(Original title: Anthroposophische Medizin. Versuch einer Darstellung der Praxis. Merkurstab 1994; 47:541-550. English by A. R Meuss, FIL, MTA.) Christof Schnuerer

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.(1)

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 modem quantum mechanics.(2)

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(4) 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,(5) 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 modem 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 anemia, 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 modem intensive care unit.

Finally, the patient also developed a gastrointestinal hemorrhage 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 chemo- therapy 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 modem 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. (1) This is a single case, which proves nothing. A thesis can only be proven by conducting high-quality trials. (2) Changing from one system of treatment to another and using several principles at the same time is unscientific, it is polypragmasy par excellence.

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 (1) 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 (2) 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 modem 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, and

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, e.g. 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.

Christof Schnuerer, MD Gernein. Gemeinschaftskrankenhaus Beckweg 4 D-58313 Herdecke Germany

References and note

1. Dentsches Aerzteblatt 1988; 85: No. 25/26.

2. For a full review see Horgan J. Quanten-Philosophie. Im Spektrum tier Wissensclwft 1992; No. 9.

3. Most recently in Deutsches Aenteblatt 1992, No. 9.

4. Petersen P. (Hrsg.). Ansaetze kunsttherapeutischer Forschung. Springer 1990.

5. On one hand, the object of research divided into progressively smaller units; on the other hand, analysis of conditions of time and space in progressively larger areas, e.g. ecosystems.