Challenge and Opportunity
Dr. Robin Pinsent was a founder member of the Royal College of General Practitioners
and co-founder of the College's Birmingham research unit. His friendship with a prominent
member of the Faculty of Homeopathy and fellow Birmingham general practitioner (GP),
and his enquiring mind, attracted him to homeopathy and the investigation of its rationale
and the action of its medicines. He became an active member of the Faculty's Midlands
Research Group in the 1980s, and in 1983 he gave the Faculty's first Blackie Memorial
Lecture.[1] In it, he proposed an exciting and prophetic scenario for the future of homeopathic
medicine, predicting as great or even a greater impact upon the progress of medicine
from its renaissance as he had helped to engineer in the renaissance of general practice.
Forty years on, his vision still offers an inspiration to the homeopathic medicine
community. In a paper of my own, presented to the Faculty Congress in 1984, I invoked
the example of that general practice renaissance (of which many Faculty members are
heirs) as a model for the work that the Faculty needed—and still in fact needs—to
do.[2]
But Dr. Pinsent concluded that resolving the controversy around the biological action
of the homeopathic medicines themselves would be critical to that achievement, and
it is here that my own perception of the role of homeopathy in the advancement of
medicine diverges from his. I agree with the importance of pursuing this enquiry,
with all the resources of energy and ingenuity available to us and to our colleagues
from many disciplines in science who are contributing to that research. It is a major
part of homeopathy's responsibility to medical science—not least because of the potentially
transformative challenge to our existing knowledge of physics and biology that it
presents.
A fully developed role of homeopathy within medicine does indeed involve the eventual
resolution of that debate. However, it does not depend upon it in the sense that we must wait for that resolution to happen before homeopathy can
establish any authority within medicine. Nor in the sense that it is the only criterion of value
which homeopathy can display to the medical and scientific world. On the contrary,
there is a great deal to be learned from the homeopathic approach and therapeutic
method that is of inestimable value to health care, and that medicine badly needs.
Hence the second part of the title of this paper, ‘Medicine needs healing’, which
is based on the central theme of a new book by rheumatologist Paul Dieppe, Emeritus
Professor at both Bristol and Exeter universities.[3] It was also the core theme of my own book, Remodelling Medicine.[4] This presented a broad critique of the dominant biomedical model of modern Western
medicine, exploring the question in the title of an earlier paper, Medicine and healing: a broken marriage?
[5] In the book, I sought to re-establish medicine as a healing vocation. I proposed
occupational therapy and homeopathy as examples of how a broader understanding of
healing should inform clinical practice,[6] and that science should be true to its purpose in exploring that understanding as
far as it is legitimately able to do so.[7] The real excitement, challenge and purpose of science is to explore what lies beyond
the horizon of the known. But medicine does not deal only with questions that science
can legitimately ask and hope to answer: it also deals with questions of human experience,
value and meaning that occupy a different landscape from that bounded by the legitimate
horizon of science. Medicine cannot afford to limit itself to the set curriculum of
biomedical science, however magnificent its achievements. It must not do so, because
it excludes not only subject matter that could be accessible to science but that has
not yet been explored, but also everything that belongs to that other landscape not
so accessible to science, which is nevertheless the whole context within which science
operates. “We do not need to esteem science less. What we need is to esteem it in
the right way. Especially we need to stop isolating it artificially from the rest
of life.”[8]
Homeopathy has a narrative to share that touches upon that wider landscape—“the rest
of life”—and can illuminate many facets of health care that are integral to the healing
process and that are common to most, if not all, health care professions.
Defining the Narrative
If homeopathy is to play its part in the evolution of medicine beyond the provision
of a niche (albeit globally popular) therapeutic method, we need to tease out the
narrative strands that comprise its science and its art, and to think critically and
creatively about each one. In every case, we need to ask questions such as: How intellectually
coherent and consistent is this narrative? What are its weaknesses, and how do we
address them? How does this narrative relate to, complement and enhance, diverge from
or challenge, other narratives in other medical and scientific disciplines? And other
narratives in our shared understanding of health, illness and healing? And of human
nature more broadly? What common ground may be cultivated, and how? How may we better
communicate this narrative, and to whom—amongst the health care professions, and beyond?
Here are some of the narrative strands in homeopathic medicine that invite this enquiry.
Whole Person Medicine
Whole person medicine is not just a romantic notion. It is probably what most doctors
aspire to, but often find difficult because of the constraints of the biomedical model,
dominant in Western medicine, and the targets and guidelines that are often its political
manifestation. In a survey of over 2,000 Scottish GPs, 87% felt that a holistic (whole
person) approach was essential to providing good health care, but only 21% felt that
primary care (general practice-based care) was delivering high-quality holistic care
and only 7% felt that the organisation of primary care was conducive to it.[9]
This view from the ‘coal face’ reflects a widely held frustration with the limitations
of conventional modern medicine. In Homeopathic Method: Implications for Clinical Practice and Medical Science, I described how homeopathy offers a remedy for this malaise.[10] I was fortunate in enticing the heads of two university departments of primary care
to write forewords for the first and second editions. Both were sceptical of the specific
action of homeopathic remedies, but impressed by the homeopathic approach and its
benefit to medicine in general. And, in their commentaries, they summarised those
benefits very neatly. For the second edition, referring to his own passing acquaintance
with homeopathy, Stewart Mercer, Professor of Primary Care Research at the University
of Glasgow, wrote[11]:
“…exemplified by the homeopathy history taking, was the requirement for an open-minded
and meticulously detailed assessment of the patient in front of you. […] We had to
learn to listen to exactly what the patient was saying and how they were saying it.
We had to learn not to dismiss any information as trivial. We had to accept stories
as they were. And in doing so, we had to learn to be ‘with’ the patient, to be present.”
Those words encapsulate homeopathy's commitment to whole person medicine.
Pathography: The Natural History of Illness, Disease and Healing
In his foreword to the earlier edition, Conrad Harris, Emeritus Professor of General
Practice at the University of Leeds, made a similar point, despite his scepticism,
commending its account of how homeopaths approach their therapeutic tasks.[12] “At this level”, he wrote, “it has a great deal to teach conventional doctors, and
I find it both fascinating and full of wisdom.” His interest was particularly aroused
by the emphasis on ‘pathography’ in homeopathy—the detailed description of what is
wrong with the patient; a neglected phase of research, tailor made for GPs but unlikely
to encounter because of current trends in general practice. “It was a joy, therefore”,
he wrote, “to learn that pathography is not an optional extra for homeopathic practitioners,
but an essential part of their methods, and safe in their hands. I hope they will make their findings known outside their own literature, as an important
contribution to medicine [my own emphasis].”
In an article of his own on this theme that I have discussed elsewhere,[13]
[14] he makes a plea for “the observation and description of what is before one's eyes,
unconditioned by preconceived ideas”, echoing Thomas Sydenham, the 17th century ‘father
of modern clinical medicine’, who, in “his empiricism and determination to observe
and examine each patient with the open mind of a natural historian”, taught us “to
listen intently and question the patient minutely about the march of events in the
development of disease”.[15] Here are the founding precepts of the homeopathic approach, articulated by Hahnemann,[16] vividly expressed across the centuries as precepts for all medical practice.
I do not know enough about other therapeutic modalities—Naturopathy or Ayurveda, for
example—to be sure, but I suspect that homeopathy is unique in its insistence on attention
to this level of detail not only in recording and construing the whole story of the
patient's life, past history and present experience in the evolution of the illness,
but also in studying the response to treatment—the healing process—which I will return
to when discussing ‘natural healing’ and placebo.
Epidemiology
The study of the ‘march of events in the development of disease’—its evolution or
etiology,[17] essential to the homeopathic method—is one of the opportunities that homeopathy
provides for the “observation and description of what is before one's eyes” that Conrad
Harris insists is “the starting point of all scientific research”, in this instance,
epidemiology.
Another is the concept of ‘constitution’ as an indicator both of susceptibility to
certain patterns of illness and of resilience and the ability to heal. Unfortunately,
‘constitution’ means different things to different people (from psychological profile
to body shape).[18]
[19] But the concept that a constellation of inherent personal characteristics is significantly
related to patterns of illness and disease is important, both in terms of patient
care and therapeutics, and in epidemiology. The systematic documentation and study
of this phenomenon is a huge challenge, but it is another contribution that homeopathy
can make to medical science.
Multimorbidity, Chronic Disease and Polypharmacy
In his foreword to Homeopathic Method, Stewart Mercer went on to say:
“…there is still a lot to be learned from the homeopathic approach to care. Not least
the fact that modern conventional healthcare is not meeting the needs of the populations
and people it serves. The greatest challenge facing healthcare systems around the
world is the challenge of managing patients with chronic conditions, most of whom
have two or more rather than one condition. Yet healthcare…remains focused on single
conditions and a disease-centred approach…[which] has led to mass polypharmacy, and
in many cases harm.”
Good ‘pathography’, with its focus on the ‘individuality’ and ‘totality’ of the patient's
condition,[20] the tailoring of treatment regimens to accommodate that totality, and the fact that
co-existing symptoms or syndromes that would be conventionally treated separately
respond to one homeopathic regimen, is homeopathy's answer to this ‘greatest challenge’.
It is perhaps the most powerful argument for homeopathy within health care, and its
biggest contribution—and one of its biggest research challenges.[21] The Bristol Homeopathic Hospital Outpatient Survey[22] and an article in a recent issue of this journal[23] are good examples of the attempt to meet this challenge.
Clinical Fact
In the last paragraph, I referred to ‘the fact’ that co-existing syndromes respond
to a homeopathic regimen, and here I want to point out, with the greatest possible
emphasis, that nothing I have described so far has to do with a theory or hypothesis. The virtues that Harris and Mercer recognise in the homeopathic method, and that
Sydenham demanded of all medicine, are all to do with the art and science of clinical
observation. The changes that are reported are matters of clinical fact. If a practitioner
records at follow-up that a patient's eczema and asthma or irritable bowel syndrome and migraine have improved following treatment, or when a chronic illness resolves following
an ‘etiological’ prescription—say, Brucella nosode in a patient with chronic brucellosis—then either the patient and the practitioner
are lying or those are clinical facts. The ‘how’ and the ‘why’ are irrelevant. We
do not have to distinguish conclusively between the specific activity of the homeopathic
prescription and other contextual factors to acknowledge the value of the therapeutic
method as a whole.
Evidence that the change has occurred is, of course, essential. But where it is provided
from ‘real world’ clinical practice,[22]
[24] it is often dismissed because the ‘how’ and the ‘why’ have not been elucidated to
the satisfaction of the critic, usually with a demand for a positive outcome from
a randomised placebo-controlled trial—which, however solid,[25]
[26] is then likely to be dismissed as insufficient. But accumulating the evidence and
its effective communication is a priority. The power and importance of clinical outcomes
and case studies, and the need to generate, systematically collate and publish more
of them, cannot be overemphasised. Their value and significance in demonstrating effectiveness (‘real world’ treatment outcomes) vis-à-vis efficacy (experimental/trial outcomes) needs to be argued vigorously.
Academic Standards and Academic Integrity
Above all, the evidence for these facts, and the conclusions we draw from research—subject
to the necessarily provisional nature of all science—must be beyond reproach. From
my experience of national and international organisations as Dean of the Faculty of
Homeopathy (1997–2003), and from the evident standards of peer review and editorial
scrutiny that attend publications in Homeopathy, I believe that the academic standards and integrity that prevail in mainstream homeopathic
medicine are of a high degree. Sadly, the same cannot be said of some of homeopathy's
detractors.[27]
[28]
[29]
[30] This makes it even more important that we are rigorously self-critical and vigilant
in maintaining those standards ourselves and that we challenge pronouncements and
publications from within the wider homeopathy community that misrepresent homeopathic
medicine.[31]
[32]
[33]
There are significant challenges to homeopathy's academic credibility that need to
be addressed,[34] even accepting that the arguments in this article transcend the enduring problem
of the specific action of homeopathic medicines and the high dilution of many of the
medicines. Although excellent work has been done, and is ongoing, to make the process
more systematic,[35]
[36] foremost amongst these, perhaps, is the diversity and inconsistency of prescribing
regimens.[37] It is the sort of problem that, when the Faculty was brave enough some 20 years
ago to include sceptics in the peer review of its comprehensive and rigorous medical
core curriculum (Faculty of Homeopathy, archive, unpublished), caused one critic to
include the remark that ‘Even well organised rubbish is still rubbish!’
The Healing Response: The ‘How’ and the ‘Why’
The questions whether and how homeopathic medicines themselves have any biophysical
activity remain to be resolved. But it is beyond doubt that the healing response to
homeopathic treatment cannot be through any currently recognised pharmacological action.
It is also beyond doubt that the homeopathic approach, as succinctly described by
Stewart Mercer, is powerfully conducive to well-recognised healing responses commonly
described as ‘placebo’ or ‘contextual’.[38] In other words, regardless of any specific action of the medicines, the nature of
the consultation will evoke and reinforce ‘natural healing’, the innate capacity of
body and mind for repair and healing.[39]
[40]
This fact, which should be applauded—and, as the foundation of the holistic approach
to which those Scottish GPs aspire, should be a sine qua non of all therapeutic relationships[41]—is ironically often used to devalue homeopathy. Whereas, the therapeutic consultation's
evidently important contribution to the effectiveness of homeopathic treatment should give pause for thought to those responsible for health
care education and policy.
Integrative Medicine
One of the most salutary (health giving) features of the homeopathic approach is that
it is truly ‘integrative’ (combining to form a whole) for the patient, serving to
affirm or restore their sense of ‘integrity’ (being whole). A patient will rarely,
if ever, have thought or talked about so many different aspects of themselves as they
will do in a homeopathy consultation—never perhaps have seen themselves ‘as a whole’,
nor been seen and heard as such an integrated individual. This integrative approach
is essential to the healing process that homeopathy supports, and it is an example
that medicine as a whole needs if it is to fulfil its healing vocation more effectively.
In the United Kingdom, the Faculty's inter-professional structure and our involvement
in the integrative care movement and the wider Complementary and Alternative Medicine
movement[42] are part of this. Truly integrative health care must be integrative of the different
perspectives, methods and approaches of different health care professionals around
the patient, creating an entire ‘community’ of care, which is essential to the core
aim to be integrative of the patient, as against the dis-integrative and de-meaning
influence of the biomedical model.[43]
What Western medicine calls ‘integrated medicine’ or ‘integrated care’ may not be
integrative of the patient at all. It is often a loose aggregation of different therapeutic
methods, resources or services, perhaps within a geographical or administrative framework.
They may not share any common model of disease processes, healing processes or whole
person care, and they may not engage in any process of shared management that effectively
integrates their different methods and perceptions within a coherent care plan for
the individual patient. This is not truly ‘integrated’ care. It is still a fragmented
service, likely to have a fragmenting effect on the patient within it. The inter-professional
ethic within homeopathy is an antidote to this failing.
Multidisciplinary and Inter-professional Learning
Occasions when two or more [health and social care] professions learn with, from and
about each another to improve collaboration and the quality of care.[44]
The better integration of homeopathic medicine in health care and medical education
will help to remedy the disintegrative tendency in modern Western medicine. Although
inter-professional education is essential to truly integrated and integrative medicine,[45] and has been a core principle of undergraduate and continuing medical education
for all health care professionals in the United Kingdom for a long time,[46] it is still by no means the norm. But because in many homeopathy organisations their
practitioners come from, and work within, a variety of clinical disciplines in medicine
and those allied to medicine, and because their curricula cross inter-disciplinary
boundaries, this is an aspect of medicine in which homeopathy offers a model of good
practice. I have learned much about the dynamics of health and illness—particularly
the psychodynamics—from attending lectures by homeopathic veterinarians, just as I
have from attending the conferences of another such exemplar, the multidisciplinary
Philosophy & Ethics Special Interest Group of the British Pain Society.[47] As Dean of the Faculty of Homeopathy, I gained as valuable an insight into different
aspects of health care by helping to develop curricula and examinations for dentists
and podiatrists, for example, as I did when working with speech and language therapists
and occupational therapists in the development of common terminology for electronic
medical records.[48]
There are exceptions,[49] but we are perhaps too timid in our engagement with other disciplines: in academic
discourse[50] and medical education (undergraduate and postgraduate),[51] in clinical work[52] where we are offering shared care with colleagues in other specialities, and in
communication with doctors whose patients consult us ‘on the side’. If we do not demonstrate
high standards of general medical competence, and do not set out clearly how our intervention
has benefitted individual patients, we cannot expect homeopathy to be taken seriously
amongst colleagues who are otherwise ignorant of the subject and are legitimately
sceptical. This area of activity needs to be developed and enhanced if homeopathy
is to be valued properly.
