AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. June 2011, Volume 13, Number 6: 333-335.

From the Editor

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Physician Responsibilities in a World of CAM

Introduction to the June 2011 issue of Virtual Mentor on the subject of complementary and alternative medicine.

In 2009 the family of 13-year-old Daniel Hauser, who was diagnosed with Hodgkin lymphoma, refused chemotherapy in favor of “alternative medicines,” despite a predicted 90-percent chance of cure with chemo. As members of the Nemenhah Band, a religious organization that advocates natural healing based in Native American tradition, they believed that dietary changes, sweat lodge visits, and herbal supplements would prove superior to chemotherapy, and thus declined it. Physicians brought the case to court, and after ruling that Daniel had been “medically neglected,” the judge ordered that he proceed with infusions. In a last-ditch effort to avoid this, he and his mother fled their home state of Minnesota, but within a week reluctantly returned, daunted by the potential legal consequences [1]. Daniel received his chemotherapy and is now in full remission, but the Hausers remain firmly convinced that he would have been better off without it.

To what was the Hauser family referring when they spoke of “alternative medicines” and “natural healing?” Complementary and alternative medicine, or CAM, is any healing practice that falls outside the sphere of conventional allopathic medicine, or “that which has not been shown consistently to be effective” by peer-reviewed, appropriately controlled studies [2]. These methods are instead based on spiritual teachings, cultural traditions, or recently conceived approaches to health [3], and remain scientifically unvalidated. For this reason, many in the scientific community criticize such practices, asserting as Richard Dawkins has done that “there is no alternative medicine. There is only medicine that works and medicine that doesn’t work” [4].

While it is true that Daniel Hauser’s story represents an extreme on the spectrum of CAM use, it is no doubt a reminder that unconditional belief in CAM efficacy can encourage a rejection of evidence-based lifesaving care. It is also true that some alternative medicine supplements, including those that interact with prescribed drugs in unforeseen ways or those that themselves contain toxic chemicals, have the potential to directly inflict bodily harm. Yet CAM is immensely popular in the United States, and most patients use methods like acupuncture, chiropractics, herbal supplements, and homeopathy concurrent with evidence-based treatments, without ever experiencing adverse effects.

So the question remains—how can physicians approach CAM ethically? Should we support its use, reject it outright, or individually tailor our judgment to specific types of CAM and the particular patients using it? And what of academic and intellectual integrity? As scientists do we have a responsibility to actively discourage unproven medical modalities, and if so, how do we determine what qualifies as legitimate evidence in the first place? Perhaps most importantly, how can we effectively and compassionately manage patients seeking alternative therapies, without compromising honesty, a value central to the practice of medicine?

When addressing the importance of honesty, or truth telling, we must consider that the reported success of some alternative therapies is due to placebo effect. Thus, at the heart of the debate over CAM ethics is the question of whether placebo use is itself ethically justified, since the very nature of placebos requires that patients be deceived about their function. Many argue that if a placebo decreases a patient’s perceived level of pain, then it is in essence “effective” and is therefore acceptable. Proponents of this rationale no doubt value the possibility of improved symptoms, or patient beneficence, over patient autonomy (which requires that the patient be fully and honestly informed). After all, the end result does matter, and recent national surveys have revealed that roughly half of internists and rheumatologists prescribe placebos regularly for this reason [5]. But this side of the argument fails to address the larger picture—that the adoption of any kind of systematic deception in medicine has the potential to erode patients’ trust in physicians—a consequence that could be devastating to the physician-patient relationship, and therefore to patient care overall.

This issue of Virtual Mentor seeks to examine all of these questions in depth, since the widespread use of complementary and alternative medicine has rendered it a topic with which almost every physician must contend, regardless of his or her specialty. We cannot ignore its importance to patients, whether or not we agree with its use. But what is it about CAM or its practitioners that makes it so appealing? Why do millions of people—38 percent of U.S. adults [6]—choose to use alternative therapies when evidence-based-medicine has been so effective; providing vaccines, antibiotics, state-of-the-art surgical techniques, and a vastly longer and improved quality of life? What is allopathic medicine lacking that drives patients to pursue other options? It is often observed that homeopaths, naturopaths, chiropractors, hypnotists, and practitioners of traditional Chinese medicine provide far more caring attention to patients. Unlike the typical busy, matter-of-fact, and overworked physician, who spouts baffling medical jargon and then scoots off to the next patient in his or her conveyer-belt practice, CAM practitioners often work in soothing environments tailored to patient comfort, use understandable language, and provide the time necessary to establish a warm therapeutic relationship. Such care is also patient centered, which grants them a sense of control over their own health. For terminal oncology patients in particular, this can provide optimism and empowerment in what often feels like an overwhelmingly futile situation [7]. But does this interaction actually help such patients or does it take advantage of their vulnerability by offering a false sense of hope?

Although some physicians do feel that allopathic and alternative medicine are mutually beneficial, the deep divide between the approaches more often than not pits advocates of truth, reason, and cold hard science against a multi-billion dollar industry that gives patients precisely what they want to feel and hear. This fascinating struggle unfurls in this issue of Virtual Mentor, with passionate contributions from both avid skeptics and proponents of CAM, including physicians, attorneys, PhDs, and CAM practitioners. It is my hope that these discussions not only provide an intriguing glimpse into the controversy surrounding complementary and alternative medicine, but also help to inform those in the medical community about how to approach CAM philosophically and in daily clinical practice.



References

  1. Wasserman S. Daniel Hauser turns 14, is cancer free. My Fox Twin Cities. http://www.myfoxtwincities.com/dpp/news/Daniel-Hauser-Turns-14,-Is-Cnacer-Free-mar-28-2010. Accessed May 5, 2011.
  2. Bratman S. The Alternative Medicine Sourcebook. Los Angeles:Lowell House; 1997: 7.
  3. Acharya D, Shrivastava A. Indigenous Herbal Medicines: Tribal Formulations and Traditional Herbal Practices. Jaipur, India: Aavishkar Publishers Distributor; 2008: 440.
  4. Dawkins R. A Devil’s Chaplain: Reflections on Hope, Lies, Science, and Love. New York: Houghton Mifflin; 2003: 58.
  5. Tilburt J, Emanuel EJ, Kaptchuk TJ, Curlin FA, Miller FG. Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists. BMJ. 2008;337:a1938.
  6. National Center for Complementary and Alternative Medicine. The use of complementary and alternative medicine in the United States; 2008. http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm#use. Accessed May 18, 2011.
  7. Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med. 1998;129(12):1061-1065.

Kara J. Gulewicz MS-3 Washington University in St. Louis St. Louis, Missouri

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