Causality, Anthroposophic Medicine and Statistics
By: Helmut Kiene, M.D.
(Original title: Kausalitaet, anthroposophische Medizin und Statistik. Merkurstab 1995; 48 389-95. English by A. R. Meuss, FIL, MTA. A lecture given at the 40th Biometric Colloquium, German Region of the International Biometrics Society. Munster, 15-18 March 1994. German original reprinted from Antes G., et al. Biometrische Berichte Bd III. Munster-Hiltrup: Landwirtschaftsverlag 1995 (with kind permission).
The aim is to show the area in which the "cause and effect" concept and its application in experimental work are not appropriate or relevant to anthroposophic medicine and consider the potential consequences.
Cause and effect
The "cause and effect" concept emerged, together with the experimental method of research, at the beginning of the present age in western science. Before that, ideas relating to causality took their orientation from Aristotle's thinking in terms of causa fomulis, causa materialis, etc.
Modem experimental exploration of cause-effect relationships is essentially governed by two criteria. The first criterion is the principle of regularity. David Hume, Scottish empiricist and discoverer of the famous induction problem, was the first to stress this characteristic of the cause-effect relationship. In effect, he said, if A is always followed by B, we call A the "cause" and B the "effect".(1)
Hume's concept of causality did not actually define real causality but only a correlation. A second criterion had to be added, the principle of actuation. This only became established in science at the beginning of the modern age, when individual self-awareness was growing. Scientists cannot be as passive in experimentation as they are in observation, for - and this is where the greater egoity element comes in - they must intervene in nature actively and on purpose. In an experiment, the human being interrupts the normal course of events by taking action, and this human intervention originates events; it becomes a cause. It is exactly because of this that scientists can monitor and assess the connection between those interventions and their effects with greater certainty than by mere observation.
If we take the two principles of regularity and actuation together, we have the principle of reproduction, the most reliable method of gaining knowledge in modem science: experimental reproducibility.
This basic model of experimental investigation can be varied in many ways. The first principle (regularity) is often attenuated, i.e. if B does not follow A with absolute regularity but only now and then. The result is that the cause-effect connection is harder to establish. (As is generally known, this is also the key problem in clinical research and in causality assessment for therapeutic measures.)
Attenuation of the first principle can be counteracted by strengthening the second principle (actuation) and intervening in two consecutive stages. You all know this inspired solution to the problem: instead of merely letting factor A, e.g. a drug, take repeated effect, one also produces a random constellation of conditions for the experiment, i.e. letting causal factor A take repeated effect or not letting it do so, controlling this by deliberately-introduced random factors. This is the method of "randomization", producing random, i.e. anti-causal, conditions for the experiment.
If a more-than-random (i.e. "significant") connection is found between A and B, this signifies a more-than-random, non-random (and therefore causal)(2) relationship between them.
The elements of experimental work are the following:
1 The two principles of regularity and actuation together provide for reproducibility, which is the basic causality criterion in experimental research.
2 If reproducibility is limited, randomized reproduction is aimed at.
3 In addition, there are numerous secondary measures of excluding other factors that might cause interference, examples being; exact definition of inclusion and exclusion criteria, blinding, monitoring, etc.
These are different aspects of experimental work in our profession. We now come to the key issue I am concerned with: in Anthroposophy, efforts are made to go beyond all this, using research methods that are in accord with its own scientific approach.
Limits of the cause and effect concept
Why do anthroposophists endeavor to do this? It is because the experimental method has exactly-definable limits, e.g. as regards the issue of autonomic morphogenesis.
If one wishes to study the morphogenesis of a plant, for instance, following the process from seed to shoot and to the fully-developed, fruit-bearing plant, one finds that here causality cannot be established by experimental methods. Experimentation on any organism automatically presupposes the existence of that organism. To influence morphogenesis experimentally, one has to presuppose the existence of the process. Please note carefully: if morphogenesis were not occurring, it would be impossible to experiment with it. This means that we can, at most, investigate the connection between a specific stimulus (influence) and a specific reaction from the organism (effect) but not the cause of the morphogenesis itself. This has to be postulated for the experiment. The experimental method, thus, has no access to the cause of a morphogenetic process. This cause, in fact, is completely outside the cause-effect concept. Here, experimental research and the cause-effect concept reach the limits of possibilities and applicability.
Critics will immediately ask: what does "cause" of morphogenesis mean unless it is the cause of an effect? We should have no problem answering this question if we consider that the German word for "cause" - Ursache - means "original" (Ur-) "object" (sache), not "effect". This notion of "original object" and "object" has scientific consistency.
The term "object" applies to something of scientific interest, the cause of which is to be sought, and "original object" to something from which the actual nature of the object can be derived if this something is fully known. The criterion of causality is not a matter of external experimental reproducibility but of the potential of deriving the one from the other inwardly In/ a mental process.
This criterion is met by an element that exists in conventional science - the quantitative laws of nature. A typical example is the law of falling bodies. The form a particular free fall takes can be precisely derived and calculated on the basis of this law. All we need are data such as the figures for initial velocity, duration of fall and acceleration.
Here, one really knows the "original object", and it usually has two components: 1) the general law and 2) the specific data. Together with the object we thus have three elements of the causality concept. Causality is then not a two-stroke principle involving "cause" and "effect" but a threefold principle consisting of the general law, the specific data and the object which is the outcome.
Anyone familiar with the history of science will know that this is the ancient Aristotelian pair of concepts of the causa formalis and causa materially(3) in a new guise, the former corresponding to the law of nature, the latter to the specific data.
The "original object" and "object" principle is greater and more comprehensive than the cause and effect principle. If we are dealing with a process, as in free fall, the immediately preceding momentary state in the process may always be the "original object" and the state which follows the "object". "Original thing" is then followed by "object", but the process itself is an "object" to be entirely derived from the more comprehensive "original object".
Cause of organic and organismic morphogenesis
This principle of "original object" and "object" can be used to state precisely under which conditions the cause of a specific process of morphogenesis has been fully defined. The cause is fully understood if knowing it allows us to derive the morphogenetic process and the resulting organic form exactly.
Having clarified this, the important, critical question arises: how far is it possible in conventional biology to recognize causal relationships on the basis of this principle? We can say that:
1 At present, no one is able to derive the form or morphogenesis of any organ or organism from material the physics and chemistry of which ARE understood. We are thus able to state emphatically that the cause of the morphogenesis of an organ, let alone an organism, is entirely unknown in conventional biology. People fail to notice this, however, because conventional science does not offer a causality principle that meets the case, with the enormous gap in their knowledge obscured in consequence. To state it clearly: the causes of ontogenetic morphogenesis are not known in conventional biology. The exact functions of DNA, RNA, etc. in this respect are equally unknown.(4,6)
2 The cause of phylogenetic morphogenesis extending through generations is conventionally ascribed to the Darwinian duo of random mutation and selection. These two factors are supposed to provide an adequate explanation for the evolution of all species. A huge problem exists, however: with the two factors supposed to explain the origin of all species, they cannot be said to explain the specific morphologic features of a particular species. The concept of mutation and selection cannot be used to derive this. Again, it has to be stated clearly: the causes of phylogenetic morphogenesis are not known in conventional biology; this goes unnoticed, however, because there is no adequate theory of causality.(4,5)
Anthroposophy, with its endeavors to extend the methods of scientific investigation, enters the field where this problem arises in morphogenesis, and conventional experimental methods and conventional biological models prove inadequate. Causal research does not primarily mean investigation at the particulate level (i.e. molecules, atoms and subatomic particles) but, rather, the opposite. The causes of a thing are not explained with reference to smaller and smaller parts but by considering the wider context.
We can see how this works if we consider the momentary form an organ or organism has in space. It is perfectly possible to derive this form in our thoughts - this is almost too commonplace to mention - if we know the context which is greater by one order of magnitude, i.e. the whole process of morphogenesis in time for the organ or organism, say from fertilized ovum to fully developed organism. This process in time may also be called the "time form" of the organism. Knowing this time form it is, of course, also possible to derive individual momentary forms of the organ or organism, for these are contained in the time form.
The next question would be how the time form may be derived. In Anthroposophy we go to an even wider context for this, speaking of forces or principles that create typical forms holistically. These (the causa formalis) combine with the material conditions in the given case (causa materialis) to create the time form. (For the connection between energy and movement and energy on one hand and morphogenesis on the other, see(7)). To demonstrate the existence of these morphogenetic principles we take a further step into an even wider context. We show that relationships exist between morphogenetic processes that go beyond species and type: relationships that follow laws (ideal, essential, spiritual - call it what you will). In Anthroposophy, a fundamental polarity is seen to exist between the type-related morphogenesis of human being and plant, for instance.
The difference between conventional and anthroposophic science is therefore the following.
In conventional science the causes are sought in narrower and narrower, in anthroposophic science in ever wider contexts. In conventional science the causes of organic forms are thought ultimately to lie in the particles; in anthroposophic science, the causes of organic forms are seen in holistic, generative principles.
In addition, conventional scientists take the Darwinian view that evolution of form in biologic species is due to chance, with no laws determining relationship to the morphogenesis of other forms. In anthroposophic science, on the other hand, efforts are made to discover these laws.
In anthroposophic biology, the nature of processes in which organic forms are generated and the nature of the relationship between them have the same ranking value as the natural laws governing conventional mechanics. These processes and their relationships are, however, assessed qualitatively and not quantitatively as in the case of conventional natural laws, for such is their nature.
The consequences of the above for anthroposophic medicine are the following:
Firstly, medicines are produced with the specific aim of achieving activities at the level of principles and forces that generate form and function. Particularistic analysis of constituents is not of primary importance with such medicines.
Secondly, the diagnosis should be such that it becomes evident how the symptoms requiring treatment are part of a total constitutional imbalance. The term used is "aspects of being diagnosis".
Thirdly, knowing the natural processes the physician seeks to think of the medicament suitable for treating the total constitutional situation.
Fourthly, the medicament is given and its actions observed, i.e. whether symptomatic improvement is part of improvement in, or healing of, the patient's whole constitution and results from this.
Anthroposophic medicine and statistics
Let me stress again: we observe the action or effect of the medicine in the individual patient. The endeavor is to see the connection between cause and effect in the individual situation.
It may well be that someone dedicated to conventional science believes this to be quite impossible in the case of the individual patient, and that there is only one sure method, which is the experimental method with statistical evaluation. The fact is, however, that non-statistical methods of assessing cause-effect relationships definitely exist.
A well-known instance from everyday life is causal processes generating images. Exact structural agreement between image and original generally permits a causal relationship to be established in the individual case. Fingerprints are a prime example. They are actually accepted as evidence in forensic detection of causal relationships in an individual case.
Another instance concerning the actions of medicines is specific to anthroposophic medicine. It presents when regression of the pathologic change is part of improvement in, or healing of, the patient's whole constitution and results from this. If this is the case, treatment causality is highly probable. This would not be an unstructured (black-box type) A-B relationship, but the specific quality of the relationship would show it to be a causal one.
For this kind of causal relationship, plausibility is, of course, different from a randomized trial; however, one is of no less value, validity or reliability than the other.
In conclusion, I am going to attempt to answer the question of whether statistically-evaluated clinical trials are possible, meaningful or necessary in anthroposophic medicine against the general background so far presented.
1 As stated, we have specific methods of assessing efficacy in anthroposophic medicine. These are fundamentally different in design from experimental trials. This makes the ranking value of experimental proofs of efficacy relative.
2 Specifically, anthroposophic assessment of efficacy has an ontological precondition which is the existence of morphogenetic principles and relationships between them that follow specific laws. Issues relating to assessment of efficacy must not be considered without this precondition. The techniques used to assess efficacy in anthroposophic medicine cannot be fairly judged unless account is taken of the causality problems relating to morphogenesis and evolution, i.e. the dogmas of particularism and Darwinism.(8)
3 Anthroposophic medicine is still in its beginnings, with practice generally not reaching the ideal standard. It is nevertheless true anthroposophic medicine if, at the beginning of treatment, the physician is convinced he has chosen medicine that is suitable for the patient from the anthroposophic point of view. With this, the null hypothesis loses its justification, and there is no precondition for comparative experimental trials. (If the precondition exists, this means, conversely, that the criteria for anthroposophic medicine have not been met, even if the medicines used seem appropriate in an external sense.) The ethical problems that exist with clinical trials(8,9) are thus specifically extended in the case of anthroposophic medicine.
4 There is urgent need to demonstrate the position and potential of anthroposophic medicine compared to other clinical methods, and this may include the use of statistical analysis. Adequate, non-experimental methods of documentation exist, and anthroposophic medicine needs to open up to the outside world more than it has in the past. It is an area were considerable catching up has to be done, both in anthroposophic medicine and in biometrics.
Helmut Kiene, MD
1 Hume D. Treatise on Human Nature. 1740.
2 Homung J. Personal communication 1992.
3 Aristotle. Metaphysics.
4 Kiene H. Zwei irrationale Dogmen der Naturwissenschaft. Beitraege zu einer Enveiterung der Heilkunst 1984; 37:174-80.
5 Kiene H. Naturwisenschaftliches Denken in der Medizin. In Matthiessen PF, Tautz C. Onkologie im Spannungsfeld konventioneller und ganzheitlicher Betrachtung. Aktuelle Onkologie 48 S. 23-32. Munchen: W. Zuckschwerdt 1988.
6 Heusser P. Das zentrale Dogma nach Watson und Crick und seine Widerlegung durch die modeme Genetik. Merkurstab 1990,43:141-54; 1991,44:93-103; 1993 46:472-90.
7 Kiene H. Essentiale Naturwissenschaft. Die Emeuerung des wissenschaftlichen Denkens. 250 pages. For publication in 1995.
8 Kiene H. Komplementaermedizin - Schulmedizin: der Wissenschaftsstreit am Ende des 20. Jahrhunderts. Schattauer 1994.
9 Kiene H. Aerztliche mdividualethik und randoinisierte Studien. Cast Editorial. Therapeutikon 1993;7:283.