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OHSU Ethicist Offers Guidance for Physicians With Patients Using Alternative Medicine

   Portland, Ore.

Guidelines printed in Annals of Internal Medicine

An ethicist in the Oregon Health & Science University Center for Ethics in Health Care has published new guidelines for conventionally trained physicians whose patients are interested in utilizing complementary and alternative medicine (CAM). The guidelines are contained in an article published in the Oct. 15 edition of the Annals of Internal Medicine. The article is part of a series of reports on various aspects of CAM treatments appearing in the journal. Collaborators from Beth Israel Deaconess Medical Center, Harvard Medical School and University of Washington Medical Center also contributed to the paper.

The report comes in response to the exploding popularity of CAM among the general public and its expanding use among patients, health care providers and institutions. According to a national survey conducted in 1997, more than 42 percent of the American public used complementary and alternative medicine, at a cost of $27 billion per year. CAM therapies include acupuncture, herbs, chiropractic manipulation, mind-body interventions and naturopathic medicine. While there is little scientific information on the effectiveness of most CAM therapies, some treatments such as chiropractic manipulation for temporary back pain, appear to be more successful than conventional therapies.

"It is imperative that physicians consider the ethical obligations when tolerating or recommending for or against CAM therapies. CAM should not be dismissed out of hand or accepted blindly," said Karen Adams, M.D., an assistant professor of obstetrics and gynecology in the OHSU School of Medicine and lead author of the paper. "Many physicians are unfamiliar with CAM therapies. There is also a lack of scientific evidence about most forms of CAM, and some therapies may even be harmful when used alone or in combination with conventional medicine. This provides the potential for serious patient-physician conflict."

To aid physicians in consulting patients undergoing or considering CAM therapies, authors provided a list of factors that must be considered as part of a risk-benefit analysis. These factors include severity and acuteness of the illness, curability with conventional treatment, the degree of patient discomfort associated with conventional treatment, and safety of the CAM treatment. Physicians should also have a degree of understanding of the risks and benefits of the CAM treatment, ensure patient knowledge of those risks, and evaluate the patient's degree of persistence in using CAM treatment.

To illustrate the varying ethical consideration physicians must make when working with patients undergoing CAM therapies, the paper utilizes real-life case examples. The identities of the doctors and patients involved were concealed to maintain confidentiality.

In one case example, a female patient refuses to undergo surgery for the removal of a tumor on her cervix, which if left untreated could result in serious illness or death. Instead the patient informs the physician of her wishes to treat her condition with Reiki therapy, which is said to involve moving energy through the body in order to balance it. The patient makes this decision despite the fact that surgery is a commonly successful treatment for her condition. Following much discussion and evaluation, the physician respects the patient's strong wishes, documents her rejection of medical recommendations and offers continued medical advice if needed.

"One of the major messages of the paper is to thoroughly investigate treatment options and hold in-depth discussions with a patient," added Adams. "The promise to face the future together is one of the obligations of the physician-patient relationship and should not be taken lightly. Our hope is that whatever care options a patient chooses, communication with their conventional medicine provider will continue."

Karen Adams, M.D., assistant professor of obstetrics and gynecology, OHSU School of Medicine; clinical consultant, OHSU Center for Ethics in Health Care; Ethics Committee chairwoman, American Medical Women's Association

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