Virtual Mentor. November 2004, Volume 6, Number 11.
Ethics, Education, and Integrative Medicine
Physician knowledge of complementary and alternative medicine can help patients make informed decisions regarding treatment plans.
Victoria Maizes, MD, and Randy Horwitz, MD, PhD
The Evidence Question
The increasing number of patients who use complementary, alternative, and integrative therapies raises new ethical challenges for physicians. These challenges arise in part because some of the therapies recommended in integrative medicine (IM) have not been assessed with the rigorous scientific testing recommended to validate conventional allopathic treatments. The dominant approach to medical research is the randomized double-blind clinical trial originally developed for evaluating the efficacy of new medications versus placebo. This pharmaceutical model is not well suited to integrative research for a number of reasons including: the requirement that identical, rather than individualized treatments be administered, a single modality focus that ignores the real-world multiple treatment approach used in clinical IM practice, and the lack of outcome measures which assess nondisease-specific (wellbeing), global, and multidimensional/multisystem changes that many IM practitioners report seeing in their patients .
To evaluate the utility of IM prior to the availability of broad, multidimensional health outcomes trials, a sliding scale of efficacy is used. The greater the potential for harm, the stricter the standards of evidence to which the treatment is held. Where no satisfactory conventional therapy has been shown to be effective, the IM physician considers appropriate alternatives and discusses the potential risks and benefits with the patient. A therapy that lacks substantial evidence for efficacy can be recommended in good conscience if the potential benefit is based on theoretical grounds or clinical experience and the risk to the patient is negligible. The physician explains the basis on which the recommendation is made to the patient in an honest, forthright, and supportive discussion.
Defining Integrative Medicine
Integrative medicine is defined as healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative . In IM, the patient is a partner in his or her health care, with the physician taking the role of the informed, beneficent guide. The physician seeks to understand and respect the patient's beliefs and goals as well as his or her physical and psychological health and ailments. This is accomplished by asking a broader set of questions and listening carefully to the responses . The welfare of the patient is considered paramount, and the physician tailors her actions to result in the best possible outcome for the patient. Allopathic and integrative medicine share the same ethical framework; integrative medicine training reaffirms the importance of beneficence, nonmaleficence, respect for patients, and patient autonomy.
In the United States, up to 88 percent of patients with chronic illness use some form of complementary or alternative medicine (CAM) . The majority of patients do not share their use of CAM with their physicians often fearing the physician's scorn or skepticism . Communication is central to the therapeutic relationship. The ethical principle of nonmaleficence may be violated unintentionally if physicians fail to take a complete history and patients refuse to fully and honestly disclose health information. The most prominent example of this possibility is physicians' failure to ask patients about their use of dietary supplements, botanicals, and vitamins. Because of the widespread use of these compounds in the US, the potential for drug-herb interactions should be explored through a thorough history by the physician.
In addition, skepticism or negative statements on the part of the physician may diminish a patient's hope or damage his or her belief system. This represents a more subtle violation of the ethical principle of beneficence. The impact of reduced hope should not be underestimated. Research reveals that the strongest predictor of mortality is neither lab tests nor physician assessment but rather the patient's own self-rated health status .
The University of Arizona's Program in Integrative Medicine (PIM) has been offering fellowship training in IM since 1997 and has trained more than 100 physicians . The following cases are examples of specific ethical dilemmas that have arisen in the PIM training clinic. These cases serve to highlight the often challenging position of the physician seeking to balance allopathic and integrative medicine.
Patients' use of CAM and IM highlights existing, and presents some new, ethical challenges to physicians in training. Broadening the health history to understand a patient's belief system and motivation, as well as the full range of therapies he or she might be using is a first step to good care . Developing a clear awareness of how one's "own personal, cultural, ethnic, and spiritual beliefs may affect [his or her] choice of recommendations regarding patients' treatment decisions" is another . Greater self awareness is a stimulus of ethical behavior and can be developed through case discussions, reflection, and group process. Finally, broadening medical training to encompass the integrative paradigm provides a forum where ethics, science, and patient preferences are all considered in service to the best of medical care.
Victoria Maizes, MD, is the executive director of the University of Arizona, Program in Integrative Medicine and an assistant professor of Medicine, Family and Community Medicine and Public Health. After completing a residency in Family Medicine at the University of Missouri, Columbia, Dr. Maizes did a fellowship in Integrative Medicine at the University of Arizona.
Randy Horwitz, MD, PhD, is a member of the core faculty and is the research director for the Department of Emergency Medicine at Lincoln Medical and Mental Health Center in the Bronx, New York. He is board certified in both pediatrics and pediatric emergency medicine with a special interest in teaching and medical writing. Dr. Waseem is also an associate professor of emergency medicine at Weill Medical College of Cornell University in New York City.
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