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Regulation, religious experience, and epilepsy: a lens on complementary therapies
Epilepsy & Behavior Epilepsy & Behavior 4 (2003) 602–606 www.elsevier.com/locate/yebeh
Special Communication
Regulation, religious experience, and epilepsy: a lens on complementary therapies Michael H. Cohen*,1 HMS-Osher Institute, Harvard Medical School, 401 Park Drive, 2nd Floor West 22-A, Boston, MA 02215, USA Received 20 August 2003; accepted 20 August 2003
Abstract Complementary and alternative medical (CAM) therapies include chiropractic, acupuncture and traditional Oriental medicine, massage therapy, and herbal remedies; mind–body therapies (such as meditative practices and visualization); and folk practices and religious healing. Of these, modalities based on spiritual healing create a number of conundrums for the clinician, including legal, regulatory, and ethical issues. Further, the historic relationship between the study of epilepsy and religious experience suggests particular, potential associations between CAM therapies (and especially spiritual healing) and care for epileptic patients. There are at least two dimensions to this exploration: first, the widespread use of spiritual healing for treatment of epilepsy; and second, the hypothesized connection between epileptic seizures and mystical states. A number of legal rules help address potential abuse of authority by health care professionals, and include: (1) medical licensure; (2) scope of practice; (3) professional discipline; (4) malpractice; and (5) fraud. This article offers a preliminary resource for clinicians interested in these topics. Ó 2003 Elsevier Inc. All rights reserved. Keywords: Complementary therapies; Integrative health care; Spiritual healing; Regulation; Legal issues
1. Complementary therapies and integrative health care Complementary and alternative medical (CAM) therapies refer to ‘‘a broad domain of healing resources that accompanies all health care systems, modalities, and practices and their accompanying theories and beliefs other than those intrinsic to the politically dominant health care of a particular society or culture in a given period’’ [1]. Major CAM therapies include chiropractic, acupuncture, and traditional oriental medicine, massage therapy, herbal remedies, and mind–body therapies (such as meditative practices and visualization); folk practices and religious healing are also included within contemporary definitions of CAM therapies. CAM therapies, as thus described, may be provided by several groups of clinicians, such as: (1) medical * Fax: 1-617-384-8555. E-mail address: [email protected]. 1 Michael H. Cohen is Director of Legal Programs at the Harvard Medical School Osher Institute, an Assistant Professor of Medicine at Harvard Medical School, and a 40th Anniversary Senior Fellow at the Center for the Study of World Religions, Harvard Divinity School.
1525-5050/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2003.08.014
doctors who may be counseling their patients regarding these therapies or offering such modalities in clinical care (e.g., physicians counseling patients regarding their use or avoidance of herbs); (2) allied health providers similarly counseling or offering therapies (such as nurses performing massage therapy); (3) CAM providers, offering therapies such as acupuncture needling; and (4) providers in the arena of mental health care using therapies that could be considered either biomedical or within the CAM domain (e.g., psychologists offering guided imagery and visualization) [2]. A 1998 study published in the Journal of the American Medical Association found a 47% increase in total visits to complementary and alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, with total 1997 out-of-pocket expenditures relating to alternative therapies estimated at $27 billion [3]. The study suggested that use of complementary and alternative medicine is likely to continue to increase, particularly as insurance reimbursement for complementary and alternative therapies grows [3]. In similar fashion, a
Special Communication / Epilepsy & Behavior 4 (2003) 602–606
2000-2001 survey of 5,810 hospitals by the American Hospital Association reported that 15% of the respondents offered CAM therapies [4]. Given these developments, medical academics increasingly have begun to conceptualize the notion of ‘‘integrative health care,’’ which integrates biomedical and CAM therapies in clinical care. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) presently defines integrative medicine as health care that ‘‘combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness’’ [5]. The very existence of such a definition in an NIH document suggests that clinicians increasingly are called on to recognize the importance of considering inclusion of CAM therapies in the diagnostic and therapeutic armamentarium, as well as patient preferences for discussing options involving such therapies. 1.1. Frontier CAM therapies One of the more controversial arenas within clinical consideration of using or discussing CAM therapies involves therapies that lack a significant—or, from the clinicianÕs standpoint, satisfactory—evidentiary basis of safety and efficacy, yet may offer hope and possibility to patients whose belief systems encompass spirituality. Indeed, modalities based on spiritual healing create a number of conundrums for the clinician, including legal, regulatory, and ethical issues. The term spiritual healing here is used to encompass a number of practices, including healing practices within the context of specific religious traditions (e.g., anointing of the Spirit and laying on of hands in Christian ministry), as well as healing involving intentionality or consciousness that is connected with religious teachings (as in, e.g., Christian Science) or taught in secular settings (such as Therapeutic Touch within the nursing school curriculum [6]). Although such a definition may lack sufficient scholarly rigor for disciplines such as anthropology and the study of world religions, it may offer a sufficient generalized starting point to help frame a discussion for the clinician who is interested in patient beliefs and practices. Such an inclusive definition also may help the clinician interested in using knowledge of such experiences, not only to offer proper medical counseling and satisfy any informed consent obligation, but also to help facilitate and augment the therapeutic relationship. Interestingly, though spiritual healing historically has been connected with religious movements, more recently, as suggested by the above example of Therapeutic Touch, the phenomenon has entered secular, clinical contexts such as nursing practice. Indeed, there may be significant overlap between CAM therapies such
603
as massage therapy and healing practices involving touch that suggest spiritual practice. For example, chiropractic, one of the most commonly accessed CAM therapies, partly originated in its founderÕs interest in so-called ‘‘magnetic healing’’ (referring to the notion of a kind of fluid ‘‘magnetism’’ between individuals), and shares ground with spiritual healing in its application of an intuitively guided, kinesthetic sense of the patient through sensations in the hands [7]. More recently, in acknowledging such interrelated phenomena as touch, emotional contact, and assertions by CAM practitioners regarding the possibility of nonbiologically mediated healing mechanisms, NCCAM has established a program for ‘‘frontier science,’’ seeking scientific explanations as to mechanisms of observed phenomena as well as methodological approaches to study them.2 1.2. Complementary therapies, spiritual healing, and epilepsy While all the above may concern clinicians generally, the historic relationship between the study of epilepsy and religious experience suggests particular, potential associations between CAM therapies (and especially spiritual healing) and care for epileptic patients. There are at least two dimensions to this exploration: first, the widespread use of spiritual healing for treatment of epilepsy; and second, the hypothesized connection between epileptic seizures and mystical states. A corollary to the latter inquiry is the question as to whether seizures provide access to states of consciousness in which the patient glimpses an aspect of the divine, or whether the reported, numinous experience can simply be reduced to a series of biochemical responses. This simple corollary has been subject to intense debates. Weighing in on one side, William James articulated his view that ‘‘whatever our organismÕs peculiarities, our mental states have their substantive value as revelations of the living truth; we wish that all this medical materialism could be made to hold its tongue’’ [9]. James argued that medical materialism ‘‘finishes up Saint Paul by calling his vision on the road to Damascus a discharging legion of the occipital cortex, he being an epileptic’’ [9]. Whether or not the view espoused by James is correct, the debate as to whether mystical experience is primarily transcendental and beyond the body (though it may, perhaps, also be understood to include the body) or merely a flash of neuronal or other physiological activity extends throughout philosophy as well as in psychology, and certainly offers one window into the study of epilepsy and religious experience. This debate also is echoed in controversies concerning the validity of 2 NCCAMÕs ‘‘frontier medicine’’ research program is described in a Request for Applications [8].
604
Special Communication / Epilepsy & Behavior 4 (2003) 602–606
ideologies and approaches taken in CAM therapies to effectuate healing [10], methodological, and study design issues [11], and discussions about hierarchy, supervision, status, and autonomy in integrative teams that include biomedical and CAM providers [12]. In particular, perspectives differ as to whether spiritual healing involves any readily identifiable, biological mechanism, or involves a more nebulous concept of ‘‘organizing principles of vitalism and life force which bring about a harmonizing of the whole person’’ [13]. Certainly, patients are turning to spiritual healing for treatment of epilepsy, particularly in cultures that value spiritual healing as part of their traditionÕs heritage. For example, a recent study in Nigeria evaluated the use of alternative treatment methods, in various forms, by epileptic patients who had used these forms of treatment before seeking hospital treatment. Among the 265 epileptic patients, 47.6% used African traditional medicine alone; 24.1% combined traditional medicine with spiritual healing, 20.4% used spiritual healing alone, and 7.5% used other forms of alternative medicine [14]. Similarly, in a study of a state in southern Brazil, roughly 60% of the sample had tried CAM therapies for epilepsy, including blessing, home remedies, prayers, mediumship, and spiritual surgery [15]. A recent report described the work of a neurologist affiliated with Michigan State University who spends 3 months a year treating epileptic patients in Zambia, where she works with native healers and combines her biomedical approaches with theirs.3 But even in the U.S., patients increasingly are turning to ‘‘holistic’’ approaches to help self-manage an epileptic condition.4 CAM therapies include relaxation techniques, such as yoga, meditation, and biofeedback, to help control stress and thus reduce potential seizure activity; acupuncture and acupressure; and various nutritional therapies [18]. While patients can easily find self-help resources on the Internet, the medical evidence is not yet robust; for example, a 1999 systematic review to assess the efficacy of yoga in the treatment of people with epilepsy stated no reliable conclusions could be drawn regarding the efficacy of yoga as a treatment for epilepsy [19]. At the same time, while the medical evidence remains in flux, many proponents of CAM therapies, and of religious healing in general, suggest spiritual etiologies and treatments. For example, some Christian fundamentalists point to a passage in the New Testament in which Jesus healed an individual afflicted with epilepsy by casting out a spirit that had possessed him [20]; the scriptural text points to faith, prayer, and fasting for 3 The story is reported as Doc’s Work in Africa Blends Traditional Healing, Modern Medicine [16]. 4 Among the books offered on the subject is Epilepsy: A Holistic Approach [17].
treatment [Mark 19: 14–29]. Shamanism, an ancient set of practices involving meditation between the physical and the spirit world, also applies a kind of exorcising practice to help treat epilepsy, though practitioners are careful to point out the difference between voluntarily entering trance states to control spirits, and possession or ‘‘mad’’ states, in which persons are hypothesized to be subject to involuntary control by spirits [21,22]. Doubtless, the whole phenomenon of access to trance states deserves much deeper study, as the spiritual healerÕs claim to enter such states at will, and receive information through nonordinary, intuitive senses [23,24], may have parallels to the notion that a patient with temporal lobe epilepsy may ‘‘suddenly hear or smell something odd that does not come from the surrounding environment, and then appear absent or vacant for a couple of minutes.’’5 1.3. Legal and regulatory issues The legal issues relating to clinical inclusion of CAM therapies are different than the legal issues typically associated with epilepsy as a disability. The latter involves such considerations as discrimination in employment; applicability of the Americans with Disabilities Act (ADA); legal rules pertaining to state driver licensing requirements; and family law considerations.6 On the other hand, clinical inclusion of CAM therapies raises a host of other legal and regulatory issues, including licensure and credentialing of CAM providers and therapies, malpractice liability considerations, informed consent obligations, relevant food and drug law concerns, and issues of third-party reimbursement [25– 28]. Many of these issues are novel and unresolved, with little legal precedent to guide decision makers. On the other hand, a number of tools are available to help clinicians decide which CAM therapies to recommend, avoid and discourage, or monitor [26], to help institutions make decisions concerning credentialing of CAM providers [29], to facilitate ethical decision making concerning CAM therapies [30], and to evaluate legal rights and obligations generally [31]. Legal concerns, however, may be heightened when contemplating therapies that have an overt or explicit spiritual dimension [2,32]. More specifically, boundaries can be unclear, and patients may have heightened sensitivity to conversations about spiritual dimensions of illness, as well as to suggestions concerning spiritual therapeutics [32]. Patients, as well, may wish to discuss 5 Interestingly, this description comes not from a clinician, but from a web site for legal services surrounding head injury: http:// www.headinjurylaw.com/html/glossary.htme#epilepsy. 6 The Epilepsy Foundation, 4351 Garden City Drive, Landover, MD 20785, USA, publishes a number of helpful texts on these subjects for patients and their families.
Special Communication / Epilepsy & Behavior 4 (2003) 602–606
with their physicians concerns about their interactions with spiritual healers. The spiritual healer ‘‘acts not only as a confidant and therapist, but also as a medium through whom the energies of healing are purported to flow’’ [32]. As such, the client may be especially vulnerable to abuse of power and authority, ‘‘by virtue of claimed access to specialized, intuitive information—that is, access to the shamanic worlds of non-ordinary consciousness that give the healer a privileged glimpse into the clientÕs condition and potential mechanisms to resolve the clientÕs health care issues or crisis’’ [32]. A number of legal rules help address potential abuse of authority by health care professionals. Such rules may be applicable to the arena of spiritual healing, and include: (1) medical licensure; (2) scope of practice; (3) professional discipline; (4) malpractice; and (5) fraud [2,32,33]. Although a fuller discussion of the rules and their applicability is beyond the scope of this article, the references herein should offer the clinician additional sources of research and guidance.
2. Conclusion CAM therapies offer unique legal and regulatory, as well as clinical, conundrums. Although historically, healing in the religious and spiritual realms has coexisted with medicinal healing on the physical level, in modern times, there appears to be increasing convergence among different systems of knowledge and in consumer (as well as clinician) interest in bridging these various approaches to health and healing. While an exhaustive treatment of all the relevant issues is not feasible, and the field of CAM therapies is very much in flux, the clinician can remain alert to potential clinical as well as legal arenas of controversy, and thereby help empower patients toward greater selfknowledge and self-care in the management of disease and in healing. References [1] OÕConnor BB et al. Defining and describing complementary and alternative medicine. Alt Ther Health Med 1997;3(2): 49–57. [2] Cohen MH. Healing at the borderland of medicine and religion: regulating potential abuse of authority by spiritual healers. J L Relig., in press. [3] Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–75. [4] American Hospital Association (Health Forum). 2000–2001 Complementary and alternative medicine survey. Chicago: American Hospital Association; 2002 (available on-line at http:// www.hospitalconnect.com). [5] National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine (available at http://www.nccam.nih.gov/health/whatiscam/#sup2).
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[6] Krieger D. The therapeutic touch: how to use your hands to help or heal. Englewood Cliffs, NJ: Prentice–Hall; 1979. [7] Jamison JR. ChiropracticÕs functional integration into conventional health care: some implications. J Manipulative Physiol Ther 1987;10(1):5–10. [8] Exploratory grants for frontier medicine research, 2002 (available at http://www.grants1.nih.gov/grants/guide/rfa-files/RFAAT-00-002.html). [9] James W. The varieties of religious experience. New York: Collier Books; 1961. p. 29. [10] Kaptchuk TJ, Eisenberg DM. Varieties of healing: I. Medical pluralism in the United States. Ann Intern Med 2001;135: 189–95. [11] Shaffner KF. Assessments of efficacy in biomedicine: the turn toward methodological pluralism. In: Callahan D, editor. The role of complementary and alternative medicine: accommodating pluralism. Washington, DC: Georgetown Univ. Press; 2002. p. 1–14. [12] Cohen MH, Ruggie MC. Integrating complementary and alternative medical therapies in conventional medical settings: legal quandaries and potential policy models. Univ Cinn Law Rev, in press. [13] Aldridge D. Spirituality, healing and medicine: return to the silence. London: Jessica Kingsley; 2000. p. 42. [14] Danesi MA, Adetunji JB. Use of alternative medicine by patients with epilepsy: a survey of 265 epileptic patients in a developing country. Epilepsia 1994;35:344–51. [15] Trevisol-Bittencourt PC, da Silva VR, Fereira LR, Troiano AR. Alternative medicine in patients with epilepsy in Santa Catarina, Southern Brazil (available on-line at http://www.sites.uol.com.br/ paulo_ctb/hp/alternativa-en.htm). [16] DocÕs work in Africa blends traditional healing, modern medicine (available on-line at http://www.newswise.com/articles/2002/5/ EPILEPSY.MSU.html). [17] Thomas C. Epilepsy: a holistic approach. Images Booksellers and Distributors; 1993. [18] Tran M. Epilepsy. Gale encyclopedia of alternative medicine. In: Gale Group; 2001. [19] Ramaratnam S, Sridharan K. Yoga for epilepsy (Cochrane Review), in The Cochrane Library (Issue 1, 2003). [20] Spiritual warfare: epilepsy (available on line at http://www. line-sand.com/teachings/epilepsy.html). [21] Perkins LL. Shamanism and the spirit world (available on-line at http://www.bewellnaturally.com/HTML/Library/Articles/shamanism.html). [22] Eliade M. Waiting for the dawn. In: Carrasco D, Law JM, editors. Waiting for the dawn: Mircea Eliade in perspective. Boulder: Univ. Press of Colorado; 1991. p. 11. [23] Bruyere RL. In: Wheels of light: a study of the Chakras, vol. I. Sierra Madre: Bon Productions; 1991. [24] Schwartz J. Human energy systems: a way of good health. New York: Penguin Books; 1980. [25] Cohen MH. Complementary and alternative medicine: legal boundaries and regulatory perspectives. Baltimore: Johns Hopkins Univ. Press; 1998. [26] Cohen MH, Eisenberg DM. Potential physician malpractice liability associated with complementary/integrative medical therapies. Ann Intern Med 2002;136:596–603. [27] Ernst EE, Cohen MH. Informed consent in complementary and alternative medicine. Arch Int Med 2001;161(19) 2288–92. [28] Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Brennan TA. Medical malpractice implications of alternative medicine. JAMA 1998;280:1610–5. [29] Eisenberg DM, Cohen MH, Hrbek A, Grayzel J, van Rompay MI, Cooper RA. Credentialing complementary and alternative medical providers. Ann Intern Med 2002;137:965–73.
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[30] Adams KE, Cohen MH, Jonsen AR, Eisenberg DM. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med 2002; 137:660–4. [31] Cohen MH. Legal issues in alternative medicine. Canada: Trafford; 2003.
[32] Cohen MH. Future medicine: ethical dilemmas, regulatory challenges, and therapeutic pathways to health and healing in human transformation. Ann Arbor: Univ. of Michigan Press; 2002. [33] Cohen MH. Beyond complementary medicine: legal and ethical perspectives on health care and human evolution. Ann Arbor: Univ. of Michigan Press; 2000.
Special Communication
Regulation, religious experience, and epilepsy: a lens on complementary therapies Michael H. Cohen*,1 HMS-Osher Institute, Harvard Medical School, 401 Park Drive, 2nd Floor West 22-A, Boston, MA 02215, USA Received 20 August 2003; accepted 20 August 2003
Abstract Complementary and alternative medical (CAM) therapies include chiropractic, acupuncture and traditional Oriental medicine, massage therapy, and herbal remedies; mind–body therapies (such as meditative practices and visualization); and folk practices and religious healing. Of these, modalities based on spiritual healing create a number of conundrums for the clinician, including legal, regulatory, and ethical issues. Further, the historic relationship between the study of epilepsy and religious experience suggests particular, potential associations between CAM therapies (and especially spiritual healing) and care for epileptic patients. There are at least two dimensions to this exploration: first, the widespread use of spiritual healing for treatment of epilepsy; and second, the hypothesized connection between epileptic seizures and mystical states. A number of legal rules help address potential abuse of authority by health care professionals, and include: (1) medical licensure; (2) scope of practice; (3) professional discipline; (4) malpractice; and (5) fraud. This article offers a preliminary resource for clinicians interested in these topics. Ó 2003 Elsevier Inc. All rights reserved. Keywords: Complementary therapies; Integrative health care; Spiritual healing; Regulation; Legal issues
1. Complementary therapies and integrative health care Complementary and alternative medical (CAM) therapies refer to ‘‘a broad domain of healing resources that accompanies all health care systems, modalities, and practices and their accompanying theories and beliefs other than those intrinsic to the politically dominant health care of a particular society or culture in a given period’’ [1]. Major CAM therapies include chiropractic, acupuncture, and traditional oriental medicine, massage therapy, herbal remedies, and mind–body therapies (such as meditative practices and visualization); folk practices and religious healing are also included within contemporary definitions of CAM therapies. CAM therapies, as thus described, may be provided by several groups of clinicians, such as: (1) medical * Fax: 1-617-384-8555. E-mail address: [email protected]. 1 Michael H. Cohen is Director of Legal Programs at the Harvard Medical School Osher Institute, an Assistant Professor of Medicine at Harvard Medical School, and a 40th Anniversary Senior Fellow at the Center for the Study of World Religions, Harvard Divinity School.
1525-5050/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2003.08.014
doctors who may be counseling their patients regarding these therapies or offering such modalities in clinical care (e.g., physicians counseling patients regarding their use or avoidance of herbs); (2) allied health providers similarly counseling or offering therapies (such as nurses performing massage therapy); (3) CAM providers, offering therapies such as acupuncture needling; and (4) providers in the arena of mental health care using therapies that could be considered either biomedical or within the CAM domain (e.g., psychologists offering guided imagery and visualization) [2]. A 1998 study published in the Journal of the American Medical Association found a 47% increase in total visits to complementary and alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, with total 1997 out-of-pocket expenditures relating to alternative therapies estimated at $27 billion [3]. The study suggested that use of complementary and alternative medicine is likely to continue to increase, particularly as insurance reimbursement for complementary and alternative therapies grows [3]. In similar fashion, a
Special Communication / Epilepsy & Behavior 4 (2003) 602–606
2000-2001 survey of 5,810 hospitals by the American Hospital Association reported that 15% of the respondents offered CAM therapies [4]. Given these developments, medical academics increasingly have begun to conceptualize the notion of ‘‘integrative health care,’’ which integrates biomedical and CAM therapies in clinical care. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) presently defines integrative medicine as health care that ‘‘combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness’’ [5]. The very existence of such a definition in an NIH document suggests that clinicians increasingly are called on to recognize the importance of considering inclusion of CAM therapies in the diagnostic and therapeutic armamentarium, as well as patient preferences for discussing options involving such therapies. 1.1. Frontier CAM therapies One of the more controversial arenas within clinical consideration of using or discussing CAM therapies involves therapies that lack a significant—or, from the clinicianÕs standpoint, satisfactory—evidentiary basis of safety and efficacy, yet may offer hope and possibility to patients whose belief systems encompass spirituality. Indeed, modalities based on spiritual healing create a number of conundrums for the clinician, including legal, regulatory, and ethical issues. The term spiritual healing here is used to encompass a number of practices, including healing practices within the context of specific religious traditions (e.g., anointing of the Spirit and laying on of hands in Christian ministry), as well as healing involving intentionality or consciousness that is connected with religious teachings (as in, e.g., Christian Science) or taught in secular settings (such as Therapeutic Touch within the nursing school curriculum [6]). Although such a definition may lack sufficient scholarly rigor for disciplines such as anthropology and the study of world religions, it may offer a sufficient generalized starting point to help frame a discussion for the clinician who is interested in patient beliefs and practices. Such an inclusive definition also may help the clinician interested in using knowledge of such experiences, not only to offer proper medical counseling and satisfy any informed consent obligation, but also to help facilitate and augment the therapeutic relationship. Interestingly, though spiritual healing historically has been connected with religious movements, more recently, as suggested by the above example of Therapeutic Touch, the phenomenon has entered secular, clinical contexts such as nursing practice. Indeed, there may be significant overlap between CAM therapies such
603
as massage therapy and healing practices involving touch that suggest spiritual practice. For example, chiropractic, one of the most commonly accessed CAM therapies, partly originated in its founderÕs interest in so-called ‘‘magnetic healing’’ (referring to the notion of a kind of fluid ‘‘magnetism’’ between individuals), and shares ground with spiritual healing in its application of an intuitively guided, kinesthetic sense of the patient through sensations in the hands [7]. More recently, in acknowledging such interrelated phenomena as touch, emotional contact, and assertions by CAM practitioners regarding the possibility of nonbiologically mediated healing mechanisms, NCCAM has established a program for ‘‘frontier science,’’ seeking scientific explanations as to mechanisms of observed phenomena as well as methodological approaches to study them.2 1.2. Complementary therapies, spiritual healing, and epilepsy While all the above may concern clinicians generally, the historic relationship between the study of epilepsy and religious experience suggests particular, potential associations between CAM therapies (and especially spiritual healing) and care for epileptic patients. There are at least two dimensions to this exploration: first, the widespread use of spiritual healing for treatment of epilepsy; and second, the hypothesized connection between epileptic seizures and mystical states. A corollary to the latter inquiry is the question as to whether seizures provide access to states of consciousness in which the patient glimpses an aspect of the divine, or whether the reported, numinous experience can simply be reduced to a series of biochemical responses. This simple corollary has been subject to intense debates. Weighing in on one side, William James articulated his view that ‘‘whatever our organismÕs peculiarities, our mental states have their substantive value as revelations of the living truth; we wish that all this medical materialism could be made to hold its tongue’’ [9]. James argued that medical materialism ‘‘finishes up Saint Paul by calling his vision on the road to Damascus a discharging legion of the occipital cortex, he being an epileptic’’ [9]. Whether or not the view espoused by James is correct, the debate as to whether mystical experience is primarily transcendental and beyond the body (though it may, perhaps, also be understood to include the body) or merely a flash of neuronal or other physiological activity extends throughout philosophy as well as in psychology, and certainly offers one window into the study of epilepsy and religious experience. This debate also is echoed in controversies concerning the validity of 2 NCCAMÕs ‘‘frontier medicine’’ research program is described in a Request for Applications [8].
604
Special Communication / Epilepsy & Behavior 4 (2003) 602–606
ideologies and approaches taken in CAM therapies to effectuate healing [10], methodological, and study design issues [11], and discussions about hierarchy, supervision, status, and autonomy in integrative teams that include biomedical and CAM providers [12]. In particular, perspectives differ as to whether spiritual healing involves any readily identifiable, biological mechanism, or involves a more nebulous concept of ‘‘organizing principles of vitalism and life force which bring about a harmonizing of the whole person’’ [13]. Certainly, patients are turning to spiritual healing for treatment of epilepsy, particularly in cultures that value spiritual healing as part of their traditionÕs heritage. For example, a recent study in Nigeria evaluated the use of alternative treatment methods, in various forms, by epileptic patients who had used these forms of treatment before seeking hospital treatment. Among the 265 epileptic patients, 47.6% used African traditional medicine alone; 24.1% combined traditional medicine with spiritual healing, 20.4% used spiritual healing alone, and 7.5% used other forms of alternative medicine [14]. Similarly, in a study of a state in southern Brazil, roughly 60% of the sample had tried CAM therapies for epilepsy, including blessing, home remedies, prayers, mediumship, and spiritual surgery [15]. A recent report described the work of a neurologist affiliated with Michigan State University who spends 3 months a year treating epileptic patients in Zambia, where she works with native healers and combines her biomedical approaches with theirs.3 But even in the U.S., patients increasingly are turning to ‘‘holistic’’ approaches to help self-manage an epileptic condition.4 CAM therapies include relaxation techniques, such as yoga, meditation, and biofeedback, to help control stress and thus reduce potential seizure activity; acupuncture and acupressure; and various nutritional therapies [18]. While patients can easily find self-help resources on the Internet, the medical evidence is not yet robust; for example, a 1999 systematic review to assess the efficacy of yoga in the treatment of people with epilepsy stated no reliable conclusions could be drawn regarding the efficacy of yoga as a treatment for epilepsy [19]. At the same time, while the medical evidence remains in flux, many proponents of CAM therapies, and of religious healing in general, suggest spiritual etiologies and treatments. For example, some Christian fundamentalists point to a passage in the New Testament in which Jesus healed an individual afflicted with epilepsy by casting out a spirit that had possessed him [20]; the scriptural text points to faith, prayer, and fasting for 3 The story is reported as Doc’s Work in Africa Blends Traditional Healing, Modern Medicine [16]. 4 Among the books offered on the subject is Epilepsy: A Holistic Approach [17].
treatment [Mark 19: 14–29]. Shamanism, an ancient set of practices involving meditation between the physical and the spirit world, also applies a kind of exorcising practice to help treat epilepsy, though practitioners are careful to point out the difference between voluntarily entering trance states to control spirits, and possession or ‘‘mad’’ states, in which persons are hypothesized to be subject to involuntary control by spirits [21,22]. Doubtless, the whole phenomenon of access to trance states deserves much deeper study, as the spiritual healerÕs claim to enter such states at will, and receive information through nonordinary, intuitive senses [23,24], may have parallels to the notion that a patient with temporal lobe epilepsy may ‘‘suddenly hear or smell something odd that does not come from the surrounding environment, and then appear absent or vacant for a couple of minutes.’’5 1.3. Legal and regulatory issues The legal issues relating to clinical inclusion of CAM therapies are different than the legal issues typically associated with epilepsy as a disability. The latter involves such considerations as discrimination in employment; applicability of the Americans with Disabilities Act (ADA); legal rules pertaining to state driver licensing requirements; and family law considerations.6 On the other hand, clinical inclusion of CAM therapies raises a host of other legal and regulatory issues, including licensure and credentialing of CAM providers and therapies, malpractice liability considerations, informed consent obligations, relevant food and drug law concerns, and issues of third-party reimbursement [25– 28]. Many of these issues are novel and unresolved, with little legal precedent to guide decision makers. On the other hand, a number of tools are available to help clinicians decide which CAM therapies to recommend, avoid and discourage, or monitor [26], to help institutions make decisions concerning credentialing of CAM providers [29], to facilitate ethical decision making concerning CAM therapies [30], and to evaluate legal rights and obligations generally [31]. Legal concerns, however, may be heightened when contemplating therapies that have an overt or explicit spiritual dimension [2,32]. More specifically, boundaries can be unclear, and patients may have heightened sensitivity to conversations about spiritual dimensions of illness, as well as to suggestions concerning spiritual therapeutics [32]. Patients, as well, may wish to discuss 5 Interestingly, this description comes not from a clinician, but from a web site for legal services surrounding head injury: http:// www.headinjurylaw.com/html/glossary.htme#epilepsy. 6 The Epilepsy Foundation, 4351 Garden City Drive, Landover, MD 20785, USA, publishes a number of helpful texts on these subjects for patients and their families.
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with their physicians concerns about their interactions with spiritual healers. The spiritual healer ‘‘acts not only as a confidant and therapist, but also as a medium through whom the energies of healing are purported to flow’’ [32]. As such, the client may be especially vulnerable to abuse of power and authority, ‘‘by virtue of claimed access to specialized, intuitive information—that is, access to the shamanic worlds of non-ordinary consciousness that give the healer a privileged glimpse into the clientÕs condition and potential mechanisms to resolve the clientÕs health care issues or crisis’’ [32]. A number of legal rules help address potential abuse of authority by health care professionals. Such rules may be applicable to the arena of spiritual healing, and include: (1) medical licensure; (2) scope of practice; (3) professional discipline; (4) malpractice; and (5) fraud [2,32,33]. Although a fuller discussion of the rules and their applicability is beyond the scope of this article, the references herein should offer the clinician additional sources of research and guidance.
2. Conclusion CAM therapies offer unique legal and regulatory, as well as clinical, conundrums. Although historically, healing in the religious and spiritual realms has coexisted with medicinal healing on the physical level, in modern times, there appears to be increasing convergence among different systems of knowledge and in consumer (as well as clinician) interest in bridging these various approaches to health and healing. While an exhaustive treatment of all the relevant issues is not feasible, and the field of CAM therapies is very much in flux, the clinician can remain alert to potential clinical as well as legal arenas of controversy, and thereby help empower patients toward greater selfknowledge and self-care in the management of disease and in healing. References [1] OÕConnor BB et al. Defining and describing complementary and alternative medicine. Alt Ther Health Med 1997;3(2): 49–57. [2] Cohen MH. Healing at the borderland of medicine and religion: regulating potential abuse of authority by spiritual healers. J L Relig., in press. [3] Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–75. [4] American Hospital Association (Health Forum). 2000–2001 Complementary and alternative medicine survey. Chicago: American Hospital Association; 2002 (available on-line at http:// www.hospitalconnect.com). [5] National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine (available at http://www.nccam.nih.gov/health/whatiscam/#sup2).
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