The Concept Of Medical Pluralism

Categories: Medical ethics Medicare

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Medical pluralism can be defined as the use of more than one medical system or the use of both conventional and complementary and alternative (CAM) therapies. A commonly used definition of CAM is that it includes heterogeneous therapies not taught in medical schools or typically prescribed by conventional medical doctors, yet CAM users do not commonly forsake conventional medicine, usually taking a pluralistic approach to illness and wellness behaviors.

There are 4 200 public health facilities in South Africa. People per clinic is 13 718, exceeding WHO guidelines of 10 000 per clinic.

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However, figures from March 2009 show that people averaged 2.5 visits a year to public health facilities and the usable bed occupancy rates were between 65% and 77% at hospitals. Since 1994, more than 1 600 clinics have been built or upgraded. Free health care for children under six and for pregnant or breastfeeding mothers was introduced in the mid-1990s.The National Health Laboratory Service is the largest pathology service in South Africa. It has 265 laboratories, serving 80% of South Africans.

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The labs provide diagnostic services as well as health-related research.

An estimated 80% of South Africans consult with traditional healers alongside general medical practitioners. The Medical Research Council (MRC) founded a traditional medicines research unit in 1997 to introduce modern research methodologies around the use of traditional medicines. It also aims to develop a series of patents for promising new entities derived from medicinal plants. Department of Environmental Affairs, The Council of Scientific and Industrial Research (CSIR) has signed a benefit sharing agreement with the Traditional Healers Council. This agreement is made in terms of the Bioprospecting, Access and Benefit Sharing Regulations (2008) and the National Environmental Management: Biodiversity Act (2004).

The agreement involves the utilization of the following plant species to develop potential commercial products:

Monsonia angustifolia (crane's bill, malengoana, tee ya thaba)
Elephatorrhiza elephantina (dwarf elephant-root, elandsboontjie, intolwane, mositsane)
Siphonochilus aethiopicus (Natal ginger, gemmerhout, indungulu).

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To establish the Interim Traditional Health Practitioners Council of South Africa; to provide for a regulatory framework to ensure the efficacy, safety and quality of traditional health care services; to provide for the management and control over the registration, training traditional health practitioners profession traditional health practitioners profession diverse medical systems, based on fundamentally different medical theories and methods of validating treatments, inhabit the medical landscape; (2) despite many irreconcilable epistemological and practical differences, mainstream and alternative medicine share the goals of promoting health, relieving suffering and avoiding harm; and (3) both mainstream and alternative medicine should respect the autonomy of competent patients to make therapeutic choices in consultation with mainstream physicians or alternative providers.

The pluralistic model fosters tolerance and/or cooperation between mainstream medicine and CAM. It recognizes unbridgeable epistemological differences in the methods of developing medical knowledge and validating treatments, but acknowledges that both mainstream medicine and CAM can offer clinically valuable treatment options for patients in the light of informed choices based on their preferences and values. As an ethical basis for relationships between biomedicine and CAM, pluralism avoids the pitfalls of both the opposition and integration models.

The pluralistic model does not amount to a relativistic stance, where judgments about effectiveness and ethical norms are internal to particular medical systems, resulting in the inference that CAM treatments are just as good as conventional treatments. Pluralism is consistent with biomedical standards of objective efficacy assessment and universal ethical principles of respecting patient autonomy and selecting treatments according to patient-centered benefit-to-risk assessments. Furthermore, the pluralistic model does not require any compromise in ethical standards. For biomedicine, evaluation of benefit and risk depends on scientific evidence. To take an extreme example, it is rational to prefer surgical intervention or chemotherapy over homeopathy for treatment of life-threatening cancer if the former is likely to offer long-term survival and the latter to have no effect on disease progression. Although a competent adult is free to refuse conventional therapy and choose homeopathic treatment in this circumstance, a physician is obligated to vigorously recommend the conventional therapy and argue against the CAM alternative. Biomedical practitioners (and CAM providers) should counsel patients to avoid irreversible harms that are likely to result from forgoing validated, medically indicated treatment. When sacrificing health is not at stake and there is little threat of harm, then a wider latitude for open-mindedness towards patients’ choices is appropriate.

From the biomedical side, pluralism implies the need for openness and continued research. The research infrastructure of biomedicine must provide more definitive answers on the possible efficacy, adverse events, and social behavior implications of CAM. Positive and negative effects of combining conventional and CAM treatments need to be studied. Pluralism encourages cooperation and a common ground between biomedical investigators and CAM practitioners who want to participate in research. Pluralism might also encourage more debate between CAM traditions, which have often buried their conflicts in order to maintain a united front.

The fundamental differences between mainstream medicine and CAM do not preclude the benefits of reflective exchange and productive cooperation. For example, CAM has selectively borrowed mainstream data and techniques. Certainly, many patients of herbalists have benefited from the new revelations on the adverse effects of some botanicals, the potential for drug-herb interactions, and the discovery of contamination/adulteration from herbal products from Asia. And vitamins long ago crossed over from the mainstream world. Biomedicine has also borrowed from the CAM world (e.g., nitroglycerin from homeopaths, breastfeeding/home birthing from popular health reform, and an openness to the importance of diet and exercise in health). Learning the strengths of each other's approaches might also benefit these dual streams in medicine and even improve patient care. In addition, a pluralist model offers the benefit of competition and self-reflection, where each system's strengths can flourish and their weaknesses can be more easily perceived.

Pluralism between systems can improve communication between health care providers and patients. Within a pluralistic framework, physicians should accept the responsibility to engage in informed discussion with patients about CAM options. Such respectful relations can make patients feel that their choices to seek alternatives (or mainstream medicine) are genuinely respected and can promote open communication between patient and physician. Pluralism would demand that physicians and alternative providers become well educated in “other” medical systems and be able to provide respectful and critical feedback, guidance and coordination between systems. Pluralism might also encourage dual-trained physicians – alternative providers who would be thoroughly and uncompromisingly educated in both biomedicine and different CAM modalities. Such individuals could act as specialist clinical guides and cultural-educational bridges between the two worlds.

Active cooperation with CAM providers is also possible. When a physician sees no harm in a CAM practice, especially in a refractory patient or a patient who has received insufficient relief from conventional medicine, referral to a CAM practitioner may be legitimate. Also, creating health care facilities where different medical systems coexist may have the added value of facilitating genuine cooperation and less fragmented patient care.

It is possible that for some conditions, CAM may have placebo effects — that is, clinically significant benefit greater than would occur with no treatment. A meta-analysis of randomized trials provided evidence that there is only a small and possibly insignificant placebo effect (compared to no treatment) for subjective and continuous outcomes. However, a more recent meta-analysis looking at placebo analgesia experiments that compared placebo treatment administered with positive suggestion, as if in real clinical situations, with no treatment demonstrated large and significant placebo effects. Some have suggested that CAM provides an enhanced placebo effect, but research on this question is still limited. Nonetheless, when conventional medicine has nothing beneficial to offer particular patients it seems reasonable for physicians to consider referring them to CAM providers who genuinely believe in their therapy, provided that such treatment poses little threat of harm. At the least, patients may receive the therapeutic benefits of attention, care, and empathic witnessing.

Traditional African medicine often carries with it a perception and stigma of being irrational and ungrounded in scientific method in academia. One reason for this common prejudicial view of traditional African medicine is the failure to effectively interpret African traditional medicine concepts, as these are often metaphorical descriptions of the biological and psychological effects of plants or combinations of them used in the traditional medicine preparations. When translated into other languages such as English, these metaphorical descriptions of medicinal plant use can seem to incorrectly reflect mysticism and/or superstition with no scientific basis. This difficulty in interpreting cultural descriptions of medical phenomena, together with the fact that there are hardly any academic papers engaging the science of South African traditional medicine in the biological sciences, is an indication of the disconnection between the humanities studies and the biomedical studies of South African traditional medicine.

Scientists have taken advantage of the region’s immense botanical diversity with South African research institutions being at the forefront of phytopharmacological studies of South African plants with the aim of developing new allopathic medicines. These studies focus predominantly on screening and isolating phytochemicals for specific pharmacological actions. This has resulted in an increasing trend in validating traditional medicine claims from scientific studies, especially for plants with traditional uses for physical ailments, such as plants with antibiotic properties used for infections. One example is the pharmacological validation of uterotonic compounds and activity of Rhoicissus tridentata that is traditionally used in pregnancy to augment labor. However, the same research validation has not yet occurred for the majority of plants used for spiritual healing in South African traditional medicine. One reason for this may be because the psychological effects from the internal administration of psychoactive plants in humans are more difficult to test, assess and interpret using the scientific method than those producing physical effects. However, I argue in this paper that a more prevalent reason is the culturally ingrained prejudice against traditional medicine and its associated religious or spiritual plant use, which is often deemed irrational, non-empirical and unscientific. Medicinal plant use in South African traditional medicine occurs on a sliding scale from physical to spiritual uses. There are polar extremes of plants used only externally and exclusively as charms for magical purposes, while others have only physical uses. However, for numerous plants that are administered internally for spiritual healing purposes in South African traditional medicine, there exist mutually inclusive physical, psychological and spiritual therapeutic effects, as in the case of ubulawu plant mixtures. This overlapping physical and spiritual medicinal plant use coincides with the African worldview of the co-existing and interdependent relationship between the physical and spiritual nature of sickness, medicines and existence.

Medicines have evolved over time and so has the realization of the importance of quality control and regulatory processes. The regulatory practices include all the steps from the development and manufacture of the active ingredients until the medicines reach the consumer. The Medicines Control Council (MCC) is mandated to regulate medicines in South Africa. Complementary medicines were previously perceived to be unregulated, although the Medicines Act does not distinguish between allopathic and complementary medicine. As the era of unregulated complementary medicine ended, the requirements in terms of dossier content left many role-players at odds. However, the MCC has a mandate to ensure that the registration of a medicine is in the interest of the public and that complementary medicine is manufactured in a facility adhering to good manufacturing practice, according to which efficacy and safety are supported by reliable data with a known shelf-life. The quality of complementary medicines is measured in terms of factors such as Good Manufacturing Practice (GMP), Good Laboratory Practice and Good Agricultural and Collection Practices specifications, identification of impurities, analytical validations and stability, ensuring attributes such as identity, strength and purity of a medicine that have to be met consistently.

When evaluating the efficacy of complementary medicines, established traditional use, preclinical data and evidence from clinical trials in animals and humans are used. Literature, such as acceptable monographs and pharmacopoeial references, also needs to be taken into account to the extent depending on the risk level of the claim made. The data must support efficacy aligned with the proposed indications and claims on the label and package insert. Safety may be established by detailed reference to the published literature and/or the submission of original study data. If a complementary medicine has been traditionally used without demonstrating harm, a review of the relevant literature should be provided. Reference should also be made to official monographs supporting safety and toxicological studies, if available. Safety is the ability of the medicine not to cause serious side-effects when assessed against its risk-benefit profile.