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?
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
How extensively used is alternative medicine?
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
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?
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?
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
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?
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
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
What are the physician's professional obligations with respect to
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
MAJOR DOMAINS OF
COMPLEMENTARY AND ALTERNATIVE MEDICINE
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
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
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
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.
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
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
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.
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
What should you do?
Your patient has been suffering from chronic low back pain for many
years now. She voices her frustration with the various treatment
modalities that you have been trying and says her friend had
recommended a homeopath.
How do you respond?