JCSH 1 2 Ar3 Christine

Journal of Case Studies in Homeopathy
Cite it as: Christine Wittenburg. Cognition-Based

Medicine: A new paradigm for medicine - applied to
Homoeopathy. Journal of Case Studies in Homeopathy
2013; 1(2): 7 - 16
Available online at www.jcshom.com
Review: Developing Homeopathy-Assignment Module
Cognition-Based Medicine: A new paradigm for medicine - applied to

Homoeopathy
Christine Wittenburg*
Abstract
The objective of this article is to introduce the concept of Cognition Based Medicine (CBM) as a
convincing alternative to Evidence Based Medicine (EBM). CBM was developed on the basis of a
refutation of the positivist paradigm through Karl Duncker and Curt J. Ducasse. Contrary to Humes
ideas, we are well capable to discern causality by observation in single cases. This has been demonstrated
by Duncker through some simple examples of causal cognition. He termed this concept Gestaltcognition. Gestalt means form, structure and process and stretches from a cause into its effect.
Helmut Kiene, a German medical doctor and researcher, introduced CBM in 2001, by publishing his book
Komplementre Methodenlehre der Klinischen Forschung (Complementary Methodology in Clinical
Research).
Following Kienes arguments, the development of the epistemological foundations for EBM from the 16 th
up to the 20th century will be depicted, with a special focus on RCTs, and on placebo in its role as a
surveyors rod for measuring the effect of any given therapy.
Next, CBM with its focus on single-case-cognition as the basis of progress in medicine will be described.
Kiene analyzed the published research of four volumes of The Lancet to demonstrate the validity of this
concept.
Hahnemanns finding of the Law of Similars serves as an example of gestalt-cognition.
Practitioners should make the tacit knowledge they are gaining from single-case-cognition available to
other colleagues, to improve the bases of clinical judgement. Kiene and his co-researchers propose a
structure for the publication of single cases, which contains various important criteria to be fulfilled.
This structure will be applied to the special necessities of Homoeopathy. A custom-made questionnaire
will be presented.
Keywords: Cognition-based medicine, CBM, evidence-based medicine, EBM, gestalt, clinical
judgement, single-case-cognition, tacit knowledge, RCT, placebo, homoeopathic questionnaire
*Christine Wittenburg
Heilpraktikerin
Student of MSc Homeopathy, School of Health,
University of Central Lancashire, UK.
cwittenburg@hotmail.com

2013; 1(2): 7 - 16
The development of Evidence-Based Medicine

(EBM)
Following the analysis of Helmut Kiene, a
German anthroposophist, medical doctor and
researcher, EBM relies on four basic scientific
methodological findings, which formed the
overall epistemological paradigm of positivism:
Francis Bacon (16th Century) introduced

the figure of the active involvement of
scientists in research, the experiment, to
answer the ontological question What is
causality?
David Hume (17th Century) founded the
empirical base of EBM: We can recognize
causality only by repeated observation.
Hume was convinced of the impossibility
to observe causality directly only if on
every A always follows B we can presume
a causal context. Yet his contemporary
Thomas Reid asked him the question:
then, we should suppose day as the cause
of night, and night as the cause of day?
(Ducasse 1966). Hume described mere
correlations where he named causality
(Kiene 2001).
John Stuart Mill (19th century) unifies
Humes
and
Bacons
paradigms,
proposing a new one: if we compare two
groups under experimental circumstances,
then adding factor A to only one group,
and observing result B only in this group,
we can assume a causal connection
between A and B.
Ronald Fisher, in 1935, finally brings
randomization into being. By now, the
activity of the researcher can be divided
into two stages. He produces the repeated

influence of factor A to one of two
randomized groups. Then he measures the
effect, comparing the aimed-at parameters
of the two groups. Here, causal cognition
is indirect. It emerges from mathematical
comparison of effects in the two (or more)
groups, where the difference should be
statistically significant to prove effects.
(Kiene 2001)
After World War II, randomization enters clinical
research. Through Beechers article The
Powerful Placebo the idea of proving substances
against placebo takes over. Double- blinding and
the use of placebo is introduced, to guard
against any use of judgement (Pokock 1991,
cited in Kiene 2001); the clinical practitioner is
excluded from being the subject of research.
From the 1960s on, the requirement of RCTs
influences legislation on pharmaceutical drugs in
the US, from the 1970s on in Europe, too. The
possibility of mathematical demonstration for
empirical expression of causal context arouses
fascination in researchers, and RCTs become a
dogma. In the 1980s, first meta-analyses on RCTs
were conducted. The availability of electronic
data-processing in the 1990s enables more than
9000 RCTs a year, worldwide. All other forms of
clinical trials and ways of judging the
effectiveness of a given therapy are phased out.
EBM is becoming the reigning paradigm, with
RCTs as the gold-standard of clinical research.
The dream of the new millennium is one of
practitioners who, once having diagnosed their
patients disease, access via mouse-click to the
best available treatment. (Kiene 2001)

2013; 1(2): 7 - 16
Next, RCTs main-pillar placebo will be

scrutinized. An in-depth critique of RCTmethodology, pointing out all flaws and biases
which creep into clinical trials would go beyond
of the scope of this article.
A short history of placebo
Prologue:
Kaptchuk (2009) found that the first use of
placebo was documented in 1599, in France. A
placebo was used for testing a young womans
state of being possessed by the devil, showing
fake holy-water to her and observing her
reaction.
1. Chapter:
Cornell University Conference center, NYC,
1946. In his opening speech of Cornell
Conference, E.F. DuBois said: The study of
placebo is the most important step to be taken in
scientific therapy () the enormous success of
homoeopathy, where drugs are given in high
dilution, is a good example. Its success and
therapeutic results are probably better than those
in case of the regular drugs given in huge doses
by the rival practitioners. At least, it demonstrates
quite clearly what can be done by placebo.
(Cornell Conference of Therapy 1946, cited in
Kiene 2001, p.166)
2. Chapter:
1955. Publishing of Beechers article The
Powerful Placebo. Revising this article, Kiene
and Kienle could not find a single demonstration
of a placebo-effect in the 15 scientific studies
used by Beecher. Beechers work is inaccurate
and riddled with faults. He considered the
recovery of placebo-patients from a mild flu in 6
days as evidence for a placebo-effect (what did

verum do to the remaining patients?). His records
are incorrect: the original research he used
recorded the number of coughs in a given time, or
the number of doses, day of actual research or
volume of inhaled gas. He converted these
numbers in numbers for the placebo-effect. These
faults occurred in 10 of the 15 studies Beecher
mentions. Everybody got excited about Beechers
article, but nobody looked at the data. (Kienle
1995, Kiene 2001)
3. Chapter
Since then, the meaning of the word placebo has
gradually changed to everyunspecific effect in
therapies. So, any drug-effect which is superior to
the powerful placebo must be a really
important one. This was a strategy to introduce
RCTs as the gold-standard for scientific research
in EBM, and is built on the good results of
homoeopathy.
Accurate portrayal of the placebo effect was of
less importance than invoking it as a threat to
scientific evaluation. (Kaptchuk 1998)
Interestingly, a RCT was done on the positive
effect of praying of outside-of-the-clinic people
on patients health in a coronary surgery (Byrd
1988, with placebo control, cited in Kiene 2001).
Result: praying is not unspecific.
Homoeopathy, which gave the ultimate push for
the development of EBM, cant make much use
of RCTs itself. They merely serve for refutation
of EBMs assertion potentised homeopathic
medicines are placebo through randomized,
placebo-controlled experiments on plants (Jger,
Scherr, Simon, Heusser, Baumgartner 2010). A
second field of application for RCTs lays in the

2013; 1(2): 7 - 16
treatment of epidemics, where nearly all affected

patients need the same homoeopathic remedy
(Gaucher, Jeulin, Peycru, Amengual 1994;
Bracho, Varela, Fernandez, Ordaz, Marzoa,
Menndez, Garca, Gilling, Leyva, Rufn, del la
Torre, Solis, Batista, Borrero, Campa 2010).
Where do we find an epistemological approach
which suits homoeopathy? It has to be a theory
which is substantially different to - and hopefully
more convincing than - positivism.
DEVELOPING AN EPISTEMOLOGICAL
MODEL FOR HOMOEOPATHY
Cognition-based Medicine (CBM): a new
paradigm for CAM, grounded on the reality of
human cognition
Helmut Kiene introduced the concept of CBM in
2001, publishing his book Komplementre
Methodenlehre der klinischen Forschung. He
builds on the philosophical work of Karl
Duncker, Curt John Ducasse and Helmut Kienle,
founder of the anthroposophic University of
Witten/Herdecke. Coinciding with the publishing
of Fishers The design of experiments in 1935,
Duncker, a German philosopher, refuted Humes
idea of causality. Based on simple examples from
every-day-cognition he demonstrated that the
singular causal-gestalt of the cause stretches
into the gestalt of its effect. Gestalt means:
form, structure, process. We recognize the gestalt
of a car having crossed a field in the traces its
wheels leave: Gestalt-cognition assesses the
wholeness of a pattern (or a substance, or a
meaning), that is irreducible to its parts and
conceivable independent of its particulars.
(Kienle, Kiene 2010).
Kiene and his colleagues undertook research on

four years of published volumes of The Lancet
(1996-1999), revising articles to find proof for the
concept
of
singular
causal-cognition.
Interestingly, many of the articles gave evidence
of application of convincing non-experimental
evidence: skilled practitioners applied their
ability, their personal judgement, based on tacit
knowledge to solve therapeutic problems or to
introduce new techniques. Surgeons cant rely on
repeated
observation under
experimental
conditions to perform complicated operations by
inventing new techniques they rely on cognition
of functional causality. The gestalt of
obstruction reaches into the gestalt of passage
in bowel-obstruction-surgery; anal fissures can be
cured by application of a blood-supply aiding
crme, once the functional connection between
fissures and anal lack of blood-supply is
recognized. An anesthesiologist has to know the
function and morphologic field of the nerve he
has to anesthetize; plus the function of inner and
outer fibers of this nerve and in spine anesthesia
- additionally the specific weight of the
anesthetics to be used: the functional gestalt of
the neural system/physics of fluids reaches into
the effect of anesthesia. (Kiene 2001)
Another example is a study, published in BMJ in
1996 on 122 consecutive treated patients in a
GPs clinic: 82 of the treatments were classified
as evidence-based by the practitioners, but only
31 of them were backed up by RCTs. The rest
relied on implicit evidence, on the knowledge of
the practitioner. (Gill et al 1996 cited in Kiene
2001)
In reality, the implicit, tacit knowledge of a
therapist is mainly gained by single-case gestaltcognition and reflection-in-action, which is
10

2013; 1(2): 7 - 16
followed by comparing cases (Kienle 2011). Yet

Alvan Feinstein, one of the founders of EBM,
noted that a busy clinician conducts more
experiments in a week than his colleagues from a
laboratory perform in a year. Kienle (2012)
mentions that 40% of adverse drug reactions are
detected by single-case observation.
An additional step beyond single-case causalcognition might be a comparative study of one
given treatment to others or to placebo. This
then has to be applied to daily practice in an
outcome-study (Vandenbroucke 2001).
Homoeopathy: an example of gestalt-cognition

A convincing example of singular causal
cognition might be the story of how Hahnemann
discovered the Law of Similars: the gestalt of
intoxication by china officinalis - described in the
English Materia Medica of Cullen, which
Hahnemann was translating to German - stretches
into the gestalt of typical symptoms of a certain
form of malaria. Many doctors had read Cullens
book; Europe was infested with malaria in the
19th century. Nobody but Hahnemann drew the
conclusion (Law of Similars), a finding which
relied on his being a skilled practitioner, highly
motivated by opposing the prevailing medical
paradigm - and therefore open to new ideas. This
was the first, most important step: conceiving the
idea (Greek: form, gestalt). The criterion for
defining a causal gestalt is its coherency,
conceivable without active manipulation by the
observer.
As we know, Hahnemann experimented by taking
china himself. He developed intermittent fever as
a second step of causal cognition. Here,
Hahnemann takes the active role of the

experimenter, to provoke the reappearance of the
gestalt. Kiene (2001) describes this as the
imaging method of causal cognition.
Following that, Hahnemann did cohort studies
(homoeopathic provings) on several provers,
introducing further substances as a third step. At
the same time, he began to treat patients with his
newly found medicines and developed the
method of potentization.
Next were his findings of homoeopathic
suppression of symptoms in the diseased, which
never lead to a completely restored health of the
patient. This caused him to take the whole of the
patient
in
account
for
homoeopathic
prescriptions. Here, Hahnemann perceives the
functional causal gestalt of restoring health, and
homoeopathy finally gained its ability to cure
thoroughly.
Like a skillful mechanic this is Kienes example
of functional causal cognition- does not have to
dismantle the whole car to repair a deficient
function. He rather applies his knowledge of the
functional causal gestalt, he images the functional
deficiency and this enables him to find and repair
the deficient part of the car. Nor does he need to
leave a similar, equally deficient car untouched to
get results by comparing both cars, without
knowing which one had been fixed. Instead, the
mechanic has to prove the causal efficacy of his
work through comparing the pre/post condition of
the car. Only by this he can demonstrate the
functionality of his repair. (Kiene 2001)
A last remark about the meaning of evidence:
Evidence in EBM is based on RCTs, meanwhile a
single case is no case; but also a RCT measures
11

2013; 1(2): 7 - 16
an effect only once it is not capable to predict

the results of future RCTs, which could be pretty
different.
The use of evidence in CBM, based on singlecase causality-cognition, is quicker and more
flexible (not to mention the low costs!) as
evidence based on RCTs; just as the grade of
reproducibility of effects, which can be
ascertained in a comparatively short time. (Kiene
2001, Kienle 2012)
Application of CBM to Homoeopathy:
Homoeopathic Therapeutic Case Report
By now, we have identified single-case causal
cognition as the basis of progress in medicine.
How can we make the tacit knowledge of skilled
practitioners available to the competent
community of homoeopaths? Kiene and
Kienlepropose a structured form for therapeutic
causality reports, TCRs (Kienle, Andersson,
Baars, Hamre, Murphy, Portalupi, Schneider,
Schwab, Kiene 2010). They suggest the
completion of a questionnaire to identify the
efficacy of a given therapy in single cases. It
contains a number of correspondences, which
help to judge the development of a patient, and to
compare single cases. (Kienle, Hamre, Portalupi,
Kiene, 2004)
Homoeopathy and its radical-phenomenological
approach to healing cant make use of every
single of these correspondences, whilst many of
them are of specific use to us.
A first point to make is about homoeopathy: The
only thing we can perceive in a patient are the
symptoms of his disease, which then are
compared to proving symptoms (Hahnemann
1985). So, the individual homeopathic
practitioner cant perceive causalities the onlycausal cognitive finding in Homoeopathy has
been that of a correspondence between provingsymptoms and disease-symptoms. This should
not be mistaken for causation specific rubrics
in our repertories, which refer to the sensibility of
certain remedies to different causations and
should invite us to explore the special way of
reaction different remedies/patients choose to
deal with a given causation.
So, I propose the term HTCR (Homoeopathic
Therapeutic Case Report) for structured reports.
An exact description of the case, prescription and
follow-ups should be completed by filling in a
questionnaire which consists of the following:
1. Pre-post correspondence:
Duration of illness compared to duration from
date of medication until (throughout) cure.
Example: child with 3-years-lasting asthma,
cured in 20 weeks: 20/156. This helps to exclude
false positive results (spontaneous cure, back to
the mean). For a cohort-study, we need to take
every single patient into account, not selected
positive results.
2. Correspondence of time patterns:
How long did the effect of the remedy last before
it had to be repeated?
3. Dose-effect correspondence:
How and when did the patient react to an
administered potency? This might be helpful to
exclude therapist-as-a-remedy effects. Kaplan
describes how he first gives several doses of
placebo to his patients, followed by the remedy.
If in the follow up the patient reports
12

2013; 1(2): 7 - 16
amelioration before he took verum, a clear case of

placebo-effect is detected. If s/he reports an initial
aggravation after taking verum, additional proof
for having chosen the right remedy is obtained.
(Kaplan 2004).
Three additional questions:
4. Morphologic and process-correspondence:
7. Which additional symptoms were cured in the

patient but are not known from the
MateriaMedica? This serves to broaden our
understanding of remedies.
Here we can express if the cure of a patient

followed Herings law, and in which ways.
5. Correspondence of dialogue:
This is the place to mention sequences of
remedies when the patients symptoms change
in the course of treatment. Here, we have to
annotate wrong remedies too, which were not
homoeopathic to the patients disease; very
important for learning from each others faults!
6. Which diagnostic methods were used to prove

progress of the patient, rendering what result?
(Blood-samples etc.)
8. Which symptoms were cured, but not

mentioned by the patient in the first interview?
This gives additional evidence for the
effectiveness of homoeopathy and for
correctness of prescription.
HTCR
Patients name (anonymized for publishing), date of birth, civil state, number of children and
other data if convenient.
Spontaneous report, modalities, general and local observations (guided where necessary,
underlining when the patient emphasizes a symptom)
General report (guided where necessary, underlined): Cravings and aversions, thirst, digestion,
sweat, sleep and dreams, menses, reactions to weather, climate, temperature, general timemodalities, fears and phobias.
Self-description, personality of the patient
History of patient and family: Mayor diseases, surgery, reactions to vaccinations etc
Repertorisation, MateriaMedica, Rx, potency
Follow-ups, Rx, potency
Correspondences:
Example: Child with asthma
Pre/post correspondence
156/20 weeks
Corr. of time-patterns (dates of repetitions), 4 weeks (4th July, mild attack of asthma)
reasons for repeating
10 weeks (Sept. 12th, slight wheezing at night
since 3 days)
Dose-effect correspondence
Aggravation on 7th day, followed by strong
improvement of respiration and moodiness
Morphologic corr. (Herings rule)
After 10 weeks (2nd repetition), a rash in the
face appears while respiration improves to
normal.
After 2nd remedy at 16 weeks, rash moves to
bend of left elbow and disappears after 1 week.
Respiration normal, no moodiness.
Corr. of dialogue (sequence of remedies, After 16 weeks (changes in thirst, sleep-
13

2013; 1(2): 7 - 16
with additional repertorization)
pattern, temperature and cravings), rash

persists, Rx remedy 2
Symptoms cured but not known from MM
Three soft warts on left index-finger
disappeared after 12 weeks
Symptoms not mentioned in first interview, Sour smell of sweat on head at night improved
but cured
Additional diagnostic methods
Blood-sample at start of treatment and after 20
weeks: Erythrocytes-count went down from xx
to yy
A repertorization should be added, to enable

practitioners to compare different approaches to
remedies. If available, a MYMOPS (or similar)
could be attached, to reflect the view of the
patient. A minimum time of 2 years should be
adhered to before a case can be published (with
exception
of
acute
cases/treatment
of
epidemics/treatment of adverse side-effects of
new orthodox drugs or vaccinations).
Cases should be made available through an easily
accessible database, apart from publishing them
in journals.
Conclusion
A new paradigm for CAM and homoeopathy was
created through refutation of Humes definition
of causality, replacing it by the concept of gestaltcognition.
path to be followed by homoeopaths, too. The

title of these courses:
Courage and Determination
(I would like to express my gratitude to Curt
Ksters, who put me on the track of CBM.)
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Journal of Case Studies in Homeopathy

Cite it as: Christine Wittenburg. Cognition-Based

Review: Developing Homeopathy-Assignment Module

Cognition-Based Medicine: A new paradigm for medicine - applied to

Journal of Case Studies in Homeopathy

The development of Evidence-Based Medicine

Francis Bacon (16th Century) introduced

into two stages. He produces the repeated

Journal of Case Studies in Homeopathy

Next, RCTs main-pillar placebo will be

days as evidence for a placebo-effect (what did

Journal of Case Studies in Homeopathy

treatment of epidemics, where nearly all affected

Kiene and his colleagues undertook research on

Journal of Case Studies in Homeopathy

followed by comparing cases (Kienle 2011). Yet

Homoeopathy: an example of gestalt-cognition

Hahnemann takes the active role of the

Journal of Case Studies in Homeopathy

an effect only once it is not capable to predict

Journal of Case Studies in Homeopathy

amelioration before he took verum, a clear case of

Three additional questions:

4. Morphologic and process-correspondence:

7. Which additional symptoms were cured in the

Here we can express if the cure of a patient

6. Which diagnostic methods were used to prove

8. Which symptoms were cured, but not

Journal of Case Studies in Homeopathy

pattern, temperature and cravings), rash

A repertorization should be added, to enable

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