Definitions and categorizations

There is no clear and consistent definition as to the exact nature of alternative or complementary medicines.[16]:17 In a 2005 report entitled Complementary and Alternative Medicine in the United States[16] the Institute of Medicine (IOM) adopted this definition:

"Complementary and Alternative Medicine (CAM) is a broad domain of resources that encompasses health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society or culture in a given historical period. CAM includes such resources perceived by their users as associated with positive health outcomes. Boundaries within CAM and between the CAM domain and the domain of the dominant system are not always sharp or fixed."[16]

Other groups and individuals have offered various definitions and distinguishing characteristics. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as "a group of diverse medical and health care systems, practices, and products, that are not currently part of conventional medicine."[11] NCCAM has developed what the IOM calls "[o]ne of the most widely used classification structures"[16] for the branches of complementary and alternative medicine.[11] The Cochrane Complementary Medicine Field says:

"What are considered complementary or alternative practices in one country may be considered conventional medical practices in another. Therefore, our definition is broad and general: complementary medicine includes all such practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well-being. These practices complement mainstream medicine by 1) contributing to a common whole, 2) satisfying a demand not met by conventional practices, and 3) diversifying the conceptual framework of medicine."[17]

David M. Eisenberg defines it as "medical interventions not taught widely at US medical schools or generally available at US. hospitals,"[18] while Richard Dawkins sardonically defines it as a "set of practices which cannot be tested, refuse to be tested, or consistently fail tests."[19]

Australian comedian Tim Minchin, in his nine minute beat poem "Storm", states that alternative medicine is medicine that "has either not been proved to work, or been proved not to work." He goes on to ask "You know what they call 'alternative medicine' that’s been proved to work? Medicine.”

The term "alternative medicine" is generally used to describe practices used independently or in place of conventional medicine. The term "complementary medicine" is primarily used to describe practices used in conjunction with or to complement conventional medical treatments. NCCAM suggests "using aromatherapy therapy in which the scent of essential oils from flowers, herbs, and trees is inhaled in an attempt to promote health and well-being and to help lessen a patient's discomfort following surgery"[11] as an example of complementary medicine. The terms "integrative" or "integrated medicine" indicate combinations of conventional and alternative medical treatments which have some scientific proof of efficacy; such practices are viewed by advocates as the best examples of complementary medicine.[11] Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."[20] The combination of orthodox and complementary medicine with an emphasis on prevention and lifestyle changes is known as integrated medicine. The Washington Post reports that a growing number of traditionally trained physicians practice integrative medicine, which it defines as "conventional medical care that incorporates strategies such as acupuncture, reiki and herbal remedies."[21]
[edit] Relation to evidence-based medicine
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There is a debate among researchers in the medical fields over whether any therapy may be properly classified as 'alternative medicine'. Arguments on one side make the claim that "[t]here is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work."[10] and suggest that medicine should be classified based solely on scientific evidence - an approach called 'evidence-based medicine'. Opposing sides argue that this normative argument is problematic: some CAM is tested, and some mainstream medicine lacks strong evidence.[citation needed] The IOM found that in a study of 160 Cochrane systematic reviews of mainstream techniques, 20% were ineffective and 21% had insufficient evidence of any scientifically replicable effect.[16] The IOM therefore defined alternative medicine broadly as the nondominant approach to medicine in a given culture and historical period. A similar definition has been adopted by the Cochrane Collaboration,[17] a leading proponent of evidence-based medicine, and official government bodies such as the UK Department of Health.[22] This definition does not take into account the off-label use (use of mainstream therapies for purposes other than their prescribed intent) -such drugs have been tested for safety, but often are not tested for efficacy with respect to the off-label treatment. Off-label use accounts for up to 20% of all drugs, and up to 31% of psychiatric drugs.[23]

Well-known proponents of evidence-based medicine, such as the Cochrane Collaboration and Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, use the term alternative medicine but agree that all treatments, whether "mainstream" or "alternative", ought to be held to standards of the scientific method.[24] Their view is that evidence-based medicine is an ideal state which has not yet been achieved by either current mainstream or alternative medicine. Ernst characterizes the evidence for many alternative techniques as weak, nonexistent, or negative, but states that compelling evidence exists for others, particularly certain herbs and acupuncture[25] – although this evidence does not mean these treatments are mainstream, especially not worldwide. What is alternative varies by discipline as well and country. For example, biofeedback is commonly used within the Physical Medicine & Rehabilitation community, but is considered alternative within the medical community as a whole, and some herbal therapies are mainstream in Europe, but are alternative in the United States.[26]

Criticisms of CAM by mainstream physicians have been numerous. Barrie R. Cassileth has succinctly summed up the situation:

"Not all mainstream physicians are pleased with CAM, with current efforts to integrate CAM into mainstream medicine, or with a separate NIH research entity for "alternative" medicine.[10][27] Vigorous opposition to CAM as "pseudo science" based on "absurd beliefs" continues to be voiced. CAM's deviation from basic scientific principles, implicit, for example, in homeopathy and therapeutic touch, are decried. A 1997 letter to the US Senate Subcommittee on Public Health and Safety signed by four Nobel Laureates and other prominent scientists deplored the lack of critical thinking and scientific rigor in OAM-supported research."[28]

In March 2009 an article was published about a group of scientists who made "a once-unthinkable proposal: Shut down the National Center for Complementary and Alternative Medicine at the National Institutes of Health.":

Critics of alternative medicine say the vast majority of studies of homeopathy, acupuncture, therapeutic touch and other treatments based on unconventional understandings of physiology and disease have shown little or no effect. Further, they argue that the field's more-plausible interventions -- such as diet, relaxation, yoga and botanical remedies -- can be studied just as well in other parts of NIH, where they would need to compete head-to-head with conventional research projects... "What has happened is that the very fact NIH is supporting a study is used to market alternative medicine," said Steven Novella, a neurologist at Yale School of Medicine and editor of the Web site Science-Based Medicine (http://www.sciencebasedmedicine.org), where much of the anti-NCCAM discussion is taking place. "It is used to lend an appearance of legitimacy to treatments that are not legitimate."[29]

Later in 2009 the complaints of critics were vindicated by the highly publicized negative results of ten years of big studies funded by the National Center for Complementary and Alternative Medicine (formerly OAM):

Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do... "You expect scientific thinking" at a federal science agency, said R. Barker Bausell, author of "Snake Oil Science" and a research methods expert at the University of Maryland, one of the agency's top-funded research sites. "It's become politically correct to investigate nonsense."... "There's been a deliberate policy of never saying something doesn't work. It's as though you can only speak in one direction," and say a different version or dose might give different results, said Dr. Stephen Barrett, a retired physician who runs Quackwatch, a web site on medical scams.[30]

According to the NCCAM,[11] formerly unproven remedies may be incorporated into conventional medicine if they are shown to be safe and effective. Several scientists share this point of view and state that "[o]nce a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted."[10] According to them it is possible for a method to change categories (proven vs. unproven) in either direction, based on increased knowledge of its effectiveness or lack thereof. Prominent proponents of this position are George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA), and Phil B. Fontanarosa, Senior Editor of JAMA,"[31] Richard Dawkins, former Professor of the Public Understanding of Science at Oxford,[19][32][33] Edzard Ernst and Simon Singh,[34] and Stephen Barrett, founder and operator of Quackwatch, who argues that techniques currently labeled "alternative" should be reclassified as "genuine, experimental, or questionable. Genuine alternatives are comparable methods that have met science-based criteria for safety and effectiveness. Experimental alternatives are unproven but have a plausible rationale and are undergoing responsible investigation. ... Questionable alternatives are groundless and lack a scientifically plausible rationale. ... Blurring these distinctions enables promoters of quackery to argue that because some practices labeled "alternative" have merit, the rest deserve equal consideration and respect. Enough is known, however, to conclude that most questionable "alternatives" are worthless.[25][35][36] Many CAM methods are criticized by the activist non-profit organization Quackwatch.[37]

In an article in The Medical Journal of Australia, Sampson and Atwood wrote about the inroads CAM is making as the "propagation of the absurd":

"The Absurd has gained a degree of agency and respect in some quarters of society through the CAM movement... The guardians that usually keep the institution of medicine from reeling off into irrationality are social contracts built into medical science and ethical behaviour. The academic community guards the contractual borders of science, while laws and regulations encode our ethical system. For the Absurd to have advanced, there must have been some breakdown of these social guardians. Postmodernism has promoted breakdown and reorientation of structured forms of thought. One of its guises is language distortion — the redefinition and use of words to fit personal views. For example, alternative and complementary have been substituted for quackery, dubious and implausible. Another is the invention of integrative medicine — designed to leapfrog methods into practice without need for proof... Postmodernism creates an atmosphere in which absurd claims are accepted more readily because they have simply been renamed... Postmodern CAM also tolerates contradiction without need for resolution through reason and experiment, resulting in a medical pluralism.... Implausible proposals and claims become tolerable and comfortable, and the CAM advocate’s burden of proof is shifted to disproof by the science community, which that community accepts without major objection. These are constructions designed for propagation of the Absurd... The new sociolegal order also shows breakdown of classical ethics. CAM followers declare it to be ethical to perform clinical trials on scientifically implausible treatments — merely because the treatments are popular."[38]

M.R. Tonelli argues that CAM cannot be evidence-based unless the definition of evidence is changed. He states that "the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials."[39] Further, A review of Michael L. Millenson's book Demanding Medical Excellence: Doctors and Accountability in the Information Age described it as "a wake up call to both medicine and nursing" due to what Millenson calls a "lack of scientific-based medical practice". According to the review, the book states that "85% of current practice has not been scientifically validated" and that it suggests that users of the research presented by Medline should question research articles rather than assuming they are accurate simply because of where they are published. The review states that Millenson's thesis and conclusion call for all health researchers and policy makers to do a better job in assuring valid methodology and avoidance of bias in published research.[40] Michael Dixon, the Director of the NHS Alliance stated that "People argue against complementary therapies on the basis of a lack of evidence. But I'd say only 10 per cent of what doctors do in primary care is evidence-based."[41] Angell and Kassirer acknowledge that "many treatments used in conventional medicine have not been rigorously tested, either" but say that the scientific community is generally aware that this is a failing that needs to be remedied."[10]

Oxford University Press publishes a peer-reviewed journal entitled Evidence-based Complementary and Alternative Medicine (eCAM).[42]