processes to maintain health and eliminate illness. However, both conventional and complementary practices are virtually identical in their goals and desired
outcomes and in their aspirations toward a high level of professional legitimacy in how they are conducted.
ETHICS AT THE INTERFACE
This section addresses four basic issues:
1. Ethical duties conventional medicine owes to complementary medicine.
2. Ethical duties complementary medicine owes to conventional medicine.
3. Ethical duties of complementary medicine: legitimate research of its methods.
4. Other ethical duties of practitioners.
Ethical Duties Conventional Medicine Owes to Complementary Medicine
As our historical discussion shows, these duties do not arise in a vacuum. We believe that there is an unfortunate historical precedent. Conventional medicine today
should seek not only to start on a fresh footing, but also to redress its questionable aspirations toward power and economic dominance.
This ethical duty begins with fidelity to the interest of the patient. Widely quoted research has shown that many patients who see conventional physicians have also
used complementary healing (
6
). Therefore, physicians should assume, until proven otherwise, that their patients have seen a complementary practitioner. An overall
appreciation of the patient's health and treatment requires an understanding of this aspect of care and sometimes cooperation between conventional physicians and
complementary healers.
Both the nature of the complementary method used and the patient's reasoning in choosing to employ that method are part of the conventional physician's
holistic
approach to patient care. Some have used the term
holistic to distinguish some complementary approaches from conventional medicine. We dissent from use of this
term and insist instead that conventional medicine
should be holistic in its approach to the patient (in which holism may be seen as identical with the so-called
biopsychosocial model) (
7
). To us, this means that the patient should be approached as a whole person, not as a collection of organs containing a disease, and that
the patient's body, mind, spirit, community, and culture are all part of the broad understanding required for successful healing. This approach is not a public relations
ploy on the part of conventional medicine; it is instead required by a scientific understanding of human health and disease. To practice in a nonholistic, reductionistic
manner is, simply put, unscientific. A holistic physician should account for the patient's use of any complementary remedies and what the patient thinks about his or
her illness that led him or her to try these remedies.
An ethical and holistic approach to medicine is also a
relational approach. A model of
sustained partnership should mark the physician's approach to patient care,
especially in the primary care specialties (
8
). We believe that physician and patient can be effective partners if the physician is open to learning about any and all
remedies the patient uses and how these remedies relate to the treatments the physician recommends.
The following are recommended approaches for conventional physicians.
D
UTY TO
W
ARN THE
P
ATIENT
In a few cases, complementary practices are known to be positively harmful to patients, based on firm data; and a few complementary claims for healing are grossly
exaggerated. In these cases, the conventional physician has the same duty to warn the patient as he or she would in the case of another conventional practitioner
who is behaving incompetently.
B
ENEFIT OF THE
D
OUBT
In the absence of firm data that a treatment is harmful, which will almost always be the case (see
Chapter 4
, “ Evaluating Complementary and Alternative Medicine:
The Balance of Rigor and Relevance”), the conventional physician should give the complementary practitioner the benefit of the doubt as long as the delivery of good
medical care is not compromised. The physician should investigate sufficiently to be assured that the complementary practitioner is competent and that the healing
employed is efficacious for the healer's intended purposes, or is at least harmless to the patient.
U
NDERSTANDING
C
OMPLEMENTARY
M
EDICINE
Ideally, the physician would become sufficiently versed about complementary practices so that he or she can discuss them with the patient and become familiar with
local complementary practitioners and their degrees of skill. Realistically, however, this scenario is unlikely. In the absence of detailed knowledge, the physician may
inform the patient that some complementary therapies seem to work, at least for some patients; that conventional medicine does not understand fully the means by
which these remedies work; that the physician appreciates the patient discussing this with the physician and hopes he or she will continue this discussion in future
visits; and that the physician welcomes this opportunity to learn more about specific complementary practices. Agreeing to search the medical literature to examine
the evidence for CAM is useful (see
Chapter 5
, “How to Practice Evidence-Based Complementary and Alternative Medicine”). We believe this type of exchange
reinforces the ideal partnership between physician and patient without going beyond the physician's actual knowledge base.
C
ONSULTING WITH
C
OMPLEMENTARY
P
RACTITIONERS
The complexity of the patient's case may require the conventional physician to consult with the complementary practitioner to effectively coordinate the patient's care.
Some models for this approach exist in the United States Indian Health Service, which has encouraged conventional physicians and native healers to practice
cooperatively.
Once the conventional physician becomes aware of local, skilled complementary practitioners and of the efficacy of their treatments for certain classes of patients,
and once he or she has examined the medical literature for evidence of safety and effectiveness, he or she may recommend these approaches to patients who
demonstrate openness to such recommendations, precisely as he or she would recommend the use of other medical specialists and allied health services.
However, because of the multitude of complementary approaches available and the wide variability in state credentialing or licensure of complementary practitioners,
this may be a more daunting task than it appears. Although the state may not recognize a complementary modality, local practitioners frequently belong to
organizations or possess certification that assures a prescribed level of training.
In the absence of official licensure or prescribed legal standards, conventional practitioners must select complementary “colleagues” partially based on local
reputation and community acceptance, partially based on knowledge of their training, and partially based on trust and goodwill.
Once a complementary medical practice has been validated by adequate scientific evidence, conventional practitioners should either provide the treatment
themselves if possible, or provide the patients with access to that treatment through referral or other channels (see
Chapter 2
, “The Physician and Complementary
and Alternative Medicine”).
Ethical Duties Complementary Medicine Owes to Conventional Medicine
If conventional and complementary practitioners are to pay equal ethical respect to each other, they must recognize ethical obligations in both directions. It might
seem to complementary practitioners that, because conventional medicine remains socially more powerful and wealthy, the principal ethical duties should lie on that
side. However, we argue for reciprocal obligations.
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