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Complementary Medicine

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The term complementary medicine (also alternative medicine and integrative medicine) is applied to a broad range of therapies that are not commonly taught in medical schools or utilized by the medical profession. In recent years, the acronym CAM (Complimentary and Alternative Medicine) has come into wide use to identify unconventional approaches to healing.

What is the scope of complementary medicine?

Since anything outside mainstream medicine is alternative to it, the spectrum of alternative medicine spreads over a confusingly wide area. At one end are fully professionalized systems of practice that operate schools, publish journals and textbooks, have local, state, and national organizations, and subscribe to codes of ethical practice (chiropractic and naturopathic medicine are examples). Across the middle regions are any number of methods (aromatherapy, for example, or iridology) at a less systematized stage of development. There are also different versions of faith healing, Christian Science being the most extensive. Finally, at the darker end are the misguided notions and purely moneymaking schemes better classified as quackery, even though their proponents advertise themselves as practitioners of complementary healing.

How extensively used is complementary medicine?

Complementary therapies have been growing in public recognition and support since the 1970s. A 1993 survey determined that one-third of Americans use one or another alternative method (generally in conjunction with mainstream, or so-called "allopathic," measures, though the great majority do not inform their physicians of their use); and that the annual number of office visits to complementary practitioners is somewhat greater than the number of visits to all primary care MD and osteopathic (DO) physicians. Surveys conducted since then have determined that patronage of unconventional practitioners has been steadily growing and is well over fifty percent in some regions of this country.

What is the medical profession's understanding of complementary medicine?

Several studies have demonstrated that most allopathic practitioners have only a vague awareness of the practices and underlying principles of complementary medical systems. Many are prejudiced against alternative medicine, furthermore, by the profession's long history of opposition to "sectarian medicine" and "medical cultism." From the 1847 founding of the AMA until quite recently, conventional medicine has presumed alternative treatments to be ineffective, and has condemned any cooperation with alternative practitioners as unethical. Over the last quarter century, however, something of a rapprochement has been established between the two sides, and many physicians are now open to the possibility of alternative therapies being useful in particular situations, and some regularly refer patients to alternative providers.

What is known about the efficacy of complementary therapies?

Generally speaking, alternative methods have not been subjected to the orthodox gold standard of controlled clinical trials, though a few have. Chiropractic has been found effective for some forms of back pain, for example, and several investigations of homeopathic remedies have shown positive results. In 1992, Congress established the Office of Alternative Medicine at NIH precisely for the purpose of funding clinical evaluations of the efficacy of complementary therapies; in 1998, Congress upgraded the Office to The National Center for Complementary and Alternative Medicine (NCCAM), giving the Center more autonomy within the NIH. A number of studies funded by NCCAM are presently being conducted, but results thus far are largely inconclusive. Nevertheless, some of these studies have yielded positive results. A special issue of JAMA published in November, 1998 contained reports of trials demonstrating the efficacy of yoga and relaxation techniques, moxibustion, and Chinese herbal remedies in certain conditions. Acupuncture was found to have "promising results" in controlling postoperative pain and nausea, and to be possibly useful in a range of ailments that includes addiction, stroke rehabilitation, asthma and osteoarthritis. Alternative practitioners maintain many more of their methods are validated by clinical experience, and claim a high rate of successful outcomes. Physicians tend to dismiss these claims as anecdotal and attribute positive outcomes to the placebo effect and the self-limited nature of the ailments. Both sides agree on the need for more substantial evidence of efficacy, but there is much debate over whether or not randomized, placebo-controlled trials can be successfully applied to complementary therapies.

What ethical issues are associated with complementary medicine?

"Complementary medicine" implies cooperation between two or more approaches to treatment, each balancing and complementing the other(s). The recent appearance of "complementary medicine," to replace the older term "alternative," signifies the desire in the complementary community to integrate their services with allopathic methods. Simultaneously, patients are showing more interest in and requesting complementary therapies. Thus the referral of patients to complementary practitioners has emerged as a fundamental ethical question for physicians.

The normally straightforward duty to direct patients to treatments that are known to be effective, and to advise them against those that are useless or harmful is seriously confounded in the case of complementary medicine by physicians' scant knowledge (and negative preconceptions) of alternative therapies, the sheer number and bewildering variety of practices that fall under the complementary heading (no one can be familiar with them all), and the shortage of evidence for the efficacy of many complementary treatments. The decision to refer or not to refer should be based on sufficient information about the benefits and dangers of the treatment being considered, and too often in the case of complementary therapies the information either does not exist or is not known to the physician. This situation is certain to improve over the next few years, given the quantity of research now being done on the efficacy of complimentary medicine; for now, the physician may often find herself unsure whether to refer to an alternative practitioner or not. There is nevertheless an ethical obligation to attempt to stay current with evidence for effectiveness of complementary therapies, since presenting conventional treatment as the only option for a condition would in certain situations deny a patient the help of a useful CAM method. Physicians should apply a risk-benefit analysis to each case, weighing the evidence for efficacy and harm for both conventional and complementary therapies, while also taking into account the severity of the patient's illness and the degree to which the patient desires CAM treatment.

How is informed consent related to complementary medicine?

The principle of informed consent requires that the patient be adequately informed of therapeutic options and the benefits and risks associated with each. Historically, physicians have simply ignored alternative treatments when presenting options, or have summarily dismissed them as quackery. Given the current level of public interest in complementary treatments, though, many patients will expect or request information about unconventional therapies. Ideally, any complementary treatments that might be of benefit should be presented to the patient, and any that involve significant risk identified as dangers.

By now, many physicians accept the value (and safety) of some chiropractic adjustments for low back pain, and regularly refer patients to chiropractors. But in those situations where the physician does not feel he has adequate knowledge of a complementary option, he is not ethically obligated to inform the patient of that system. At most, a particular alternative method, or "complementary medicine" in general, might be mentioned as a possible adjunct, and the patient given the responsibility of investigating options and obtaining sufficient knowledge for a sound decision.

The potential interactions of various treatments present a further challenge to the practice of informed consent when using complementary medicine. The risk of harm is simply unknown when therapies are combined in new, as yet untested, ways, making truly informed consent impossible to achieve. It is essential that the physician make herself aware of whatever complementary treatments the patient pursues so as to advise on the risk of untoward interactions between the complementary medications and any conventional therapies also being used.

What is the proper approach when alternative medicine is used for children?

Parents of seriously ill children sometimes forego beneficial allopathic treatments in favor of an alternative method that is useless or injurious. One of the physician's ethical duties in this case is to find a way to work with the parents. However, if the physician believes the child is in danger, she should counsel the parents to abandon the therapy, or, if they refuse, attempt to obtain a court order to discontinue the treatment. This situation most frequently arises with the children of Christian Scientists, who rely on prayer for all healing, and there is ample legal precedent for assuming custody of the child and substituting conventional care. If the child is in the advanced stages of terminal illness, cannot be helped by allopathic treatment, and will not be further harmed by the complementary practice, then, of course, no action need be taken. There are also opportunities in these circumstances to turn an adversarial relationship into a collaborative one by frankly discussing concerns with the alternative practitioner and jointly working to support the child's healing.

What are the physician's professional obligations with respect to complementary medicine?

Offhand dismissal or ridicule of complementary medicine will only close off communication with patients, and perhaps encourage them to seek complementary options more aggressively. Rather, the allopathic practitioner must encourage patients to inform him of their use of complementary therapies, and should attempt both to learn more about the complementary methods his patients select, and to coordinate care with their complementary practitioners.

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Core clerkship material for: General Curriculum

James Whorton, PhD
Professor, Medical History and Ethics

Cases contributed by Kelly A. Edwards, MA

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Last date modified: April 11, 2008