Involving Voters and Consumers in Decision-Making about the Health Care System – The Swiss Case: A Review

Advancing effective involvement of consumers in the health services has been high on the policy agenda since the beginning of a new millennium [1, 2]. A driving force is the concept of democratic accountability and citizenship and the desire to make services more responsive to users’ definitions of need [3‒8]. Other reasons identified in the literature explaining the quest for user and public involvement in health care provision are the rejection of professional dominance, an increase in lay knowledge and a general move toward CAM, a growing awareness of patients’ rights, a shift from acute to chronic health problems in combination with rising of health care costs, and last but not least developments in health technologies giving concern for ethical, moral, and political issues that require a public debate [1].

Behind the principle of involving users in decision-making about the health care system are ideas relating to empowerment [9, 10]. Therefore, it is necessary that in the future users in terms of patients, clients, or other private individuals will be more involved in medical research [11, 12].

From the perspective of scientific theory and the history of science, the question of whether complementary medicine and conventional medical procedures must provide proof of efficacy according to a uniform scientific standard can be clearly answered in the negative [13]. As the term complementary medicine (in its original meaning) already expresses, it is about complementarity in the sense that medicine is a science of action and not a pure natural science. Medicine is to great extent a practical science. It is not only about observing “facts” and diagnosing diseases but is also about doing something, i.e., trying to heal someone who is ill. And this DOING something for or with patients involves other spheres of human culture, such as ethics or psychology, and not only natural science.

Complementary also implies that two or more conceptually completely different healing methods can exist side by side, unless fundamentalist tendencies make coexistence impossible (as can be seen outside medicine, for example, in the dispute between evolutionary biologists and supporters of creationism) [14, 15].

In a 2009 referendum, two-thirds of Swiss voters who had taken vote approved a new article (§ 118a) in the Federal Constitution providing that CAM should be recognized by the authorities (“The Confederation and the cantons ensure that complementary medicine is taken into account within the scope of their competences”). This decision in favor of CAM was only possible due to the specific political system in Switzerland (“direct democracy”) that gives more power to the citizens compared to representative democracies. In 2017, four CAM therapies (anthroposophic medicine, homeopathy, herbal medicine, and traditional Chinese medicine (TCM)) were approved for full coverage by mandatory basic health insurance if delivered by a certified physician [16]. Other consequences of the referendum also have to be mentioned in this context: (1) nation-wide uniform regulation for CAM therapists; (2) incorporation of CAM into the official university curricula for students of medicine, pharmaceutical sciences, dentistry, and veterinary medicine [Bundesgesetz über die universitären Medizinalberufe (Medizinalberufegesetz, MedBG)]; (3) and special regulations for CAM remedies [Verordnung des Schweizerischen Heilmittelinstituts über die vereinfachte Zulassung und das Meldeverfahren von Komplementär- und Phytoarzneimitteln (Komplementär- und Phytoarzneimittelverordnung, KPAV)] [17].

But before CAM was finally integrated into the mandatory basic health insurance in 2017, resistance had to be overcome as the Federal Office of Public Health in the Swiss Department of Home Affairs was besieged by requests from opponents who pretended to be deeply concerned and worried that a rise in CAM could put patient safety at risk. This claim was based on the widespread assumption by critics that the voters in the referendum are unknowing and ignorant consumers of unproven and hazardous medical therapies applied by “enemies of reason” [13, 18].

Indeed, there is the problem that for numerous complementary medicine procedures, proof of efficacy according to the principles of Health Technology Assessments (HTA), RCTs as well as systematic reviews are not or only imperfectly possible. But the same lack of evidence is, for example, also true in the case of surgery as a recent studies and review articles have shown [19, 20]. Therefore, the question arises, whether complementary medicine differs from conventional medicine in such a way that different evaluation standards of efficacy are justified – also under consideration of the principle of equal treatment [21‒23]. As the provision of health care services is finally paid by the citizens (through their taxes), one could also argue (in the context of empowerment) that they should also be able to decide on what kind of medical services they get for their taxes.

In the following, an answer to this question will be given from the perspective of the history of medicine and science based on an assessment report requested by the Federal Office of Public Health in the Swiss Department of Home Affairs in 2013 [24]. This different view on evidence-based medicine thus played a part in finding a feasible way out of the “impasse” on the implementation of the will of the Swiss population after 2009.

Important for a change of perspective is the concept of “normal science” introduced by Thomas Kuhn [25, 26]. This includes, for example, activities such as the determination of universal physical constants, the establishment of quantitative laws, or the incorporation of new phenomena into the paradigm. “Normal science” does not aim at fundamental innovations that could overthrow the world view but has in mind only the gradual improvement of theories within the framework of the given paradigm. In contrast to the falsifiability proposed by Karl Popper, Kuhn considers the possibility of doing normal science to be the decisive criterion of demarcation from pre-scientific or pseudoscientific theories. According to Kuhn, “3 classes of problems - determination of significant fact, matching of facts with theory, and articulation of theory - exhaust […] the literature of normal science, both empirical and theoretical. They do not, of course, quite exhaust the entire literature of science.” [25]. Unlike medical pseudoscience characterized, for example, by dogmatic empiricism, complementary medicine, as discussed here, falls outside of Kuhn’s classes of problem. The following juxtaposition illustrates which different approaches are paradigmatic for complementary medicine in contrast to conventional medicine [27, 28] (Table 1).

If we compare these two paradigms with each other, we will find that the basic assumptions of CAM and biomedicine are largely incommensurable because central concepts used in both theories, such as energy, have different meanings (physical quantity or qi or fluid). While in TCM, for example, the concept of Qi – to be understood as a kind of subtle energy – which goes back to Daoism, is central for the therapeutic approach, this model mostly earns head shaking by scientifically influenced physicians since the existence of such a form of energy is not scientifically proven [29]. This phenomenon is further complicated by the fact that highly regarded and methodically sound clinical studies on acupuncture (for example, GERAC) have shown that sham acupuncture also works and is in part better than real acupuncture or even than standard therapy [30]. In this context, it must also be mentioned that users of TCM methods (for example, acupuncturists) who have been influenced by Western medicine often adapt for good reasons the conception of Chinese authors, which is foreign to them, to their acquired thought patterns by not ascribing a physical reality to Qi, but by seeing in it only a phenomenological description of reality, which then no longer completely contradicts scientific findings [31].

The same applies to therapeutic directions with European roots. Vitalistic thought, for example, continues to form the theoretical basis of homeopathy to the present day. The idea of a vital force as the active principle is not compatible with today’s scientific concepts. The principle of similarity, which is so important in homeopathy, corresponds to analogical rather than causal thinking too [32, 33].

Those critics who question the scientificity of these concepts should look at physics which is one of the most fundamental scientific disciplines [34, 35]. Newtonian physics, for example, cannot be considered as an approximation to special relativity for velocities that are small compared to the speed of light. Similarly, if Kuhn’s postulate of incommensurability is taken seriously, a “smooth” transition of Alternative Medicine into Complementary Medicine is not possible. On the other hand, Niels Bohr’s model of complementarity which means that items could be separately analyzed in terms of contradictory properties could be applied in medicine analogously [36]. The term complementary medicine therefore makes sense, if one uses it to solve an epistemological problem and not as description of scientifically less ranked therapies which could be used to supplement existing standard therapies [15].

The hypothesis of incommensurability, moreover, lends a particular poignancy to Kuhn’s conception of the development of science [25]. The incommensurability assumption is namely directed against the idea that scientific progress is to be understood cumulatively: as a kind of continuous accumulation of scientific knowledge without substantial retractions and breaks, as Karl Popper assumed [37]. This is particularly true of medicine, which, as is well known, is not a pure natural science but necessarily a science of action, in which progress does not simply result from the exchange of outdated knowledge.

As the late Heidelberg physician and philosopher Wolfgang Wieland points out, there is no natural scientific image of man; for “every natural science always examines only factual circumstances when it asks under what conditions something is or is not the case in the real world” [38]. However, as is well known, medicine is not only natural science, but a “practical science” (Wolfgang Wieland), which therefore also has an image of man, even if it is only a reduced one, which is oriented only “to statistical laws with their relative frequencies and probabilities” [38].

In the Swiss debate on the scientificity of Complementary Medicine after the referendum of 2009, reference was repeatedly made to the holistic world view as an alleged distinguishing feature between conventional and unconventional directions in medicine, and this is interpreted positively or negatively depending on the camp to which one belongs [39]. But even representatives of so-called Orthodox Medicine have repeatedly emphasized that the separation between body and mind is only an artificial one, and that in practice psychosomatic approaches are receiving more and more attention in recent years. That there are still deficits here in the face of increasing specialization is another matter.

In contrast to natural science-based medicine, which – as already mentioned – does not have a conception of man in the proper sense, or at least no specific one, the majority of the most widespread complementary therapies are based on different conceptions of man. Without an understanding of their distinctive world views on cannot judge these healing methods.

According to the Swiss Federal Law on Health Insurance, one of the requirements for coverage of a medical service is proof of effectiveness “according to scientific methods” (Art. 32, 1). But which methods are “scientific?” Are there also “unscientific” methods? The reference to natural science-based standards is not sufficient, because there are competing standards, such as the approach of cognition-based medicine or documented medical experience. In this context, the alleged opposition between science and pseudoscience or parascience also plays a role, which will be briefly discussed [40‒42].

According to the Viennese historian of science Mitchell Ash, there can be “no universally valid, supra-temporally valid answer to the question of how science can be distinguished from non-science or even para-science. For there is no way […] to do so without considering the intellectual and social inclusion and exclusion criteria of the scientific collectives of thought and action of the time” [43]. The criteria (holism, esoterism, metaphysical speculation, subjectivism) that are commonly used for the classification as parascience, are time and culture bound. The recent philosophy of science and with it the history of science have therefore long since refrained from elaborating universally valid criteria of distinction. Those who think they can continue to methodically separate the wheat from the chaff in the current debate about the scientific nature of medicine, especially with regard to unconventional procedures, should be reminded of what the Swiss historian of science, Michael Hagner, who teaches at ETH Zurich, wrote in 2008 to the supporters of such ideas: “Whether someone has proceeded scientifically or pseudo-scientifically can […] only ever be judged in retrospect, i. e., from a historical perspective, and while this is nice for historians of science, it is not a particularly comforting perspective for theorists of science and politicians who have to allocate research funds” [44].

This does not mean, however, that in the future we should pay homage to “anything goes,” as the philosopher Paul Feyerabend postulated in his much-discussed book Wider den Methodenzwang (1976) [45]. Feyerabend by no means claims that science does not need any methods and rules. Rules that emphasize reason, objectivity, or rationality may thus be appropriate in one case and not in the other. Here, a bridge can be found to another solution model, Niklas Luhmann’s concept of system [46]. “In this sense, medicine,” according to Luhmann’s disciple Werner Vogd, “must by no means be understood here as a subdivision of the scientific system. As an independent functional reference, it is precisely not the strict truth criteria that apply here, for example in the sense of epidemiologically proven efficacy, but first of all the primacy of being able to offer diagnosis and therapy in the face of illness” [47]. In other words, the proof of scientificity is secondary with regard to the goal of action. What counts for the patient is that therapeutic options for action are made available to him.

From the perspective of scientific theory and the history of science, the question of whether complementary medicine and conventional medical procedures must provide proof of efficacy according to a uniform scientific standard can be clearly answered in the negative. As the term complementary medicine (in its original meaning) already expresses, it is about complementarity in the sense that in medicine, which is a science of action and not a pure natural science, two or more conceptually completely different healing methods can exist side by side. This is, for instance, the case not only in Switzerland but to even larger scale in India where medical pluralism rules the health care system [48]. The Swiss example also indicates that prevalence of CAM use might be influenced by cultural factors and mentality [49, 50]. There can also be no doubt about the pivotal role of regulations in terms of inclusion of CAM in biomedical practice and health insurance [51]. In Switzerland, as we have seen, the mandatory basic health insurance covers now anthroposophic medicine, homeopathy, herbal medicine, and TCM if delivered by a certified physician who has proven his or her competence in alternative methods. A recent study shows that prevalence of CAM use significantly increased from 2012 to 2017 in Switzerland [39]. Unfortunately, the design of the questionnaire used and the early date of the survey (2017) make it impossible to find out whether a patient resorted to a CAM-therapy reimbursed by mandatory or by private health insurance. This issue thus warrants further research attention.

The author has no conflicts of interest to declare.

The manuscript was prepared without external funding.