Alternative Medicine

• What is the scope of alternative medicine?
• How extensively used is alternative medicine?
• What is the medical profession's understanding of alternative medicine?
• What is known about the efficacy of alternative therapies?
• What ethical issues are associated with alternative medicine?
• How is informed consent related to alternative medicine?
• What is the proper approach when alternative medicine is used for children?
• What are the physician's professional obligations with respect to alternative medicine?
  
  

The term alternative medicine (also complementary 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.

What is the scope of alternative 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 professional 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 naturopathy 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 wave the alternative medicine banner.

How extensively used is alternative medicine?

Alternative 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 alternative practitioners is somewhat greater than the number of visits to all primary care MD and osteopathic (DO) physicians.

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

Several studies have demonstrated that most allopathic practitioners have only a vague awareness of the practices and underlying principles of alternative medical systems. Many are prejudiced against alternative medicine, furthermore, by the profession's long history of opposition to "sectarian medicine." 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 alternative 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 alternative therapies. A number of studies are presently being conducted, but results thus far are inconclusive. Alternative practitioners maintain 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.

What ethical issues are associated with alternative 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 alternative community to integrate their services within allopathic systems. Simultaneously, patients are showing more interest in and requesting alternative therapies. Thus the referral of patients to alternative 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 alternative medicine by physicians' scant knowledge (and negative preconceptions) of alternative therapies, the sheer number and bewildering variety of practices that fall under the alternative heading (no one can be familiar with them all), and the shortage of evidence for the efficacy of many alternative 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 alternative 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. But for now, the physician may often find herself unsure whether to refer to an alternative practitioner or not.

How is informed consent related to alternative 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 alternative treatments, though, many patients will expect or request information about unconventional therapies. Ideally, any alternative 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 alternative option, he is not ethically obligated to inform the patient of that system. At most, a particular alternative method, or "alternative 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 alternative 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 alternative treatments the patient pursues so as to advise on the risk of untoward interactions between the alternative 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 alternative 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 alternative medicine?

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

MAJOR DOMAINS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE

Complementary and alternative healthcare and medical practices (CAM) are those healthcare and medical practices that are not currently an integral part of conventional medicine. The list of practices that are considered CAM changes continually as CAM practices and therapies that are proven safe and effective become accepted as "mainstream" healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologically-based treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this document. Thus, only limited examples are provided within each.

I. ALTERNATIVE MEDICAL SYSTEMS

Alternative medical systems involve complete systems of theory and practice that have evolved independent of and often prior to the conventional biomedical approach. Many are traditional systems of medicine that are practiced by individual cultures throughout the world, including a number of venerable Asian approaches.

Traditional oriental medicine emphasizes the proper balance or disturbances of qi (pronounced chi), or vital energy, in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods, including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy described more fully below). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a needle.

Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning "science of life") is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit, and strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing.

Other traditional medical systems have been developed by Native American, Aboriginal, African, Middle-Eastern, Tibetan, Central and South American cultures.

Homeopathic and naturopathic medicine are also examples of complete alternative medical systems. Homeopathic medicine is an unconventional Western system that is based on the principle that "like cures like," i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic physicians believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness.

Naturopathic medicine views disease as a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including diet and clinical nutrition; homeopathy; acupuncture; herbal medicine; hydrotherapy (the use of water in a range of temperatures and methods of applications); spinal and soft-tissue manipulation; physical therapies involving electric currents, ultrasound and light therapy; therapeutic counseling; and pharmacology.

II. MIND-BODY INTERVENTIONS

Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a subset of mind-body interventions are considered CAM. Many that have a well-documented theoretical basis, for example, patient education and cognitive-behavioral approaches are now considered "mainstream." On the other hand, meditation, certain uses of hypnosis, dance, music, and art therapy, and prayer and mental healing are categorized as complementary and alternative.

III. BIOLOGICAL-BASED THERAPIES

This category of CAM includes natural and biologically-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. Included are herbal, special dietary, orthomolecular, and individual biological therapies.

Herbal therapies employ individual or mixtures of herbs for therapeutic value. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and bee pollen to treat autoimmune and inflammatory diseases.

IV. MANIPULATIVE AND BODY-BASED METHODS

This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure (primarily the spine) and function, and how that relationship affects the preservation and restoration of health, using manipulative therapy as an integral treatment tool. Some osteopaths, who place particular emphasis on the musculoskelatal system, believing that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body, practice osteopathic manipulation. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

V. ENERGY THERAPIES

Energy therapies focus either on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields).

Biofield therapies are intended to affect the energy fields, whose existence is not yet experimentally proven, that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, to improve blood circulation, and to enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that by channeling spiritual energy through the practitioner the spirit is healed, and it in turn heals the physical body. Therapeutic Touch is derived from the ancient technique of "laying-on of hands" and is based on the premise that it is the healing force of the therapist that affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields, to, for example, treat asthma or cancer, or manage pain and migraine headaches.

Alternative Medicine:
Case 1

A young mother has just been informed that her 2-year-old son has leukemia. The mother refuses permission to begin chemotherapy and informs the team that their family physician (a naturopath) will follow the child's illness.

What should you do?

Alternative Medicine:
Case 1 Discussion

Of utmost importance are the child's best interests, which include getting good medical care and maintaining a close connection with his mother. One way to achieve both is by requesting a care conference with both the mother and the family's naturopathic physician. If the mother refuses this meeting and you remain convinced that chemotherapy is the only hope this child has, you are professionally obligated to seek a court order to appoint a guardian for the child. If chemotherapy offers a clear and compelling survival benefit, the justification for seeking legal intervention increases.