Ethical Issues Related to Patient Use of Complementary and Alternative Medicine

Short abstract

It is important for physicians to set aside their personal opinions and establish open lines of communication with patients about alternatives to conventional medical treatment.

Vignette

A 38-year-old woman presents with severe vaginal bleeding and discharge that had continued for three months. A biopsy and CT PET scans revealed stage IIB high-grade squamous cell cervical carcinoma. Chemotherapy and radiation were suggested by the patient's gynecologist. The patient was resistant to the proposed treatment; she did not believe it would work and was concerned that it could cause menopause. Instead, the patient sought treatment at a facility whose Web site guarantees patients will be cured by their special combination of radiation and “immune boosting” herbal treatments, which preserve ovarian function. The patient's spouse was a strong advocate for the alternative therapies. Though the patient and her spouse promised to consider standard treatment, the patient did not return.

Ten months later, the patient returned to her gynecologist's office with increased vaginal bleeding and discharge. Examination revealed supraclavicular nodes suggestive of abnormality and abdominal wall skin tanning, and induration suggestive of cobalt radiation therapy with high skin dose, as well as a fungating cervical mass invading the rectal area creating a rectovaginal fistula. Computed tomography scan revealed disease in the periaortic, mediastinal, and supraclavicular chain, as well as side-to-side pelvic disease, ureteral obstruction complete on the right and partial on the left, and liver metastases. Records of the patient's radiation therapy could not be obtained.

These findings and the grave nature of the disease were discussed with the patient and her spouse. Though they initially asked the gynecologist to perform a “sensitivity” test recommended by their herbal therapist, they ultimately decided on a trial of chemotherapy. After stenting the ureters, angioemblization of the tumor to control bleeding, multiple admissions for anemia secondary to cancer related blood loss, colostomy to control vaginal discharge, and progression of disease, the patient died 21 months from her original diagnosis.

Discussion

During the course of their medical careers, many oncologists and other physicians will encounter patients who are interested in complementary or alternative medical therapies. Though sometimes referred to jointly as CAM, these terms have different meanings when it comes to their role in a patient's health care. Complementary therapies are used in addition to or integrated with conventional medical treatment, whereas alternative therapies are used instead of conventional medical treatment.¹

It is common for patients to seek out complementary therapies that can be used in addition to or integrated with standard medical care, such as using aromatherapy to alleviate nausea from chemotherapy. A survey of cancer patients in the United States indicated that one in three respondents had used at least one unconventional therapy during the course of a year.^2,3 Gaining a sense of control and relieving symptoms associated with the adverse effects of conventional treatment are reasons cited by patients for using complementary therapies.⁴

Less frequently, oncologists may encounter patients who opt for unconventional or unproven treatments, like a special diet, instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional physician.¹ For physicians who have spent a lifetime training in and practicing conventional medicine, it may be difficult to understand why patients would consider unproven alternatives to treatments that have been shown to be effective. It may be easy to dismiss patients' questions about alternative interventions, or to blame patients who pursue alternative interventions and later return with advanced disease. However, at these junctures, it is important for physicians to set aside their personal opinions and communicate openly with patients. As a primary matter, physicians play an important role in educating patients about the course of their disease and available treatments. If a patient is considering using a treatment that could be harmful or an ineffective treatment when an effective standard treatment exists, the physician should educate the patient about his condition and inform the patient of standard medical treatment options and outcomes. Furthermore, an open exchange can help patients and physicians sort out reputable alternatives from questionable ones.

Second, an open conversation allows patients to explore their reasons for deciding against conventional treatment. Once patients' concerns are known, physicians may be able to put patients at ease. For example, a patient may reveal that she does not want chemotherapy because her mother had cancer years ago and was debilitated by adverse effects. The physician may be able to allay her fears by explaining that advances in symptom management allow for better control of nausea and other symptoms. On the other hand, the physician may find out that a patient is pursuing alternatives that are more consistent with his or her cultural background than conventional Western medicine. Here the physician may be able to help the patient integrate cultural practices with conventional treatments, rather than framing them as mutually exclusive alternatives.

In addition, communicating openly with patients allows health professionals to spot factors that may diminish the patient's capacity to make competent, autonomous health care decisions. In this vignette, a forceful family member made it difficult for the patient to receive treatment-related information. In other instances, depression could compromise a patient's decision-making capacity. If these factors are addressed, the patient will be able to make a choice that is consistent with his own beliefs, even if it is not consistent with conventional medicine. It is worth noting that physicians are not ethically obligated to offer interventions that are medically futile, even if they are requested by a patient.⁵

Maintaining a good rapport with patients who choose alternative interventions may have the added benefit of encouraging them to return for conventional treatment if their disease progresses. Though there may be an emotional temptation for physicians to reject these patients, it is important to leave open the possibility of a therapeutic relationship. Even if curative treatments are no longer an option when the patient returns, physicians are able to provide palliative care. Patients may be reluctant to return to care if they think they will be judged.

When patients return for treatment, physicians should try to find out what types of alternative interventions they received. Though, as in this vignette, there may not be much information available, any information could help the physician determine how best to treat the patient moving forward. If a physician senses that the patient received inappropriate care (ie, the patient was not adequately informed about the alternative intervention, was subject to false advertising claims about the effectiveness of an intervention, or was charged an excessive amount of money for interventions not covered by insurance), she could report the provider of the alternative intervention to the appropriate state licensing board. In addition to the traditional medical licensing board, 14 states plus the District of Columbia, Puerto Rico, and the Virgin Islands license naturopathic physicians,⁶ and three states (Connecticut, Arizona, and Nevada) license medical physicians to practice homeopathy.^7–10

Patients and physicians maybe also able to notify the US Food and Drug Administration (FDA) about false claims of efficacy made by the provider of an unproven alternative intervention. Recently, the FDA initiated an investigation of questionable “cancer cures.” So far, the FDA has sent warning letters to approximately 30 companies and individuals marketing on the Internet a wide range of products fraudulently claiming to prevent and cure cancer. Because these products claim to cure, treat, mitigate, or prevent disease, and these products have not been shown to be safe and effective for their labeled conditions of use, they are unapproved new drugs marketed in violation of the Federal Food, Drug, and Cosmetic Act.^11,12 Consumers and health care professionals are encouraged to notify the FDA of any complaints or problems associated with these products by calling 800-FDA-1088, or electronically at www.fda.gov/medwatch/report.htm.¹³

Conclusion

It can be difficult for physicians to communicate with patients about alternatives to conventional medical treatment. However, it is important for physicians to set aside their personal opinions and establish open lines of communication with patients who are considering alternative interventions. By discussing alternative interventions, physicians can help patients understand how they compare with standard medical treatments and outcomes. Physicians may also be able to help patients resolve obstacles to receiving standard treatment and distinguish alternatives that are reputable from those that are not. If a patient decides to pursue alternative treatments, the physician should make sure the patient feels free to return for conventional treatment at any time. Even if returning patients can no longer benefit from curative treatments, physicians can provide palliative care. Physicians who sense that a patient was treated inappropriately may report the person who provided the alternative therapy to a state licensing board or other appropriate oversight body.

Please send comments and suggestions for future articles to jopeditorsdesk@asco.org.