific work, clinging instead to a world of
mythical images that ultimately are religious by nature.
You have to be without bias if you want to follow or dispute new areas
of theory and practice. Strange notions that may even strike one as
"mystic" are part and parcel of new territory, and that applies to
other fields of established sciences as well. An example would be the language
and experiences found in modern quantum mechanics.
Development of holistic
medicine
The basic principles have already been given by Dr. Kiene.
Characteristically, progression involves going:
- from detail to complex situations,
- from quantity to quality,
- from thinking in static terms to thinking in terms of processes,
- from microscopic to macroscopic.
Statements acknowledging the need for such an approach have increasingly
appeared in recent medical literature.(3) For example, there is the call to
replace "male, dismembering" medicine with a "female,
synthesizing" approach or to complement "technological" medicine
with one that "uses the word." Quality of life is becoming
a valid target in medicine, and terms such as "spirituality,"
"meaningfulness" and "religiosity" are included in coping
research.
Recognized research methods nevertheless continue to go in the direction
of increasingly smaller entities and quantifying paradigms, with everything
reduced to numbers. "Evidence, transparency and reproducibility" -
ultimately reduced to the mathematical parameter of "probability of
error" - are the key slogans used in the discussion of method.
Dealing with individual human lives, illnesses and death, and people's
search for meaning becomes a "strategy" to be standardized,
quantified and made subject to therapeutic functionalism. Efforts and resources
being expended on more and more sophisticated diagnostic instruments are
increasing at the same rate as the complexity of target parameters.
Methodological discussion is governed by fear of losing the solid ground of
mathematical significance with little imagination used to find new approaches.
Methods to perceive an integral reality require a mental leap to find new ways
of perception. This demand, formulated by P. Petersen is something hardly
anyone dares consider.
Two essential approaches to the exploration of
nature - the scientific approach
I am not against the established methods of research. It is not a
question of taking integration as the only true approach, saying that
particularization is wrong.
These are two routes, and both are needed if we are to get a
comprehensive picture; they are the two sides of one coin.
Confusion arises when people think the two routes can be followed using
the same methodological equipment. That would be like attempting to climb
Everest wearing a miner's outfit. In my opinion, methodological problems in
clinical research (and not only in research relating to quality of life and
coping) are due to encroachment of one route on the other. The two are
diametrically opposed, and it seems reasonable to accept that
"diametrically opposed methods of research" have to be applied.
However great the difference in methodology, neither route should
abandon the modern scientific approach. The route can be shown in outline as a
closed circuit: exact observation to developing a concept to establishing a
meaning context to establishing hypotheses on the basis of this to testing
hypotheses by means of - exact observation.
Anthroposophic medicine
- an alternative approach?
Anthroposophic medicine represents an attempt to recognize both routes
to full perception of both nature and man and enter on the difficult route of
exploring the second aspect. Anthroposophic medicine is considered to be a
complement or extension of conventional medicine. This may make it an
alternative to the "one-sidedness" of particularist medicine but not
an "alternative approach" in the established sense.
Anyone who is unable to see this will never be able to understand the
practice of anthroposophic medicine. Such a person may be surprised when an
anthroposophic physician prescribes conventional drugs. The syndrome, the
patient's receptiveness and current potential, and the physician's experience
are the factors which determine the choice of a particular treatment. Because
of this, there is no finite anthroposophic system of treatment nor routine
therapy. Anthroposophic medicine is not closed off from the outside or inside;
it is not self-sufficient. Practically speaking it evolves out of
"conventional" medicine, is still in its beginnings, and both are in
need of and capable of development.
"Alternative therapists" - preventing
essential treatment?
The argument encountered most frequently in public discussions is that
"non-conventional" therapists may delay or even prevent
"essential treatment." This caring argument is about as true as the
sweeping statement that "side effects of conventional medication can put
people's life and health at risk."
Apart from the fact that the essential nature of a treatment needs to be
defined in each individual case with human freedom taken into account, both of
the above hold true for both approaches in medicine. Quantification and proof
are only possible for statements concerning side effects of conventional
treatment. Like traffic accidents, side effects are often defined as residual
risks inherent in progress.
To avoid all misunderstanding: anthroposophic physicians also make
mistakes, make wrong assessments of situations or misdiagnose, and I am as
prone to error as anyone else. I doubt, however, that the incidence of error is
greater than among colleagues using conventional medicine only.
Let those who consider themselves to be free from such faults throw the
first stone. Everyone else should beware of blaming a particular group of
physicians for the mistakes made by individual members of the group.
Clinical practice - a case history
A male patient aged 70 had been under our outpatient care for chronic
lymphocytic leukemia, bronchial asthma and hypertension for six years. First
admission as an emergency: hypotensive crisis with epistaxis and circulatory
collapse following antihypertensive medication when anemic due to the leukemia
(leukocytes 100,000/mcL, Hgb 10.0 gm/dL).
The patient was already booked for chemotherapy at a nearby tumor
center. His admission to our hospital was "by chance" - I am
expressly choosing this term.
Initial treatment was gentle blood pressure reduction (calcium
antagonist) using the standard conventional method.
Following detailed discussion with the patient we also initiated
treatment with potentized Viscum album. The patient recovered well on this regimen,
with a slight drop in leukocyte count. We were able to discharge him, our
recommendation being not to have chemotherapy.
This is the point where ethic and legal questions arise:
1. Was the proposed chemotherapy an absolute necessity?
2. Will delaying chemotherapy have a negative effect on the patient's
health or, indeed, shorten his life?
3. What justification is there for an approach to treatment which is not
scientifically proven (as the saying goes) when there are others available that
are proven?
A young colleague in our department felt no doubt at all that the
patient should be transferred immediately for chemotherapy or that we should at
least initiate it ourselves. This is what he had been taught in medical school.
It was not easy to get him at least to consider another way. His response was
an ironic smile.
On the basis of several years of experience I had come to the conclusion
that, in answer to these questions:
1) chemotherapy was not an absolute necessity at this time,
2) there was no certainty that chemotherapy would improve either quality
of life or life expectancy at this stage (the opposite might also be the case).
The answer to question 3 arises from the other two and from the
patient's wishes. If he had shown inner resistance or anxiety when we discussed
delaying chemotherapy with him, our decision would have been different.
"Informed consent" is the term used today for what are really
self-understood ethic principles.
January, 1994, febrile "influenza-type infection" with
bronchitic and asthmatic component. His family physician, clearly concerned
about the reduced immune status with lymphocytic anaemia, prescribed
trimethoprim and sulphamethoxazole. This gave no improvement but resulted in
optic hallucinations, anxiety states, hypertensive crisis and increasingly
severe asthma. Emergency admission.
The hypertension and asthma proved treatment-resistant initially,
necessitating a move to the intensive care unit. Treatment consisted, among
other things, of nitrates by i.v. infusion, corticosteroids in high doses and
parenteral bronchospasmolytics, as in any modern intensive care unit.
Finally, the patient also developed a gastrointestinal haemorrhage which
was stopped using endoscopy and required a number of transfusions. The
leukocyte count shot up to 150,000/mcL in the meantime.
The patient was discharged home a good two weeks after his return to the
medical ward. Sole medication: Viscum album in potentized form.
The corticosteroid and the antiasthmatic agents had been gradually
discontinued, with anthroposophic medicines given at the same time; peak flow
monitoring showed no decrease in airways resistance. More or less the same
applied to medication given for hypertension and the ulcer.
The patient felt "better than I've been for years"; leukocytes
had dropped to 70,000/mcL(!), a fortnight later (out-patient) to 46,000/mcL.
During the in-patient period we had also prescribed painting therapy.
The patient showed remarkable sensitivity, ability and enthusiasm for this. New
experiences and a new field of activity opened up for him. In our opinion this
was one of the reasons for his rapid recovery and the improvement in asthmatic
and hypertensive regulatory disorder - he was able to free himself more quickly
from his fixation in illness.
Decision structures in treatment strategy
The above case history illustrates not only my thesis that
anthroposophic medicine is an extension of conventional medicine but also the
decision structures:
1. The armamentarium covers the whole range from cytostatic chemotherapy
to the use of potentized substances (with all imaginable
"concentrations" in between); from surgical removal of the tumor to
the use of mistletoe extracts; from high doses of corticosteroids to mustard
packs (accelerate reactions) or cool quark compresses (curd cheese, reduces
swelling); from modern intensive medicine to art therapies, eurythmy therapy to
rehabilitative sport. The list may be continued ad lib.
2. Differentiated choice of treatment, with stimulation and support of
self-healing taking precedence over substitution or medical measures to enforce
or suppress. In the above case: chemotherapy is only used if the disease
process threatens to get out of hand. Antiasthmatic and hypotensive drugs were
discontinued as soon as autonomic regulation had been restored. On the other
hand, all the means available in intensive care were used without hesitation in
emergency situations.
3. Taking account of individual reactivity, with the choice of treatment
dependent on this. Treatment can never be routine; therefore it is impossible
to foresee exactly which particular dose or measure will elicit a response or
may be too demanding.
4. The regimen is normally a combination of measures (including
conventional methods) acting at different levels of the homeostasis system,
supporting each other and thus having a cumulative effect (through a range of
different stimuli). The real art consists in achieving optimum efficacy and
minimum side effects using a large number of carefully balanced measures.
Last but not least, the case history provides a good illustration for
the discussion of "absolutely essential" treatments. The
antibacterial treatment which the family doctor had clearly considered
essential may be queried viz (a) its indication (antiasthmatic treatment would
probably have been more effective) and (b) choice of substance. It was not the
omission but the actual exhibition of this which put the patient at risk.
Two possible objections to the above method can be addressed here. This
is a single case, which proves nothing. A thesis can only be proven by
conducting high-quality trials. Changing from one system of treatment to
another and using several principles at the same time is unscientific.
Empathy, human feelings - a means of gaining knowledge?
In reply to the first objection: theoretical discussion on its own will
not provide conclusive evidence. The complexity of human existence can only be
conveyed if we enter into and share the real, everyday situation.
A patient's biographic aspects, intentionality and the world of feelings
can only be seen in their reality if we enter into them with empathy for the
patient who is looking for help and not infrequently is in despair. To do this,
we have to open up our senses.
The terms "empathy" and "entering into the patient's
situation" introduce a category into the cognitive process that may come
as a shock to well-trained scientists: "This is getting entirely
subjective. There are no methods that allow us to measure this."
Nevertheless, we are unlikely to arrive at useful results working with
things that do not "touch" us, for which we "have no
feeling."
Good ideas as to how to solve a problem do not come only if I do my duty
for an employer or follow a simply logical sequence of ideas. They come
"in a flash" if we enter into a problem seeking to understand it. How
much you accept what I am saying depends not only on the "truth" of
it but also on how far you enter into the subject I am presenting.
Feelings and intentions mark the beginning (selection of data) of any
investigation and if nowhere else certainly enter also at the end
(conclusions). Instead of eliminating those levels of human existence we should
use them methodically developing them so that, with practice, they can become objective.
The "instrument" for such methods can only be the
"empathetic, interested human being" - please take this as a sober,
entirely unsentimental statement. The human being is the instrument for all
scales indicating quality of life; validity of measurement depends on the
extent to which the investigator has learned to perceive the other person's
world of inner experience in an objective way.
Polypragmasy or rational treatment strategy?
Anthroposophic treatment and diagnosis will always be accused of being
polypragmasy, for it takes account of the multilevel nature of the human being
and the many different interdependences between levels (thinking and acting on
several levels at once, with the levels interpenetrating) and seeks to consider
the time element in human development when deciding on treatment (past and
future taken into account as real factors in the present). If we want to get an
idea of the pathogenesis of human diseases, four levels of human existence have
to be taken into account. The open relationship of these levels to the
environment can be explored.
Rational treatment derives from the laws governing the relationship of
these levels to substances and processes in our natural environment. The
efficacy of medicines developed on this principle must be able to stand up to
practical, critical assessment based on the above cognitive criteria.
Anthroposophic drug diagnosis and its application is neither mystic
polypragmasy nor a search for a needle in a haystack.
Human development - the random product of atomic structures?
The second of the above-mentioned aspects, the developmental aspect of
human existence, is the indispensable basis of anthroposophic medicine.
If we acknowledge the reality of human development, we as physicians,
human beings and scientists cannot avoid facing one fundamental question: is
human biography the outcome of random events - the permanent result of
collisions between atomic matter in cosmic space - or is it a meaningful
process, the logic and consecutive nature of which is evident both phylo- and
ontogenetically and, therefore, potentially open to investigation?
You may say this is of no interest for it goes beyond the potential
limits of perception - we no longer have a sound scientific base. This ranks as
a paradigm or, better, a hypothesis. It does, however, go completely against
the scientific spirit and comes close to the level of belief one has with an ex
cathedra statement that a hypothesis cannot be refuted.
Medical ethics and the question of meaning
In practical medicine we cannot evade the issue of the meaningfulness of
human development. It is indissolubly bound up with the ethics of medical
actions. The unspoken question as to meaning forms the background to many of
the problems in modern medicine: the euthanasia issue, questions concerning the
limits of maintaining life by technological means, gene technology, etc.
Where do concepts such as "basic ethic values" come from? What
right do we have to base ourselves on western Christian traditions when, on the
other hand, we accept the thesis that human existence is determined by
"chance" at the level of atoms and molecules? Atoms do not establish
ethics, nor molecules moral standards.
Where does the need for ethic guidelines come from? Is it random
energetic superstructure, emotionalism that will go away when the random
genetic mutation game of chance puts an end to the chimera? Or is it merely
internalized fear of the law givers, the guardians of social survival
convention? Are all of us really criminally inclined, needing laws and
regulations to ensure survival of accepted social forms?
How credible and effective are such ethic requirements, which have not
been thought through, when on the other hand we act on the premise that human
reality bases itself entirely on molecular and statistical laws of random
chance?
We have the outcome of the experiment based on this one-sided model
before our eyes in the socialist systems that have come to grief, with causes
and effects open to analysis: "syndrome based on illusionary misreading of
the world based on a one-dimensional model of the world; development of a
deluded substitute religion, which includes the creation of church-like
associations, veneration of idols, and millions of instances celebrating the
sacrifice of people and the environment." Such, no doubt, must be the
final diagnosis of the first "large-scale human experiment," the
attempt to organize the world on the premise that the positivist scientific
approach and the phony ethics derived from this alone have validity. Please do
not say this was only because people were not able to handle the model, for
that is exactly what all this is about: human beings are not merely the
calculable product of random chance; they are multidimensional. A complex
problem often needs to be overstated if it is to show up clearly.
How does this relate to the questions that have been raised?
- Everything has a value attached to it. Every action we take has a
"moral dimension." Impartiality to serve scientific purposes is also
a bias, that will always have real consequences.
- Basic premises - we may call them "philosophies" or
"pet ideas" perforce (and sometimes forcefully) determine our actions
down to their last consequences.
- Belief that the sense-determined aspect of human existence can be
excluded results in traditional religious affiliations being replaced by
substitute religions with known dogmatic structures: hierarchic forms,
councils, rules of behavior and exclusion without exception of anyone who does
not conform.
Human development - meaningful or meaningless?
Anyone may conclude from experience that a human biography is entirely
(mainly?) a matter of chance. The issue can only be decided on an individual
basis by sitting down and quietly going over one's own biography.
But we also have to respect physicians and scientists whose experiences
make them base their actions on the meaningful nature of individual
development. Such a basic premise inevitably leads to:
a. refusal to accept pathogenesis as meaningless, i.e. to see it in
terms of random chance, and (b) recognition of "moral principles"
(actions based on the premise that individual development is meaningful) in the
doctor-patient relationship.
An approach to medicine where chance is seen as an indispensable element
in the use of medicaments, excluding the concept of individual development and
seeing the therapeutic encounter between two individuals as an
"amoral" placebo effect - epistemologically speaking - may be right
for those who carry such convictions. They should, however, be honest enough to
admit that their scientific edifice stands and falls with the one basic
premise: chance is the meaning of human existence.
Research in anthroposophic medicine
Anthroposophic medicine and research cannot accept the paradigms of
random chance and molecular-atomic determinism. Their premises are:
- The physician is an integral part of treatment: a medicament does not,
in itself, have therapeutic action (it can at most have an effect or prove
toxic).
- Medical interventions and effects are always
a. aimed at a human being existing at many
levels
b. a combination effects, simultaneously
addressing the following levels in differentiated and individual fashion:
1. intentionality
2. mood
3. biorhythms and biological processes
4. physical and chemical reactions.
- The encounter between therapist and patient is also
a. subject to moral categories of action, which
are a primary factor
b. powers of self-determination and
self-regulation need to be strengthened at every one of the four levels,
reducing, if not removing, the need for external (medical
support.
- The doctor-patient relationship has a great deal to do with finding
the meaning in individual development and little to do with chance.
Quality standards for studies relating to anthroposophic medicine
The theoretical system that forms the background to anthroposophic
medicine is extensively defined and has a full epistemologic basis. This is in
contrast to other holistic models, e.g. the biopsychosocial model introduced by
Engel in 1977.
Trial designs to demonstrate efficacy of anthroposophic treatment
methods must at least be such that they do not reduce the "approach as
such" to an absurdity.
The approach has been briefly outlined. It requires extensive study to
find the indicated medicine, dosage criteria, knowledge of the actions and
possible side effects of therapeutic measures.