What are your ethical obligations when it comes to alternative medicine?
Being honest about what you do — and don't — know is crucial
One of your patients is undergoing chemotherapy for cancer and is struggling with severe nausea. She tells you she wants to add acupuncture to her regimen of care; you have never been convinced that acupuncture provides benefits. What is your duty to the patient?
"The doctor at least needs to take the patient's questions seriously," says Dónal P. O'Mathúna, MA, PhD, lecturer in health care ethics at Dublin City University School of Nursing (Ireland) and a frequent author on complementary and alternative medicine (CAM). "I think the days are behind us when a doctor dismissed a patient who has questions about herbal remedies, hopefully."
But when the issue of CAM therapy is raised by a patient or in the literature that applies to that physician's practice, the normally clear duty of the physician to direct patients to treatments that are known to be effective and to advise them against those that are useless or harmful can suddenly appear not so clear. Finding scientific evidence of the benefits and contraindications of CAM therapies can be a challenge, but patients usually expect their physicians to know more than they do about the CAM treatments they've read about.
In some cases, it is not only preferable but essential that the physician be completely honest with the patient about his or her knowledge of the therapy being discussed, O'Mathúna says.
"This issue has to do with the area of evidence [that exists about CAM] and the relationship the physician has with his or her patients, in that a patient coming to the doctor is expecting the doctor to provide reliable, substantiatable advice," he explains. "I think the doctor then needs to communicate exactly where he or she is coming from when it comes to alternative therapies and needs to make clear if they don't know about it."
Often, there's a middle ground, O'Mathúna points out, where the physician might have some training in herbal remedies, but because of the vast landscape of CAM and little research on many remedies, their effects, and side effects, does not feel well-versed on the subject.
"He or she can say, 'I have done some training in herbal remedies, but there's a whole host of other things I'm not sure about,' or that he or she is somewhat familiar with these things, and suggest that they talk about it," he continues. "Let the patient know just what [the physician] knows about it, without discouraging or encouraging at that point."
A report issued by the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, showed that in the United States in 2004, 36% of adults were using some form of CAM. When megavitamin therapy and prayer specifically for health reasons were included in the definition of CAM, that number rose to 62%. CAM, the report indicates, is more mainstream for Americans than many traditional practitioners realized.
CAM often used as complementary therapy
The NCCAM survey revealed that most people use CAM as a complement to, rather than an alternative to, conventional medicine. The results also showed:
- CAM use is greatest among women; people with higher educational levels; people who have been hospitalized within the past year; and former smokers.
- Prayer specifically for health reasons was the most commonly used CAM therapy.
- When prayer is included in the definition of CAM, mind/body medicine is the most commonly used domain (53%). When prayer is not included, biologically based therapies (22%) are more popular than mind/body medicine (17%).
- Most people who use CAM are self-treaters — only about 12% of respondents sought care from a licensed CAM practitioner.
- Americans are most likely to use CAM for back, neck, head, or joint aches, or other painful conditions; colds; anxiety or depression; gastrointestinal disorders; or sleeping problems.
- Those who use CAM said they did so because they hoped it would improve results when used in combination with traditional treatment (55%); because conventional medicine was not working (28%); their doctor recommended it (26%); or because conventional medicine was too expensive (13%).
Acknowledging the findings of the NCCAM, the American Medical Association (AMA) House of Delegates in June adopted a resolution encouraging physicians to increase their awareness of the benefits and risks associated with CAM. The AMA resolution calls for the incorporation of CAM in medical education, as well as continuing medical education curricula, covering its benefits, risks, and efficacy.
"This whole field is very broad, so patients can't always expect an answer of 'good' or 'bad,' because there is such a broad range of therapies," O'Mathúna points out. Some have side effects, some don't; some help one condition in one patient but not in another.
"I would think there is a responsibility among doctors to have some basic awareness of the most popular remedies and therapies for the specific conditions that they see. If a doctor is treating arthritis patients, then he or she should know the common herbal remedies or dietary supplements [popular for that condition]."
A physician whose patient is considering CAM should make it clear that he or she is open to dialogue about CAM, says O'Mathúna, not just to ensure the patient retains a sense of autonomy, but also because the doctor can learn much about why the patient is interested in CAM.
"They might be asking about herbal remedies because they can't afford traditional prescription medications," he suggests. "Or the doctor might find out that the patient is highly anxious about their treatment, and that's interfering with their general well-being."
Protect your patients, yourself
Physicians who practice allopathic medicine often know something about the most common CAM therapies used in their specialties — herbs and vitamins that aid in controlling side effects of chemotherapy, for example, or that are commonly used to ease joint pain in arthritic patients. If they don't, they should, says an expert on legal liability and CAM.
Michael Cohen, a Cambridge, MA-based attorney who specializes in medico-legal aspects of CAM, advises that physicians read up on alternative and complementary therapies that their patients might approach them about or that they might reasonably recommend.
"It is not difficult to search the Cochrane Collaboration, Medline, and other databases to find the literature," says Cohen, who has written and co-authored several papers on ethics, law, and CAM. "The best protection is to ensure that the patient is not harmed directly by the CAM therapy and not harmed indirectly by being diverted from a necessary conventional treatment."
One of the biggest problems, physicians say, is the lack of solid information that is available about CAM remedies, especially compared to the wealth of scientific information and clinical trial results available on traditional therapies.
"It puts the doctor in a very awkward situation," says O'Mathúna.
If a literature search shows that little to no information is known about a particular CAM remedy, that fact should be made clear to patients. If information is available, O'Mathúna says, the physician should take care to explain what kind of information it is — for example, if it is information derived from clinical trials, or more commonly, information that is anecdotal and testimonial.
If the patient insists on a therapy for which no evidence of benefit exists, or, even worse, if evidence of potential harm has been shown, Cohen advises physicians to inform the patient of potential risks and to have a thorough discussion in an attempt to dissuade the patient from a harmful therapy.
"In the end, the patient must make an autonomous choice," Cohen says. "Rather than abandon care, the physician who can no longer continue treating the patient in this situation should refer to a physician who can ably care for the patient."
In a 2002 Annals of Internal Medicine article1, Cohen and his co-authors explored the dilemma of giving patients sound advice when information for making such advice can be sparse. While doctors should counsel patients in a way that respects the patients' values, the authors wrote, "Physicians should not violate their own values in the process of responding to a patient's needs or abandon the practice of evidence-based medicine in order to provide support for their patients' beliefs."
Informed consent becomes an area of uncertainty when CAM therapies are involved. O'Mathúna points out that besides there often being little scientific evidence with which to inform the patient's decision, other factors, such as religion, also come into play.
Prayer and prayer-based therapies are among the remedies included in under the CAM umbrella. If a CAM therapy under consideration has a religious or spiritual component, O'Mathúna says some patients might not want to receive the therapy if the religious component differs from their own beliefs, and so that aspect of the remedy should be clearly disclosed.
Informed consent and CAM
Despite the dearth of clinical research into some alternative and complementary therapies, Cohen says, physicians can meet informed consent obligations by advising patients of CAM therapy for which there is information of safety and efficacy; clearly delineating known and potential risks; and explaining the benefits and risks of combining conventional and CAM therapy.
When the patient is a child whose parents are considering CAM, or if the child is being treated for a condition for which herbal or other alternative therapies are popular, the physician should exercise caution, O'Mathúna continues.
"There is almost no information available for pediatric patients, and as physicians know well, you don't just give pediatric patients lower doses of adult medications," he says. "In terms of herbal remedies, people's perception is that you just take less for a child, and for many of these [CAMs], we don't know how it will affect the less-developed system of a child. There has been very little research done with children."
Finally, questions about use of herbal, vitamin, and other alternative remedies should be part of any clinician's history-taking, experts recommend. CAMs that are benign on their own can have serious interactions when combined with other therapies; O'Mathúna points to cases of surgery patients who experienced unexplained bleeding that was traced back to use of supplements or herbal remedies.
Reference
- Adams KE, Cohen MH, Eisenberg D, et al. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med 2002; 137:660-664.
Sources/Resources
For more information:
- Dónal P. O'Mathúna, MA, PhD, lecturer in health care ethics at Dublin City University School of Nursing, Dublin, Ireland.
- Michael Cohen, JD, MBA, MFA, attorney, Cambridge, MA. Web site: www.michaelhcohen.com.
- Institute of Medicine of the National Academies, "Complementary and Alternative Medicine in the United States," January 2005. Available at www.iom.edu/CMS/3793/4829/24487.aspx.
- National Center for Complementary and Alternative Medicine,"The Use of Complementary and Alternative Medicine in the United States," 2004. Available at www.nccam.nih.gov/news/camsurvey_fs1.htm.
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