Government Reform and Oversight Committee
February 12, 1998 Dr. med. Peter F. MatthiessenMr. Chairman, Members of the Committee, Ladies and Gentlemen:
I am very honored to be able to speak before you today about the status of complementary, alternative and nonconventional medical practices in Germany today.
Allow me to introduce myself. My name is Peter Mathiessen. I have been wearing two professional hats for many years. Trained as a specialist in neurology and psychiatry, I am active in direct patient care as chief of the medical service in a large community hospital in Herdecke and in addition, I am active scientifically as Head of the Department of Medical Theory and Complementary Medicine at the University of Witten/Herdecke.
The Herdecke Hospital is a community hospital with close to five hundred beds and encompasses all customary medical and surgical specialty practices. Established in 1969, it rapidly became known all over Germany as the Herdecke Model and is since then the best known medical institution which includes complementary and alternative medicine in its services. In this hospital we have attempted to create care structures and a working atmosphere which have as their goal the care of the individual patient so that diagnosis and therapy is guided by the person's bodily, psychological and spiritual dimensions as well as their individual biography.
Without exception the knowledge basis of all physicians practicing there is that of modern scientifically established medicine. But beyond that we attempt to come to an extended, more encompassing comprehension of health, illness and healing and thus concern ourselves also theoretically and practically with various modes of complementary medicine. In acute patient care we then also utilize herbal medicines, remedies of anthroposophical medicine, homeopathic remedies, as well as external applications, massage, baths, etc. Beyond that we utilize various artistic therapies such as music therapy, painting therapy, curative eurythmy. It is our intent with such therapies to activate the patient as much as possible in actively participating in overcoming an illness and insofar as possible reestablish health.
Not only because of its innovative character and the countrywide interest in receiving care at this hospital, but also because of foreign, including American interests, our government has supported a further expansion of the hospital to the tune of 130 million DM.
The other institution I serve as professor is the University Witten/Herdecke, the only private university in Germany, established in 1983 by a group of established scientists. They had the goal to engage not only in mainstream scientific pursuits, but to extend the spectrum of scientific investigation; to follow up also unconventional points of view and begin to cultivate a rational scientific pluralism. Our faculty and students place upon themselves the demand to follow up questions and problems from various theoretical or philosophical perspectives and cultivate various methodologies.
Medicine in Germany is not a uniform edifice of theory and practice. In theory and practice it is highly pluralistic. This became especially evident in 1976 during the intensive and highly controversial discussions preceding and surrounding the passage of our new Medication Law of 1976.
The main focus of the debates at the time was the demonstration of therapeutic effectiveness. Our legislators acted wisely: They did not take upon themselves the role of judging the adequacy of science, but rather spoke in support of the actually existing pluralism in medicine. I am quoting from the report of the committee on the legislation in 1976: It is the unanimous view of the committee that it must not be the task of the legislator to give preference to the methods of one of the competing lines or schools of therapy in determining effectiveness of a medication. Rather, the committee was guided by the political goal that in the guidelines for acceptance of a medication there must be clearly reflected the existing scientific pluralism.''
A consequence was the establishment in 1978 of a commission for each of the so-called 'special lines of therapy', namely phytotherapy, homeopathy and anthroposophical medicine. The task of the commissions being ``the evaluation and preparation of scientific data in accordance with the standards and experiences of the corresponding lines of therapy and the formulation of indications for use.'' The implementation of this expert advice is then taken on by the Federal Department of Health.
The legislative intent and act, to permit nonconventional modes of therapy to exist besides the conventionally established medical practices was then also reflected in the German insurance legislation which applies to the institutions providing health insurance to 90% of the population. Accordingly, it is mandated that "treatment methods, remedies and medications of the special lines of therapy are not excluded from reimbursement." The special lines of therapy must also fulfill the criteria of indication, necessity, cost effectiveness, as well as quality and efficacy. These too are to be judged on the basis of scientifically reproducible data.
However it was only a few months ago, some twenty-one years after the passage of the original legislation, that the German legislative branch expressly established regulations that require the special points of view and experiences of the various lines of therapy to be taken into account when the state of prevailing scientific knowledge is judged.
Let me say a few words about the situation of research and support for research in Complementary/Alternative Medicine (in short CAM). Despite the widespread presence of those methods in the health care of our population, CAM was only marginally represented at German universities. Thus no adequate structural or personal resources could be developed for efficient and competitive scientific investigations.
For this reason and in view of widespread and ever increasing interest in non-conventional methods of treatment, the federal government supported from 1981-1996 investigations focused on "Non-conventional Methods of Cancer Treatment," and beyond that since 1989, a further project covering "Non-conventional Medical Lines of Therapy."
Under my direction a working group at Witten/Herdecke University was given the mandate
to:
1) provide an analysis and catalogue of the status of scientific research in CAM;
2) to establish a directed and efficient method of supporting research in CAM; and
3) To coordinate and support the various scientific endeavors.
A desired goal was to support serious empirical scientific endeavors in CAM and at the same time separate the wheat from the chaff.
What have been our experiences so far?
Sooner than we hoped we have arrived at a good overview regarding which directions of investigation are valuable for establishing the scientific basis of CAM, and thus potentially supplement and enrich conventional medicine. We have also gotten a good overview of questionable, even fraudulent procedures for which no plausible theoretical basis existed and where there was not even an interest in unprejudiced investigation, for it became evident that such practices were not able to meet the criteria for research proposals.
In view of the methodological aspects of proving effectiveness we have come to realize that in many cases the randomized controlled studies may not be appropriate. This is so because of therapeutic concepts which are highly individualized and also in view of the ever increasing autonomy of patients who, at least in Germany, are ever less willing to permit themselves to be randomized, thus making good randomized studies all but impossible.
Thus other study designs had to be developed and applied which were acceptable to representatives of both conventional and non-conventional medicine so that positive results could be acknowledged by established scientists and negative results would be taken seriously by defenders of non-conventional therapies.
Quite aside from the research activities and results obtained, the most important result of the efforts is that a dialogue has been set in motion, a dialogue between different modes of thinking and acting in medicine. This has led to a greater tolerance and exchange of various points of view, theoretical pursuits, and above all different questions, so that limits and possibilities are more amenable to evaluation and mutual cooperation is closer at hand.
Despite the great significance which science has in medicine, not everything which is fruitful in real life and in the individual's care in medical practice can be scientifically established and proven. Science in medicine is never an end in itself but always has only an ancillary function; it has the task to support and improve the training, contexting and careful judgment by the therapeutician. The Art of Healing however is always more than an applied science, namely it is the Art which strives to comprehend the uniqueness of each individual and to provide her with the best possible help in a situation which may be utterly unique, unexchangeable and never to recur in the same way.
On the basis of our experiences in Germany with CAM in public health care, I would like to recommend to the Committee that CAM is subjected to careful review and evaluation. However, I would caution that the legislative requirements for proof of efficacy in approving therapies and medications of CAM are not too narrow, constraining and restrictive. Room for different schools of therapeutics should be taken into account. Care must be taken not to endanger the development of potentially valuable therapies or methods of providing health care for the public. That would lead to an impoverishment through paradigmatic uniformity in medicine -- established by legislation.
It is our experience that where the legislative framework is provided for the unfolding of a pluralistic medicine (which already exists de facto), the ensuing critical but open dialogue is most efficient in distinguishing valuable and promising therapies from fraudulent methods. Thus it is in all our interests that we work for those who are ill in an open, honest and critical fashion -- the goal being to help the ill patient.
I thank you for your interest and would like to let you know how impressed I am by your pursuit of providing legislation for a free pluralistic medicine appropriate for the human individual.