Abstract
Fundamental rights are preconditions for any human to act with sufficient freedom and to be allowed sufficient choice to realize their potential. The right to indigenous medicine must be recognized as a fundamental human right for indigenous peoples. In accordance with the principles of Evidence-Based Medicine, every citizen should be allowed to benefit from the placebo effect. It constitutes an essential aspect of treatment, which is rightfully theirs on the basis of payment for health care – regardless of whether the payment is made out of pocket, or from public finance. It then follows that, the right of citizens to access the medical system of their choice should be formally acknowledged. That choice should be regarded as a Fundamental Human Right, which should under no circumstance be denied them - not for reasons of scientific prejudice, nor commercial ambition.
Keywords: Complementary and alternative medicine, citizen's rights, Human rights, UN declaration of indigenous people's medical rights
INTRODUCTION
Foundational documents such as the U.S. Bill of Rights[1] and the Declaration of Human Rights[2] embody the fundamental ideas concerning human freedoms to which individuals, institutions and governments of a liberal persuasion subscribe. Such rights are preconditions for any human to act with sufficient freedom, and to be allowed sufficient choice, to realize their potential.
These historic documents had little to say about medical systems. In September 2007, however, the United Nations General Assembly finally ratified its declaration on the Rights of indigenous people, which has enormous significance for integrative medicine. Article 24 of this Declaration states: indigenous people have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. The second clause of the same article affirms an equal right to the highest attainable standard of physical and mental health.[3]
The right to indigenous medicine must be recognized as a fundamental human right of indigenous people: it is a corollary of the right of every human being to health, which naturally includes a right to effective healthcare at an affordable level. The principle underlying this article of the Declaration is that people heal better when treated in a culturally familiar way by those whom they trust. For indigenous people, this usually means their own traditional health practitioners.
One reason is communication; when a person cannot adequately explain his/her symptoms to a healthcare provider, or does not share the provider's explanatory model for the illness, inappropriate treatment may be given. Yet the issue is more complex than that. An indigenous person, as much as anyone else, may or may not have confidence in an individual healthcare provider. Either way, emotions can strongly affect the outcome of treatment, and simple, positive emotions are well recognized to help. This forms the basis for the placebo effect, now one of the best validated effects in medical science, which seems to have been increasing over the past three decades.[4]
What this means is that, effectively, the UN Declaration is stating that:
Indigenous peoples have the right to the placebo effect.
It also implies that they also have the right to prevent any nocebo effect being inflicted on them.
PLACEBO AND NOCEBO EFFECTS
More scientific research has verified the placebo effect than any other single form of treatment, as demonstrated by the fact that randomized placebo-controlled trials have become the gold standard for developing new drugs. Placebo effects are accepted beyond doubt, and the proven interactions between the mind, the endocrine system and the immune system have given rise to an entire scientific discipline, that of psycho-neuro-immunology.
Placebo-mediated improvement has been associated with a subconscious conditioned response,[5] as demonstrated by Pavlov in his famous dog experiment. In a Western context, ‘previous benefits from taking pills or interacting with a white-coated doctor’ could act as a conditioning stimulus, generating a positive physiological response even if the condition being treated is not the same as the previous occasions.[6] Among Indigenous Peoples, previous benefits from interacting with a certain type of practitioner or being in a particular ritual context, such as a sweat lodge or forest retreat, could likewise exert a strong influence on the outcome of the treatment.
In accordance with the principles of evidence-based medicine, every citizen should be allowed to benefit from the placebo effect. It constitutes an essential aspect of treatment, which is rightfully theirs on the basis of payment for healthcare, regardless of whether the payment is made out of pocket, or from public finance.
If a patient is denied the right to visit their healthcare provider of choice, at best they are being denied an optimal placebo effect, and at worst they may suffer serious harm. This is because the human mind is capable of creating far more than a placebo effect. It can also give rise to its converse, a nocebo effect, from the Latin “I will harm”. This effect was clearly demonstrated in a study conducted by Hahn,[7] in which patients were given sugar water and told that it was an emetic; 80% responded by vomiting. It is understood that if a patient mistrusts their physician, they are liable to experience adverse results. When hospital staff members treat patients as malfunctioning machines, rather than as persons with emotional and spiritual responses, this in itself may generate nocebo effects.
This scenario raises the question: are we going to condemn a large fraction of the public to be treated by systems of medicine that they may inherently mistrust? If we do so, we may be subjecting them not only to a distasteful experience – no one enjoys consulting a person whom they feel cannot solve their problem–but also to one that is detrimental to their health.
RIGHTS OF BELIEF
In the context of asserting the right of Indigenous Peoples to utilize their traditional systems of healthcare, it can also be argued that health-related beliefs are on a par with personal spirituality and religious practices. The fragmented thinking that has emerged over hundreds of years in Western societies, which characterizes ‘health’, ‘spirituality’ and ‘culture’ as distinct fields of human endeavor, is by no means shared by intact indigenous communities. In the latter, wellness is usually understood in a holistic sense, and there may be little or no distinction between practices intended to promote spiritual well-being and those performed to improve physical or mental health; indeed, some traditional practices achieve all three of these goals simultaneously.
If a citizen wishes to participate in non-harmful practices that are in accordance with their personal beliefs, basic precedents state that it is his or her statutory right to be permitted to do so. Thus, nobody is allowed to interfere with religious practices – or, by implication, practices aimed at improving well-being in a holistic sense – on grounds of bigotry, or for any other reason.
In terms of its underlying principles, the UN Declaration can be generalized to other situations: if indigenous peoples have the right to their own systems of traditional healthcare, then displaced persons such as refugees should also have the same right. This does not necessarily imply that their indigenous system of healthcare should be forcibly introduced into the country to which they have been displaced, but if it is already available in that country, and if they are satisfied with it, then no arbitrary action by governments, organizations or individuals should be allowed to deprive them of it. A well-known example of refugees using their own system of medicine is that of Tibetan refugees living in cities such as Bangalore and New York and utilizing Sowa Rigpa, traditional Tibetan medicine.[8]
Refugees are encouraged to learn the local language, find jobs, earn an income and become active members of their adoptive society; but beliefs and preferences such as those operating the placebo effect are more deeply ingrained than language and superficial culture. It would make nonsense of humanitarian principles to deprive refugees of the Right to their system of medicine for financial reasons. Nor can it be denied that this right should extend to children and family groups, those who later join a well-established breadwinner, and so on.
From this, it also follows that other kinds of person who move to foreign countries should also be recognized as having the right to benefit from a placebo effect, and to avoid nocebo effects to the extent that is possible. For example, millions of South Asian citizens from Sri Lanka, Nepal, Bangladesh and Pakistan, as well as India, have moved to Europe and America. They should be entitled to their traditional systems of medicine – Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (often abbreviated to AYUSH) – if these systems are available through adequately qualified practitioners in the countries where they are now living.
GLOBALIZATION OF TRADITIONAL MEDICINE
The World Health Organization's Global Atlas of Traditional, Complementary and Alternative Medicine[9] clearly illustrates the globalization of traditional systems of healthcare. In many industrialized countries, these systems are not only utilized by ethnic minorities from their respective countries of origin, but also accepted or tolerated alongside the formal sector as ‘complementary and alternative medicine’. Ayurveda is one example; another is Traditional Chinese Medicine (TCM), which is now available throughout the world.
In the case of codified systems such as TCM and Ayurveda, many millennia of experience have refined their use of herbal medicines to an incredibly powerful extent. A wealth of pre-clinical and clinical studies published in world class journals testify to the effectiveness of traditional systems of healthcare, while a number of governments have already granted official recognition to systems other than biomedicine and even incorporated them into national health services.
Yet, in spite of their advantages, traditional systems of healthcare still have many detractors. Bausell, for example, makes persistent, scientifically bogus claims that they are worthless.[10] In light of this, strong public statements are necessary:
“No system of medicine satisfying patients should be allowed to be abolished, or even downgraded, simply because of the opinions of scientists or others who have not studied the system in depth, and who only understand it in the most superficial terms.”
MEDICAL PLURALISM
It is well recognized that no single system is capable of satisfying all the medical needs of a nation's citizens. As a result, many countries such as India, China, the UK, Australia and the USA have identified a need for multiple systems of medicine to be licensed and regulated, and accept ‘medical pluralism’ as the norm.
Medical pluralism develops because the public ‘votes with its feet’ for complementary systems of medicine. This usually results from the failure of biomedicine to find cures for certain chronic diseases, and the accompanying determination of patients and their family members to seek effective treatments that do not produce debilitating side effects. Word of success spreads: competent practitioners of CAM systems giving reliable results gain word-of-mouth reputations, and acquire many patients as a result. In industrialized countries, it has been demonstrated that people with the highest incomes and the highest levels of education often pay out of pocket for the services of CAM practitioners,[11,12] while in non-industrialized countries, herbal and traditional systems of medicine remain the first choice for the majority of the population.[9]
Sizable fractions of such societies require non-biomedical systems of healthcare to be available if their health needs are to be met. These requirements are based on gut instinct, and deeply rooted feelings with which people identify deep inside. A number of governments have already recognized this need of modern societies - hence, medical pluralism - but it is far from being accepted as a fundamental human right. Non-codified systems of medicine such as Aboriginal, First Nations and African traditional health care are rarely accorded the same recognition as the ancient written traditions of China and India.
CONCLUSIONS
Where only biomedical healthcare is made available in a society, a non-negligible fraction of the public is forced to visit practitioners whom they inherently mistrust, thus requiring them to go through an experience that could well be injurious to their health, rather than beneficial. Indeed, that is one of the main reasons why patients opt for systems of CAM – instinctive avoidance of a nocebo-inducing experience.
A state's duty to its citizens is clearly to give them placebo effects, and, as far as possible to avoid giving them nocebo effects.
It then follows that,
The right of citizens to access the medical system of their choice should be formally acknowledged.
That choice should be regarded as a Fundamental Human Right, which should under no circumstance be denied them – not for reasons of scientific prejudice, nor commercial ambition.
Acknowledgments
The author acknowledges the valuable contribution of Dr. Alex Hankey towards the concept and initial draft of this article.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
REFERENCES
- 1.The Bill of Rights. Washington D.C: US National Archives and Records Administration; 1986. [Google Scholar]
- 2.Universal Declaration of Human Rights: A standard of achievement. New York, N.Y: United Nations Office of Public Information; 1962. [Google Scholar]
- 3.United Nations General Assembly, Resolution 61/295 on 13 September 2007. Declaration on the Rights of Indigenous Peoples. [last accessed on 2009 Nov 20]. Available from: http://www.un.org/esa/socdev/unpfii/en/drip.html Published on the Internet .
- 4.Silberman S. Placebos are Getting More Effective. Drugmakers are Desperate to Know Why. Wired Magazine. 2009. Aug 17, [last accessed 2009 Nov 29]. Available from: http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect?currentPage=allPublished on the Internet .
- 5.Hróbjartsson A. The uncontrollable placebo effect. Eur J Clin Pharmacol. 1996;50:345–8. doi: 10.1007/s002280050120. [DOI] [PubMed] [Google Scholar]
- 6.Ader R. The role of conditioning in pharmacotherapy. In: Harrington A, editor. the Placebo Effect: an Interdisciplinary Exploration. Cambridge, MA: Harvard University Press; 1997. [Google Scholar]
- 7.Hahn RA. The nocebo phenomenon: scope and foundations. In: Harrington A, editor. the Placebo Effect: an Interdisciplinary Exploration. Cambridge, MA: Harvard University Press; [Google Scholar]
- 8.Neumann C. Treating Tibetan refugees in New York City: the healing work of a fellow refugee. J Altern Complement Med. 2003;9:189–91. doi: 10.1089/10755530360623301. [DOI] [PubMed] [Google Scholar]
- 9.Bodeker G, Ong C K, Grundy C, Burford G, Shein K. WHO Global Atlas of Traditional, Complementary and Alternative Medicine. Kobe, Japan: World Health Organization - Centre for Health Development; 2005. [Google Scholar]
- 10.Barker Bausell R. Are positive alternative medical therapy trials credible? Evidence from four high impact medical journals. Eval Health Prof. 2009;32(4):349–69. doi: 10.1177/0163278709346810. [DOI] [PubMed] [Google Scholar]
- 11.Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569–75. doi: 10.1001/jama.280.18.1569. [DOI] [PubMed] [Google Scholar]
- 12.Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548–53. doi: 10.1001/jama.279.19.1548. [DOI] [PubMed] [Google Scholar]