First do no harm” is the basis of bioethics. Embodied in this quote are the four principles of physicians’ obligations in patient care: beneficence, nonmaleficence, respect for patient autonomy, and justice. With the growing surge of people using complementary and alternative medicine (CAM), this book is a welcome treat, informative and quite refreshing to physicians—including those like me, who currently incorporate CAM in practice.
The book is divided into seven chapters written by physicians, attorneys, scholars, and a medical student with general exposure to CAM.
The first chapter is an overview of CAM and ethics. After defining CAM, it discusses the different approaches of CAM and conventional medicine and how the two are affecting each other.
Chapter 2 sheds light on the rich history of CAM. Mentioned in the chapter are the reasons for the staggering usage of CAM, seemingly without regard for the out-of-pocket costs. The different types of CAM healing are addressed in depth. This chapter also discusses the positive aspects of CAM's holistic approach, with focus on health promotion and disease prevention, compared with the disease focus of conventional medicine. While author Richard J. Carroll gives examples of some negatives of CAM—addressing claims that it is unsafe, unproven, worthless, or verges on quackery—he counters with comment on the flaws of conventional medicine. He summarizes with a quote from Fontarosa and Lundberg: “We must focus on fundamental issues—mainly, the target disease or condition, the proposed treatment and need for convincing data on safety and therapeutic efficacy.” Only then can we blend the best that both conventional medicine and CAM have to offer.
The third chapter delves more into ethics. Wayne Vaught begins with the example of a pregnant woman who wants a doula with her during labor and delivery. Her obstetrician belittles her request and ruins her expectations for her birth experience. He discusses the application of ethics in conventional medicine, the role of culture and spirituality in CAM, and why physicians need to learn about CAM.
Chapter 4, “Advising Patients and Communicating About Complementary and Alternative Medicine,” clearly illustrates the interconnectivity between the patient, conventional medicine, and CAM. Authors Arti Prasad and Mariebeth B. Velasquez state that the patient can best be served by integrating the two, as neither conventional medicine nor CAM has all the answers. As a CAM advocate, I agree with the authors’ comment that we can be more sensitive and learn from our patients—something that we may forget at times.
The fifth chapter deals with patient and medical education on CAM. The amount of information available can be overwhelming, particularly with the Internet;some sources reinforce misconceptions and inaccuracies. I was glad to see pharmacists mentioned as a resource; they should know about herbals and supplements and their interaction with drugs. The history of integrating CAM into medical education is compelling. In the mid-1990s, only 46 of the 125 medical schools included CAM topics in the curriculum. By 2004, the count was up to 84, including spirituality in medicine. Chapter 5 includes 10 pages of helpful resource information. I totally agree with the author, Catherine Leffler, that “we have the obligation to give patients the information on safety, efficiency, risks, and benefits of the therapies and a referral to a reputable CAM practitioner as necessary.”
In chapter 6, Michael H. Cohen addresses legal and risk management issues related to CAM, including information on licensure, credentialing, and scope of practice as regulated by each state. I found the malpractice section very interesting. The CAM profession has its own standard of care. If overlap with conventional medicine occurs—for example, if a chiropractor takes and interprets x-rays—then medical standards may be applied. The Federation of State Medical Boards recently issued Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice. A reprint is included at the end of the chapter.
As explained in chapter 6, treatments like herbals and supplements are not regulated by the Food and Drug Administration but rather by the Dietary Supplement Health and Education Act. These items are considered food and not drugs and can be sold without proof of safety or efficacy. As such, people take them, equating natural with safe, and face possible serious interactions with prescription drugs. A recent survey by the AARP and the National Center for Complementary and Alternative Medicine at the National Institutes of Health showed that 69% of patients using CAM therapies did not discuss their use with their physicians; 42% said the physician never asked, 30% said they did not know they needed to share this information, and 19% said they had insufficient time during office visits.
As far as third-party reimbursement, insurance companies deny payment for CAM on the basis of the lack of evidence for its safety, efficacy, and cost-effectiveness. But some insurers offer discounted access to CAM networks. Health fraud is well discussed in this chapter. In addition, the section of chapter 6 dealing with informed consent is very informative. For example, when a patient for whom surgery is recommended chooses CAM instead, the physician may still be liable, even if the patient signed a waiver of liability, since medical negligence cannot be waived. Cohen summarizes the need to engage clinical, ethical, and legal aspects when guiding patients about the use of CAM.
The final chapter reviews ethical challenges in CAM research. CAM is viewed as experience-based compared with evi-dence-based contemporary medicine; the common theme in the two is interest in patient well-being. Jon Tilburt reviews the seven requirements for ethical research as well as the five value commitments outlined by the Institute of Medicine: public welfare, the protection of patients, respect for patient autonomy, recognition of medical pluralism, and public accountability. The need for research on herbals is noted; the prevalent use of herbals by the public makes the topic ethically worthy of public funds. Some forms of CAM, such as moxa (the Asian practice of burning small cones of dried leaves on designated points of the body), are difficult to study because of the way culture and belief affect the modality. Tilburt comments on randomized controlled trials, the placebo effect, and the difference with placebo response. In addition, he recommends greater awareness of assumptions in the different healing systems, which can make researchers and practitioners better able to apply sound ethical principles.
The flaw that I note is the repetitiveness about statistics, principles, and reasons for increased CAM use, which is probably due to the interrelatedness of the chapters. At times, some sections become disjointed and the flow is interrupted. Otherwise, I recommend the book for anyone interested in having a broader view of disease, health and healing, and holistic medicine.
I quote:
Because the newer methods of treatment are good, it does not follow that the old ones were bad: for if our honorable and worshipful ancestors had not recovered from their ailments, you and I would not be here today. —Confucius (551–478 bc)
If all you do is physical technology, then you are a limited institution. —John Kawacki, MD
There are two things in medicine that we sometimes fail to remem-ber—first is the mind-body interaction, and second is the influence of the spiritual power that may be bigger than all of us. That's where the scientific method breaks down. —Jim Rohack, MD