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Asserting that evidence-based complementary and alternative medicine is a contradiction in terms must, of course, begin with defining the terms ‘evidence-based’ and ‘alternative medicine’ (which are the two terms most generally discussed). This is not a straightforward task with either term. In particular, the term ‘evidence’ in relation to the practice of medicine has been utilised in so many fashions, by so many authors, it has become completely meaningless.1 But if it is to be anything beyond an appellation designed to make things sound more scientific, ‘evidence-based’ must include some consistent and coherent definition of ‘evidence.’ Since major proponents of the evidence-based medicine movement seem unable or unwilling to define the term,2 we must revert to the original3 and still predominant notion that ‘evidence’ derives from population-based clinical research studies, preferably those that are controlled, randomised and blinded. Evidence-based alternative medicine, then, demands that all interventions under that rubric be subjected to rigorous controlled trials in order to demonstrate efficacy.

But EBM has moved beyond an approach to the practice of clinical medicine to become a defining feature of Western allopathic medicine. The claim is that once an intervention has been demonstrated to be beneficial by the appropriate clinical studies, it becomes part of scientific medicine, part of the orthodoxy. And what is left? ‘There is no alternative medicine . . . only unproven medicine, for which scientific evidence is lacking.’4 Orthodox medicine claims any therapy that has demonstrated efficacy in clinical trials regardless of how, where or by whom it was developed or introduced. Alternative medicine cannot maintain an exclusive claim on an intervention simply because it derived from a different healing tradition. The roots or rationale for a particular treatment are ‘largely irrelevant except for historical purposes and cultural interest.’4

To represent an alternative medicine, then, a healing art must reject the underlying and often unexamined tenets of EBM. An alternative medicine must reject the assertion that the best way to demonstrate benefit is always found in randomised, controlled studies.5 Rejecting the tenets of EBM follows necessarily from certain core assumptions of some of the various forms of alternative healing. If disease cannot be fully understood without understanding the individual in which it occurs, then randomised trials are inappropriate. If perceptible, but unmeasurable factors are relevant to disease and healing, then blinding in research studies is impossible. If healing requires multifaceted interventions, then the reductionist tendencies of clinical research must be resisted. When both the individuality of the patient and the individuality of the practitioner are seen as vital to the healing process, none of the current tools of EBM, which are designed to obscure those features, can be employed.

Thus, in this era of EBM, alternative medicine comes to be defined by its rejection of the metaphysics and epistemology of Western allopathic medicine. But wholesale rejection of EBM, of the need for some proof of effect beyond anecdote, runs the risk of leaving alternative medicine defending only the absurd.6 Instead, alternative medicine must develop new research designs and new standards of evidence that are consistent with a more complex understanding of illness and healing than that currently allowed by EBM.5,7 These tools must be coherent with the underlying theory of disease and healing espoused by the discipline, but must also have some face validity and comply with the basic rules of logic. The current tools of EBM produce knowledge that can neither be derived from observations of single patients nor be directly and prescriptively applied to individuals.8 The challenge for a more rigorous and convincing alternative medicine will be the demonstration of causal improvement in the outcomes of individual patients.9 This challenge must be met in order for alternative medicine not to be equated with ‘unproven’ medicine, but stand on its own as a reasonable, viable and defensible option for improving the lives of individuals in need.

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Mark R Tonelli, MD, MA, University of Washington Medical Center, 1959 NE Pacific, Campus Box 356522, Seattle, Washington 98195-6522, USA.