Essentials of Complementary and Alternative Medicine (June 1999)

CHAPTER 3. E
THICS AT THE
 I
NTERFACE OF
 C
ONVENTIONAL AND
 C
OMPLEMENTARY
 M
EDICINE
Howard Brody, Janis M. Rygwelski, and Michael D. Fetters
Introduction
Historical Background
 
Power and Ethics
Approaches to the Ethics of Practice
 
Moral Principles
 
Type of Practice
Ethics at the Interface
 
Ethical Duties Conventional Medicine Owes to Complementary Medicine
 
Ethical Duties Complementary Medicine Owes to Conventional Medicine
 
Ethical Duties of Complementary Medicine: Legitimate Research of Its Methods
 
Other Ethical Duties of Practitioners
Conclusion
Chapter References
INTRODUCTION
Every medical and healing practice applies general laws to each individual case, and the intended outcomes are to promote the health of the patient and to avoid 
doing harm (
1
). Thus, all healing practices are moral enterprises—intended to do good and to avoid doing wrong—and most healing decisions involve a moral 
dimension. For centuries in Western conventional medicine, these moral and ethical issues were assumed as the almost exclusive province of physicians. However, 
since the 1960s, this assumption has been challenged, and there is now active research in medical ethics involving both nonphysicians (mostly philosophers, 
theologians, and legal scholars) and physicians. The result of this academic interest has deepened and broadened our understanding of medical ethics and has 
exposed some aspects of historical medical ethics as narrow and unjustifiable.
This chapter addresses some ways of conceptualizing medical ethics today to show how medical ethics applies equally well to both conventional and complementary 
medicine. Detail is provided for some specific issues raised by complementary medicine, both for its own practitioners and for conventional practitioners.
HISTORICAL BACKGROUND
For much of the past 100 years, medical ethics has exacerbated tension between conventional and complementary practitioners. It is important to distinguish carefully 
between this historical experience and what we mean by medical ethics and medical morality today. To understand this distinction, a brief discussion of power may be 
helpful.
Power and Ethics
The relationship between power and ethics sometimes goes unnoticed. From one perspective, ethics is about the appropriate use and misuse of power (
2
). In human 
relationships that have an imbalance of power, the exercise of power (especially when used with good intentions) tends to be relatively invisible to the person in the 
more powerful position. To the person with less power, the exercise of power is obvious, as is how exactly it works to his or her disadvantage. However, to the person 
with more power, it is relatively easy to construe that being in and exercising power is simply a manifestation of the fixed and normal order of the universe. In this 
scenario, the use of power escapes any critical scrutiny from within the more powerful group. And, from the viewpoint of this dominant class, any rival interpretation 
may be dismissed as groundless because the interpretation originates among the “wrong” people with presumably biased and incorrect viewpoints.
Sociologists have studied conventional medicine as a manifestation of this exercise of power. The medical profession may be viewed as having, in effect, struck a 
contract with mainstream society. Society grants conventional medicine a good deal of power and the autonomy to exercise it with little societal interference. In 
exchange, conventional medicine provides society with a highly valuable service—medical care in times of illness. This contract has often been very powerful (e.g., 
when physicians have literally risked death to deliver care during epidemics). One of the powers granted to conventional medicine by society is the privilege of 
defining truth as it pertains to a number of health-related issues. For example, when a person who has been absent from work is told to provide a note from his or her 
physician to certify the legitimacy of the absence, a minor and commonplace example of this delegation of power from society to the medical profession is seen. The 
employer views the employee's report of illness as unreliable, but the physician's certification of the same phenomenon is socially unchallenged. Although a critic may 
see this as an act of social dominance, physicians presume that they are merely reporting  the truth as any rational person would see it. In this manner, physicians 
have gradually become less aware of the extent of their own exercise of social power than actually exists; that is, even though their intentions have been good, 
physicians may not realize how their use of power affects people.
The obvious, if unconscious, temptation this power creates within conventional medicine is to use the power to secure its own economic dominance over potential 
competitors and to justify these practices in the name of  scientific truth, to which only regular physicians (and, of course, never their competitors) have exclusive 
access. Another power historically ceded to the medical profession is the privilege of developing its own internal code of ethics, without input or critical scrutiny from 
nonphysicians and society. With this power, medicine may declare that certain things are scientifically true. Good ethical physicians adhere to truth and avoid 
fraudulent practices; therefore, both truth and ethics require that regular physicians condemn certain types of practices engaged in by medicine's economic 
competitors.
This tendency is well illustrated by the history of the American Medical Association (AMA), founded in 1847. One of its first official actions was to write a code of ethics 
(1848). In the 1830s and 1840s, conventional medicine was increasingly beleaguered. Complementary schools of medicine flourished; simultaneously, the Jacksonian 
democracy movement forced the repeal of all state licensing laws that had favored the conventional profession. In hindsight, it is no accident that conventional 
physicians wanted an organization like the AMA during this time; nor is it surprising that the code of ethics enjoined conventional physicians to avoid contact with 
complementary practitioners and to work to undermine public confidence in those practices (see 
Chapter 1
, “The History of Complementary and Alternative 
Medicine”). The AMA's “ethical” argument was that these practices were unscientific and grounded in a fraudulent view of the human body, so that no “regular” 
practitioner could be pure and true to his or her scientific calling if he or she recognized these practices.
A telling example of this philosophy was the relationship between conventional medicine and homeopathy during this time. Homeopathy presented two particular 
problems for conventional medicine. First, homeopathy was extremely popular for much of the nineteenth century, especially among better educated patients. Second, 
by any truly objective standard, homeopathic schools were the equal of the allopathic schools in the rigor and length of the curriculum. In New York, where 
homeopathy was particularly powerful, the stringent AMA code placed allopaths at a disadvantage. If conventional physicians refused to consult with the homeopaths 
or to attend any case in which homeopathic care was being administered, they risked a marked reduction in the size of their practices. They were also enjoined from 
consulting with physicians whom they might well have recognized personally as decent and well-informed practitioners. The end result was a curious schism within 
the state medical society, lasting from 1882 to 1900. During those years, there were two conventional medical societies in New York. One society followed the AMA 
code and continued to send delegates to the national AMA meetings. The other society allowed its members to consult with homeopaths and was denounced by the 
AMA as an illegitimate renegade group (
3
).
Well into the twentieth century, after the dominance of conventional medicine had been firmly established, the AMA shifted its attention to chiropractic. The code of 
ethics forbade consulting with or referring patients to chiropractors, and the AMA engaged in extensive lobbying to limit chiropractic scope of practice. This conflict 
was resolved by a rewriting of medicine's social contract: after antitrust action, the AMA was prohibited by the government from its anticompetitive activities and was in 
effect ordered to strike the chiropractic sections from its code of ethics (see 
Chapter 1
, “The History of Complementary and Alternative Medicine,” for more details 

regarding these dynamics).
This brief history lesson may suggest that medical ethics is the sworn enemy of complementary medicine and is nothing other than a power grab by conventional 
physicians seeking to retain all of their advantages and privileges. It is therefore extremely important to distinguish between the approach to ethics used by the AMA 
from 1848 into the 1960s from the current and legitimate academic study of ethics in medicine. Currently, ethics require that pronouncements are grounded in 
principles or concepts open to all people of reason, and any concept that attributes exclusive knowledge to practitioners of medicine is rejected. By these criteria, 
economic self-interest cannot be accepted as an appropriate basis for any ethical pronouncement. Moreover, although the former method of ethics took for granted 
the physician's power and generously bestowed a benevolent intent on any such exercise of power, current ethics work from the opposite assumption. Current 
theories in ethics assume that any exercise of medical power is in danger of trespassing on the patient's vital rights and interests. Therefore, ethics demand that 
exercise of power be critically examined and justified—not only according to what physicians think is good for the patient, but also in terms of the patient's own free 
and informed choice.
For these reasons, we argue, first, that complementary medicine can hope for fair treatment from today's ethics; and second, that there is reason to hold today's ethics 
equally applicable to conventional and complementary healing practices.
APPROACHES TO THE ETHICS OF PRACTICE
Moral Principles
This chapter looks briefly at two ways of grounding an ethics of medicine: first, in terms of general moral principles; and second, in terms of what sort of activity or 
practice medicine is. The latter approach superficially resembles the old AMA code but differs by denying that physicians themselves have special or exclusive insight 
into the relevant questions.
The most widely used and cited modern textbook of medical ethics claims that the vast majority of ethical issues in medicine can be understood through the 
application of one or more of four general moral principles: autonomy, beneficence, nonmaleficence, and justice (
Table 3.1
) (
4
). These principles apply equally to 
many nonmedical aspects of living; therefore, their general relevance to moral issues helps increase our confidence that medical–ethical issues are being resolved 
wisely when these principles are applied to them.
Table 3.1. Principles of Medical Ethics
In summary, autonomy requires that a person act in a manner that respects the rights of others to freely determine their own choices and destiny.  Beneficence 
requires that a person tries to do good for others, especially those to whom one owes a professional duty.  Nonmaleficence requires that one avoids doing harm to 
others (a duty that applies generally, even in the absence of a professional obligation).  Justice requires that one treats others fairly.
Difficult ethical dilemmas arise when one of these principles conflicts with another. The classic ethical problem of  paternalism is a conflict between autonomy and 
beneficence: the paternalistic physician is inclined to ignore the patient's expressed choice because he or she believes that more good can be done for the patient 
that way. Because most modern thinkers believe paternalism in medicine is seldom justified if the patient is capable of making a rational, informed decision, autonomy 
is regarded as the dominant moral principle in this clash. The ethical–legal requirement of informed consent is a way of setting up respect for autonomy as a basic 
requirement of medical practice.
We see no problem in using these four principles as the basis for an ethic of either conventional or complementary medicine. The major requirement is that the terms 
benefit and harm are defined in ways that are neutral to the theory of healing being invoked. The most important consideration is what the patient regards as a benefit 
or harm; the next relevant consideration is what the practitioner, based on his or her own system of practice, regards as a benefit or harm. By contrast, it is wrong for 
conventional medicine to define a complementary practice as harmful  merely because it is a complementary practice. However, if one particular complementary 
practice (or conventional practice, for that matter) leads to toxic reactions in a substantial percentage of patients, it is appropriate to regard that practice as harmful, 
assuming that the patients in question themselves label that outcome as harmful.
Type of Practice
The second approach to grounding medical ethics is through an understanding of the type of medical practice being used. This requires an understanding of the 
various goals of the healing practice and the means that the practice considers morally legitimate in pursuit of those goals (
5
). The goals and means detailed in 
Table 
3.2
 should be equally applicable to conventional and complementary practices. Based on the unfortunate historical precedents mentioned in the previous section, the 
critical terms to define are  competence and fraudulent. Again, real ethical understanding requires that these terms be defined from the standpoint of the type of 
practice employed by the practitioner in question. It is fraudulent for a conventional physician untrained in homeopathy to prescribe homeopathic remedies, and it is 
fraudulent for an herbalist to prescribe methotrexate for cancer therapy. However, if each practitioner clearly states his or her intended approach to the patient and 
uses methods in which he or she has been properly trained, then no ethical duty has been breached.
Table 3.2. Goals and Means of Ethically Sound Medical Practice
If our analysis in this section is correct, then we have shown that there is no fundamental, ethical difference between the general goals and guiding principles of 
conventional and complementary medicine. These practices differ in their understanding of how the human body works and what methods most effectively alter bodily 

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.