Ethical Challenges in Complementary and Alternative Medicine

Sound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for patients who are difficult to treat or have especially complex conditions, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.

Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define a human being as an individual, autonomous, responsible, developing, and fulfilled. Furthermore, these conditions often are characterized by great suffering, disability, and stigma; yet individuals with these conditions demonstrate tremendous adaptation and strength. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, this column provides ethics commentary on topics in clinical psychiatry. It also offers clinical ethics questions and expert answers to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in the field.

—Laura Weiss Roberts, M.D., M.A.

Complementary and alternative medicine (CAM) approaches—specifically, unconventional medicine or therapy used to prevent or treat disease—have become widely utilized by the general population. The National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) considers CAM approaches as falling into two broad subgroups: natural products (e.g., herbs or botanicals, dietary supplements, vitamins and minerals, and probiotics) and mind/body practices (e.g., yoga, acupuncture, tai chi, relaxation techniques, meditation, chiropractic and osteopathic manipulation, meditation, massage therapy) (1). While the terms “complementary” and “alternative” are often used interchangeably, the NCCIH emphasizes that they have different meanings; that is, if a nonmainstream practice is used together with conventional medicine, it is considered “complementary,” and if a nonmainstream practice is used in place of conventional medicine, it is considered “alternative.”

Furthermore, CAM should be distinguished from “integrative medicine,” which refers to the combination of conventional medicine with CAM. The most recent comprehensive assessment of CAM use in the United States comes from the 2012 National Health Information Survey (NHIS; conducted by National Center for Health Statistics, part of the Centers for Disease Control and Prevention), which interviews between 35,000 and 40,000 households every year to gather health information. Every five years, questions about CAM are included. The 2012 NHIS survey found that roughly 33% of U.S. adults used complementary approaches, with a total spending of greater than $30 billion (2).

The heterogeneous range of CAM approaches, their increasing use and availability, and their limited regulatory oversight have contributed to a range of ethical dilemmas (3). In psychiatry, although many patients use CAM approaches, the ethical issues raised by CAM have been minimally explored, and psychiatrists are often left to struggle with ethical dilemmas on their own. In this column, we discuss ethical issues in relation to CAM using several case studies.

Case 1

Ms. A is a 65-year-old woman. She was referred to the psychiatrist by the patient’s integrative medicine physician, whom she had been seeing for two years, for evaluation of worsening anxiety in the context of hyperthyroidism. Two months prior, the patient was prescribed 5 mg of diazepam twice a day after she presented to the emergency department for what she thought was a heart attack but was diagnosed with panic attacks. However, her symptoms have not resolved. In the initial interview with the patient, the psychiatrist learns that the patient has experienced a three-month history of worsening anxiety and insomnia, with the patient reporting only 3–4 hours of sleep per night, as well as racing thoughts and restlessness. The patient denies a history of mania or hypomania as well as a history of panic attacks prior to the recent episode. Ms. A also denies significant medical history. In conducting a review of the patient’s social and occupational history, the psychiatrist incidentally learns that the patient has been visiting another physician provider (“my holistic doctor”) out of state during her summer vacations, as well as having regular telephone calls with this provider. The patient states, “He only does natural treatments, and he put me on some mega-doses of iodine for my thyroid for years, because he did some tests and found that I have low iodine.” The patient reports that she did stop taking the iodine at the request of her integrative medicine physician, but she also reports that she does not want to take any more “Western” medications, because she does not believe in Western medicine and states that she has avoided taking Western medications for most of her life.

• 1.1:Which of the following is or are the most appropriate next step (or steps) for the psychiatrist?

  1. Inform the patient that unless she agrees to use “Western” medications as prescribed by the psychiatrist, the psychiatrist will be unable to continue seeing her as a patient.

  2. Do further research (e.g., by searching the medical literature, consulting with an endocrinologist, or both) regarding the possible connections between the patient’s use of mega-doses of iodine and her hyperthyroidism.

  3. Try to convince the patient that Western medicine is more evidence based than is CAM and therefore is in the patient’s best interest.

  4. Explore with the patient what her goals of treatment are and try to build rapport with her around addressing these goals in a collaborative way.

Although the potential benefits of CAM treatments are widely touted—one Website claims that their supplements are “formulated to help support mood, concentration, memory, cognitive function, and over all mental balance and wellbeing”—such claims and advertising may be associated with unrealistic expectations on the part of patients about the risks and benefits of these treatments. For example, patients may mistakenly assume that CAM treatments hailed as “all natural” are free of potential harms.

The psychiatrist’s ethical obligations—respecting the patient’s autonomous decisions while also working to maximize benefits and minimize harms—requires the psychiatrist to understand all CAM modalities that her patients are using, identify those that are potentially harmful alone or when used in conjunction with other treatments, and address these potential harms effectively in the context of the patient-physician relationship.

In the case of Ms. A., the psychiatrist was concerned that the iodine supplement may have contributed to her hyperthyroidism and concomitant anxiety symptoms. Because the patient had already stopped the supplement, the psychiatrist focused on developing a collaborative relationship with the patient in order to treat the current symptoms. One difficult aspect of this case was the question of what to do—if anything—with regard to the holistic doctor who had prescribed the mega-doses of iodine. The psychiatrist explored the medical literature and found evidence to suggest that the high doses that this particular patient was taking were inappropriate and could lead to hyperthyroidism. With the patient’s permission, the psychiatrist telephoned the holistic doctor to ask about the rationale for the high-dose iodine. In response, that physician stated, “I tested her and she has hypothyroidism and low iodine.” A request was made for the lab test results, but they were never received. The psychiatrist wondered whether the patient had been informed of the potential harms of the supplement but was unable to gather this information from the holistic provider.

Another prevailing issue directly pertaining to ethical use of CAM is the limited research base available for evaluating the safety and effectiveness of many CAM approaches. This limitation can make it even more difficult for providers to assess, integrate, and discuss these treatment options with patients. Furthermore, as CAM approaches are regulated, when they are regulated, using different standards and approaches from conventional medicine, providers should have a basic understanding of what the U.S. Food and Drug Administration (for example) does and does not require in terms of safety and efficacy testing (see, e.g., https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm050803.htm).

Thus, the basic ethical analysis of decisions related to CAM should rely on the standard framework used for evaluating and making recommendations about other individual treatments in psychiatry: a clear understanding of the indication for the treatment or approach, a thorough risk : benefit analysis of the specific treatment for the individual patient, and a discussion with the patient of his or her treatment alternatives and the risks and benefits of those alternatives. Factors to consider in evaluating a patient’s use of CAM include the severity and acuteness of his or her condition; availability and effectiveness of conventional treatments; invasiveness, toxicity, and potential side effects of the conventional treatment options; the quality of scientific evidence for efficacy and safety of the CAM treatment options; and the patient’s understanding of the risks and benefits (4).

Case 2

A 74-year-old woman with osteoarthritis and a history of two prior vertebral fractures, who was recently diagnosed with mild cognitive impairment, is referred to a psychiatrist for evaluation of symptoms of depression. The patient complains of disturbed sleep, exhaustion, digestive problems, muscle aches, and severe back pain. On examination, she is noted to have a slow and unsteady gait, despite using a cane, and is accompanied by a part-time caregiver. She reports anhedonia, sadness, poor concentration, and loneliness and is irritable in the interview with the psychiatrist. On the Geriatric Depression Scale, she scores a 10 out of 15, suggesting at least a moderate level of depression. However, as the psychiatrist begins to discuss the diagnosis of depression and the recommendation of antidepressants to address her depression, the patient again becomes irritable and states that her problems are not related to depression but to her pain. She remembers taking several yoga courses many years before and states that she feels this would be the best way for her to address her pain. She states that she does not want to take “one of those crazy pills” because she has “never had anything wrong with her mentally.”

• 2.1:What is the most appropriate response by the psychiatrist to the patient’s refusal to use antidepressants in favor of yoga?

  1. Try to convince the patient to use a very low dose of an antidepressant, because that is the gold standard treatment for geriatric depression.

  2. Tell the patient that she should try yoga if that is what she wants but also inform her that if she is not better within four weeks, she will need to start an antidepressant or else the psychiatrist will not see her for further follow-up.

  3. Explain to the patient that yoga therapy can be effective but that there may be additional risks to her given her mobility problems, osteoarthritis, and risk for fractures and suggest instead that the patient start with breath-based meditation classes.

  4. Evaluate the patient’s decision-making capacity, because the patient’s judgment seems impaired.

Yoga has grown substantially in popularity because of its reported benefits for a wide variety of conditions, effects that are believed to be mediated by enhanced parasympathetic activity (5,6). Patients with anxiety or depression in particular may be appropriate candidates for yoga. It should be noted that there may be substantial differences in the nature and quality of yoga teaching between that provided in randomized control trials (RCTs) (7) and what any given patient may encounter in his or her local community. According to a large survey of 471 extensively trained Iyengar yoga instructors, a wide variety of health conditions are brought up to teachers, who, in the case of Iyengar yoga, offer modifications to poses on the basis of the individual’s condition. The authors noted that in the majority of RCTs, study samples have been relatively homogenous, teaching procedures have been standardized, and the teaching has not been tailored to individual students. Furthermore, the majority of yoga therapists or teachers in the community do not record symptoms, progress, improvements, or side effects of their training sessions (7).

Yoga practices are not entirely safe. Over a 13-year period, a total of 29,590 yoga-related injuries were reported in emergency departments of U.S. hospitals (8). The majority of injuries occurred in the place where yoga was taught and involved the trunk of the body and strains and sprains. Furthermore, the majority of injured yoga students were age 65 years or older. One example of serious yoga-related injury is basilar artery syndrome or vertebral artery occlusion, which can be caused by unnatural neck postures and can lead to cerebrovascular accidents (9). In one reported case a 28-year-old woman suffered an ischemic infarct with secondary hemorrhages due to a bowing and displacement of the superior cerebellar artery while performing a “bow pose” for half a minute (“urdvha dhanurasana”) (10). She had felt a severe throbbing headache and was unable to stand up unassisted. Her immediate symptoms consisted of nystagmus, dysmetria in the limbs, hemianesthesia, and Horner’s syndrome, all unilaterally. Despite an extensive rehabilitation program, she still had an abnormal gait two years after the incident.

Discussion

Although CAM use appears to be growing in popularity in the general population—perhaps in part because of disillusionment with conventional medicine, as well as an ongoing interest in alternative treatments seen as more “natural”—these treatments are not without risk, can cost patients substantial sums of money, undergo limited regulation, and may have limited evidence available to support their safety and efficacy. However, scientific evidence for the effects of some treatments—such as acupuncture, meditation, and yoga—is growing and supports their use for various physical and mental conditions.

Clearly, additional CAM research is needed, including both clinical and translational work, to establish a deeper scientific basis for evaluating the safety, efficacy, and potential mechanisms of action of CAM approaches. Given the ongoing unmet needs of patients with psychiatric conditions, neither categorical rejection nor acceptance of CAM treatment is warranted. Rather, with a thoughtful approach to the ethical incorporation of CAM into integrated treatment approaches, providers may be able to bridge the sometimes-fraught territory of CAM use in psychiatry.

Answers

1.1. The correct responses are B and D. The psychiatrist should try to balance respect for the patient’s autonomy by exploring her goals of care and working with her to establish a collaborative approach to her treatment. The psychiatrist should also try to understand better the possible etiology of the patient’s symptoms in relation to her supplement use. It may be difficult to link these definitively, but the possible side effects of large doses of supplements should be discussed with the patient in order to minimize harms.

2.1. The correct response is C. Respect for the patient’s autonomy as well as the duties of beneficence and nonmaleficence guide the psychiatrist to consider the benefits of mind-body interventions for depression, as well as to inform the patient that she may be at higher risk owing to her medical conditions. A less risky alternative would be breath-based meditation. Pharmacologic treatment of geriatric depression carries risks of medication side effects and therefore is not without risk itself, so it is inappropriate for the psychiatrist to take a “hard-line” stance regarding pharmacologic treatment. The psychiatrist should instead work to establish a trusting relationship with the patient so that her symptoms and response to any treatments can be monitored adequately.