Bounding biomedicine : evidence and rhetoric in the new science of alternative medicine

During the 1990s, an unprecedented number of Americans turned to complementary and alternative medicine (CAM), an umbrella term encompassing chiropractic, energy healing, herbal medicine, homeopathy, meditation, naturopathy, and traditional Chinese medicine. By 1997, nearly half the US population was seeking CAM, spending at least $27 billion out of pocket. Bounding Biomedicine centers on this boundary-changing era, looking at how consumer demand shook the health care hierarchy. Drawing on scholarship in rhetoric and science and technology studies, the book examines how the medical profession scrambled to maintain its position of privilege and prestige, even as its foothold appeared to be crumbling. Colleen Derkatch analyzes CAM-themed medical journals and related discourse to illustrate how members of the medical establishment applied Western standards of evaluation and peer review to test health practices that did not fit easily (or at all) within standard frameworks of medical research. And she shows that, despite many practitioners’ efforts to eliminate the boundaries between “regular” and “alternative,” this research on CAM and the forms of communication that surrounded it ultimately ended up creating an even greater division between what counts as safe, effective health care and what does not. At a time when debates over treatment choices have flared up again, Bounding Biomedicine gives us a possible blueprint for understanding how the medical establishment will react to this new era of therapeutic change. This book investigates scientific studies of complementary and alternative medicine (CAM) as episodes of scientific boundary work that shift, and then seek to fix, the boundaries between what counts as proper medical science and what does not. Drawing on scholarship in rhetoric of science and medicine and science and technology studies, it shows how biomedicine itself responds to challenges both to its borders and its social and epistemic authority. Set against the backdrop of evidence-based medicine, it examines the rhetorical constituents of biomedical boundary work by analyzing a set of CAM-themed issues of the journals of the American Medical Association from 1998 and related textual artifacts. To answer the key question, “How does the notion of evidence determine the boundaries of biomedicine, from expert to public contexts?” the book examines the theme issues and related medical and public discourse to illuminate how members of a culturally dominant profession evaluate medical therapies in the face of disciplinary unrest, both within and beyond the borders of their profession. The chapters move from contexts internal to medicine to those external, mapping, sequentially, the historical-professional, epistemological, clinical, and popular dimensions of biomedical boundary work. The book provides a more nuanced, stratified account of the rhetorical negotiation of medical and scientific boundaries. Its main claim is that, despite the willingness of many medical researchers and practitioners to elide distinctions between mainstream and alternative medicine, this research on CAM, and its related activities (publication, clinical practice), ultimately strengthen those distinctions and expand science’s authority in medicine Acknowledgments Introduction CAM Enters Biomedicine Rhetoric at the Fringes of Medicine Mapping Biomedical Boundaries Analyzing a Rhetorical Moment Preview of Chapters 1 Evidence, Rhetoric, and Disciplinary Boundaries Biomedicine’s Shifting Terrain: From Intuition and Experience to “Evidence” Quantitative Evidence and Jurisdictional Control Medical-Professional Strategies of Exclusion 2 Patrolling Professional Borders Constituting the Medical Profession Peer Review as Professional Self-Regulation Categorizing Complementary and Alternative Medicine CAM à la Carte 3 Scientific Methods at the Edge of Biomedicine Idealizing Evidence: Scientific Methods and CAM Research Idealizing Research: The Genre of the Randomized Controlled Trial Report Method as a Boundary Argument Efficacy as a Boundary Object 4 Precincts of Care in CAM Research Models of Clinical Practice Regulating Rhetorical Interaction Purifying Placebo Effects Patient Choice across Medical Models Dietary Supplements and Patient Agency 5 Professional Borders in Popular Media The Newsweek Special Report as a Biomedical “Discourse Moment” Reporting the New Science “Does it Really Work?” Constructing Biomedicine in the Media Mapping Boundaries of Expertise in Newsweek Displaced Stories about CAM and CAM Research Conclusion: Boundaries as Entry Points Notes Works Cited Index Contents 10 Acknowledgments 12 Introduction 16 1. Evidence, Rhetoric, and Disciplinary Boundaries 36 2. Patrolling Professional Borders 59 3. Scientific Methods at the Edge of Biomedicine 83 4. Precincts of Care in CAM Research 121 5. Professional Borders in Popular Media 162 Conclusion: Boundaries as Entry Points 202 Notes 212 Works Cited 226 Index 246