Wednesday, March 05, 2008

The playbook for challenging medicine

The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession, by Paul Wolpe, is about doctors who promote "alternative" medicine, but it applies to any practitioner who challenges the fundamentals of any branch of medicine. According to Wolpe, an attack on an established discipline in medicine includes four specific elements. The critic:
must portray the discourse as in crisis, must provide an alternative ideology to rescue the discourse, must legitimize their ideology through appeal to a reframed historical myth, and must portray the orthodoxy as a betrayer of the discourse.
The authors applies his analysis to "alternative" medicine in general, but we are will look at homebirth midwifery in particular.

The first step is to portray the particular discipline as "in crisis".
... Modern medicine’s conquering of infecious disease set up a quasi-religious belief in its ability to reduce suffering and disease now seems stalled by a of medical economic, organizational, and social problems. [Critics try] to portray the biomedical orthodoxy as responsible for the problems confronting organized medicine .., and suggests that orthodoxy is ill suited to solve the developing challenges to care...
This is certainly the tactic adopted by homebirth midwifery. The "crisis" is the rising C-section rate, which is portrayed as unjustified, intolerable, unaffordable and injurious. A secondary "crisis" (which is fabricated) is the rate of infant mortality (the wrong statistic) and the rate of maternal mortality (which is falsely portrayed as rising).

As Wolpe points out, the critic "rarely paints its opponent in terms of benign neglect", but, rather, claims that it is evil. Therefore, the rising C-section rate is never portrayed by homebirth advocates as the regrettable but inevitable result of the desire to prevent all possible neonatal death and injury, but, instead, is characterized as the result of the obstetrician's desire to get rich, to "get home for dinner", or simply to ruin a woman's birth experience.

Next, the critic offers the new philosophy, positioning it as the replacement for the old:
... The heretical ideology is drawn as much as possible from existing strains in the discourse, strains usually ignored, slighted, or marginalized in the orthodox ideology... The heretic draws from the marginalized or folk knowledge of the tradition and elevates the constructs found there to primary importance...

... [G]reat pains are usually taken ... to show that the alien ideas are not in fact alien at all, but have existed in the discourse in a different form. [Critics] often import foreign, folk, and traditional forms of healing into their practices, [carefully describing] them as wholly compatible with Western medicine, scientifically valid, or historically present in other forms. (The ‘placebo’ effect, for example, is elevated to a central place in holistic medicine, and described as demonstrating the 'power of the mind', which is in turn said to be a central tenet of Eastern and Native healing forms. The orthodoxy is censured for slighting this most important healing modality.) ...
What does the critic offer instead?
The [critic] blurs the line between disease and health as it is usually drawn in Western medicine, and extends the range of therapeutic intervention beyond the bounds of manifest pathology. At one end is a concentration on pre-morbid states, or prevention...

Attention to the pre-morbid state is complemented by an expansion of the post-morbid state. The goal of holistic health is more than the absence of disease; it is a state of optimal functioning, often referred to as 'wellness'... [which] greatly expands the role of the HMD in medical intervention ...
In the words of homebirth midwifery: pregnancy is "not a disease", but nonetheless it requires extensive prenatal visits, preparation and education. In addition:
The [alternative practitioner] caters to the consumer; the customer is always right, and the seller does not know better than the buyer what the buyer really want or needs...
The use of touch and intimacy, the central role of patient education, and the use of Eastern and Native American medical forms and philosophies all serve to create a ritualized encounter that opens the way for ideological display. [Alternative providers] try to forge affective connections with patients by sharing their own feelings and experiences and using noninstrumental touching to develop intimacy.
Third, the critic attempts to gain legitimacy by "rewriting" the history of the discipline:
Heretics try to rewrite the discourse’s historiography to emphasize their own ideological positions. In doing so, they make heros out of the orthodoxy’s secondary players and emphasize heretical themes in the orthodoxy’s heros.
Hence the rewriting of the history of Semmelweis and puerperal sepsis to make Semmelweis the "discoverer" of puerperal sepsis, and to protray him as the man who could have cured puerperal sepsis if other orthodox physicians had not stood in his way and hounded him to insanity.

Another favored theme:
... Holistic heretics portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.
Biomedicine is portrayed as a bureaucratic juggernaut whose judgments are accepted uncritically by adherents. Technological wizardry is used as proof of sophistication without truly exploring all roads to healing their patients...

Promiscuous use of drugs and surgery represent not cures, but substitutes for curative action. They are distributed without thought and without recognition of their power to do harm...

The heretical attack both blames the orthodoxy for the crisis and for failing to accept the heretic’s remedial ideological position. The orthodoxy has betrayed the discourse through its inaction, and no longer deserves to be its guardian. The heretic is the true keeper of the flame, the savior of the discourse, and should ascend to the position of power in place of the orthodoxy.

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