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CAM on campus: Ethics

In a previous post I described a lecture given by a faculty member to first-year medical students on my campus introducing us to integrative medicine (IM). Here I describe his lecture to the second-year class on legal and ethical aspects of complementary and alternative medicine (CAM).

Dr. P began his lecture by describing CAM using the now-familiar NCCAM classification. He gave the NCCAM definition of CAM as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.” To illustrate how this definition can lead to surprises, he asked us if the therapeutic use of maggots is CAM or conventional. Although it sounds rather CAM-ish, maggot therapy is used at some surgical centers for wound debridement, he told us, and therefore is part of “conventional medicine.”

I continue to be surprised that thoughtful fans of CAM use this garbage pail definition (anything that doesn’t fit into conventional medicine), because it means that (1) no quackery can be easily excluded from the CAM tent and (2) the only common thread among the sundry modalities is a lack of acceptance from the mainstream medical community. One of Dr. P’s case studies of ethical challenges in CAM use involved a patient’s family that insisted on treating his persistent vegetative state with hyperbaric oxygen therapy — the utility of which Dr. P was highly doubtful — and later Dr. P mentioned intravenous chelation therapy as an example of a CAM treatment that he considered high-risk (compared to, say, parsley supplements). However, both hyperbaric oxygen and IV chelation have uncontroversial indications. Why are they called CAM when used in certain diseases? Presumably only because they are so poorly supported or implausible in those contexts as to be shunned by the medical community, the same community that apparently has adopted as weird (dare I say, unconventional) a therapy as maggot debridement. That maggots won acceptance leads me to be a priori skeptical of any therapy currently defined as CAM, particularly an old one (it still hasn’t been proven). Dr. P appears more optimistic than I, because he seems to interpret the same story as a reason to stay open-minded about most CAM therapies (it still might be proven).

Like the last time, Dr. P stressed that advocacy for use of CAM/IM was not a goal of his lecture. I infer from many of the points and tangential comments he made throughout the lecture, however, that he has a goal of normalizing CAM/IM for us. A frequent refrain was that some ethical precept or legal consideration regarding CAM use was “just the same” as for conventional medicine. Often I agreed with him — all therapeutic options should meet the same standards of efficacy and safety, and many ethical or legal concerns are common for either conventional or alternative approaches — but some of his comparisons seemed questionable:

  • For example, after acknowledging that “generally recognized as safe” substances may have unexpected side effects when taken as high-dose supplements (he gave the example of ephedra), Dr. P suggested that in many cases the physician can monitor a patient for side effects while using the supplement, just like we do for patients using pharmaceuticals. Outside of a research context, I would argue that most such monitoring is done for previously characterized adverse effects (e.g., known effects of statins or neuroleptics) and as such can be done more effectively and efficiently than screening for unknown reactions from a mystery drug.
  • At one point he mentioned that we accept the 10,000 yearly deaths from NSAIDs in exchange for its benefits; again, it seems to me that the benefits of aspirin are well-defined and understood, in contrast to CAM.
  • Dr. P also compared use of CAM to off-label use of pharmaceuticals, implying that both practices are, in a sense, unconventional. Is this a fair comparison?
  • He further mentioned that some unethical CAM providers may be more concerned about the health of their income stream than the health of their patients, as evidenced by recommending products they sell. He pointed to similar behavior on the “conventional” side with the example of internists giving cosmetic Botox injections to supplement their low reimbursement rates. I thought this was a bizarre example and a completely false analogy; we could argue about appropriateness, but no one is mislead about health benefits of such a procedure.
  • Finally, Dr. P talked about how an IM doc would refer patients to qualified CAM practitioners, much like all physicians refer to appropriate specialists when a patient needs care beyond the scope of their practice. He mentioned, for example, that he will refer a patient to a licensed acupuncturist or a credentialed Reiki master if the patient wants those therapies. Professor Edzard Ernst’s infamous quote regarding regulation of CAM comes to mind.

The bulk of the lecture was devoted to how a physician should respond to a patient request for or use of CAM. Dr. P began by asserting that a physician should neither categorically refuse nor automatically agree to cooperate with CAM administration. Each request should be evaluated in terms of risks and benefits, with consideration given to the patient’s beliefs, cultural values, therapeutic goals, and severity of illness. In doing so, physicians should uphold the ethical principles of autonomy, beneficence, non-maleficence, and justice. Dr. P spoke well on enabling patient autonomy, which he said involved correcting misinformation as much as supporting unconventional choices. When a patient comes to Dr. P with a bag of supplements, Dr. P will go through them and ask non-judgmentally for each, “Why do you take this?” He is then able to gently correct misconceptions or guide towards better information sources, and he has more luck paring down the list when he is knowledgeable about and accepting of the ones more likely to be useful. (Glucosamine? Sure, that may help. But I’m not so sure about this shark cartilage.) Beneficence and non-maleficence speak to risk-benefit considerations; here was the line about deaths from NSAIDs. Justice is about societal fairness and access to care. Dr. P expressed frustration that proven CAM interventions like acupuncture for osteoarthritis (he referenced twice a “definitive” study by Brian Berman, discussed on this blog here and here) are often not reimbursed by Medicare.

Dr. P described three important factors to consider when evaluating a patient request for CAM: safety, efficacy, and curability. “Curability” refers to the patient’s clinical state and prognosis. Dr. P recommends greater tolerance for ineffective or even unsafe interventions if the patient is unlikely to suffer ill effects, perhaps due to comatose state or imminent death. He pointed out that physicians often provide interventions at the end of life that are more for the family’s sake than the patient’s, such as futile resuscitation attempts, and the same leeway should be granted for last-ditch CAM efforts when no standard therapies are available. In the aforementioned (real-life) case of the coma patient treated with hyperbaric oxygen, the family was wealthy enough to easily afford the treatment and was willing to reimburse hospital resources (nursing, ambulance) spent shuttling the patient to and from the hyperbaric quack (for a planned 30+ treatments). As expected, Dr. P spoke eloquently on the need to tease out family dynamics, goals for treatment, unreasonable expectations, etc., and I agree with him that theses thorny ethical issues regarding chronic disease or end-of-life care are independent of CAM use.

On “safety” Dr. P said that CAM (or any) interventions could be classified as proven safe (within reason of course, not in any absolute sense), not proven safe, or proven not safe. He started by telling us that patient’s requests and beliefs never excuse the physician from the professional duty not to harm. Then, with the caveat that some of us may disagree with the following statement, Dr. P read from his slide, “A treatment proven to be safe should be administered out of respect for the patient and/or family autonomy, and to promote an open and cooperative relationship” (my emphasis). Although Dr. P did not mention any such consequence, I believe that this mandate would necessarily lead to physician acceptance of the use of homeopathy and Reiki, even if we all agreed they had no specific efficacy. In my opinion, a more broad-based (dare I say, holistic) consideration of adverse effects of CAM may instead conclude that physicians have a professional and societal responsibility to discourage magical thinking… As for interventions “not proven safe,” here is where Dr. P suggested that cautious use with careful monitoring was appropriate (see my third paragraph). Interventions that are “proven not safe” should be avoided except as allowed by issues of “curability” (previous paragraph).

On the slide for “efficacy” that described the requirement for physicians to “do good” in addition to “do no harm,” Dr. P read a statement that made me sit up with interest: “However, providing some CAM modalities, though not scientifically validated, may have significant benefits for patients by reason of the placebo effect or by improving psychological well-being by demonstrating concern and regard for the patients’ and/or families’ wishes.” But he immediately said that although he included this argument for completeness, he does not actually agree with it; when he uses or recommends a piece of CAM, it is because he truly believes it may have specific benefits. One factor that influences his beliefs and clinical decision making, he next mentioned, is personal experience with a CAM therapy. I must quote him directly: “if I’ve recommended glucosamine 20 times for my patients or 200 times and I’ve seen some benefit, even if a study comes out saying it may not work, that may not change how I’m practicing.” He commented that one can always find flaws in any study’s design (I agree), that one’s biases influence this critical analysis (I agree), and that only rarely does a single article change one’s practice (I agree). Where it seems we disagree is on the value of a single clinician’s uncontrolled observations; I tend to think that such data is hopelessly flawed compared to a consensus view based on the totality of scientific evidence.

Frustratingly, Dr. P segued from this interesting epistemological point to the banal assertion of the importance of listening to patients and engaging in a therapeutic relationship that may lead to healing, not just curing. The next slide implored us to administer any therapy that is proven effective “regardless of its origins.” Again, the maggot story tells me that this is done, but Dr. P seems to feel that CAM is often given short shrift. For example, although several studies have shown efficacy of glucosamine for osteoarthritis (he asserted that many rheumatologists both prescribe and personally use it), Dr. P was annoyed to read press reports of one particular study (GAIT, I presume) that described a limited effect of glucosamine without mentioning that Celebrex had similarly poor effects in some of the study groups. I guess we also agree that mainstream media reporting on science is often misleading!

Dispersed through the lecture were presentations of three cases that illustrated ethical challenges surrounding CAM use: hyperbaric oxygen for a comatose patient, a mother of five who insisted on only alternative therapies for early-stage breast cancer (he tried everything, even called a psychiatrist, to convince her to accept definitive treatment but she refused), and a terminal leukemia patient who asked his advice on an absurd alt-med regimen (massive supplement use, coffee enemas). He stressed that these three patients, like sensational public reports of chemotherapy refuseniks, are very rare exceptions and that the vast majority of his patients use CAM as a safe complement to standard care.

The discussion of legal implications was brief. In Charell v. Gonzalez, a New York court found that “no practitioner of alternative medicine could prevail…as…the term ‘non-convention’ may well necessitate a finding that the doctor who practices such medicine deviates from ‘accepted’ medical standards.” (Interestingly, Dr. P called Gonzalez a “famous” physician and mentioned that after this case he won an NIH grant for a large trial of his anticancer regimen. As of November 2009, Dr. P apparently had not yet heard about the disastrous conclusion of that trial, made public in August 2009 and described here and here.) In Schneider v. Revici, another cancer quack was exonerated because the patient had signed a detailed consent form that marked an “expressed assumption of risk.” Dr. P pointed out that CAM providers are very rarely sued because they tend to have very good relationships with patients. For protection against malpractice charges when using CAM (or any) therapies, he recommended meticulous documentation, clear communication, and a willingness to apologize for failures.

The lecture ended with a touching story about how the husband of the terminal leukemia patient (who went to the Revici clinic against Dr. P’s advice) came back to visit Dr. P after his wife’s death. The husband thanked Dr. P for talking with them frankly and compassionately about their goals and expectations for her final months.

Much of this talk, like the previous one, must have seemed attractive and reasonable to the student with no more than a passing interest in CAM. However, few details were directly relevant to the ultimate question, “Do particular CAM therapies have specific effects?” I am intrigued by how often Dr. P and I agree, such as when he suggested that selection bias may help account for success stories from heroic alternative cancer regimens (i.e., only healthy patients can tolerate them). But if I watch carefully and dig deeply I can pick out issues of contention between us. The forums where we might argue over the evidence for this or that indication, or have the general discussion about interpretation of evidence, are the elective CAM courses presumably attended only by the enthusiastic. Most of my classmates get little more than the vague and rosy exposure that I describe here and here, and in one more future post on third year. I fear that these lectures, while making CAM/IM more palatable, do not adequately equip students for critical analysis of unusual claims.

Posted in: Medical Academia, Medical Ethics, Science and Medicine

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13 thoughts on “CAM on campus: Ethics

  1. DevoutCatalyst says:

    …“However, providing some CAM modalities, though not scientifically validated, may have significant benefits for patients by reason of the placebo effect or by improving psychological well-being by demonstrating concern and regard for the patients’ and/or families’ wishes.” …

    Can the same be said for antibiotics? Patients want these. There is a poster on the wall at the local urgent care telling the patient they are worthless for certain indications and not to ask the doctor for them. Actually there are two such posters, side by side.

  2. It strikes me that Dr. P suffers from the same set of naivetes that afflicts many other academics charged with disseminating information about “CAM”: he knows little of “CAM” history, methods, or practitioners, eg, Gonzalez; he hasn’t perused ethical treatises that pertain specifically to “CAM”; and he seems unaware of the deceptive language (“healing”) or logical fallacies (tu quoque, especially) that permeate the ‘field’.

  3. Diane Henry says:

    ugh, ugh. Your experience, Tim, is much more intense than mine, but I’m feeling kinship with this. I have just completed my first 3 days of nursing school, and oh boy. We’ve got the “Western medicine doesn’t have the answers for everything” “we’re finally realizing that we need to treat the WHOLE patient and not just their symptoms” and “Health is more than absence of disease.” Although my big giant textbook has “only” one official chapter dedicated to CAM (completely uncritical) but there are “helpful” CAM strategies sprinkled throughout the book for dealing with various problems.

    I can’t stomach the idea of taking a test about CAM–”Which condition is contraindicated for reflexology?”. But I at the very beginning of my schooling, and I don’t think I can raise a stink yet. I think I will tape record the lectures, though, and complain later.

  4. Skeptinurse says:

    Diane,

    I’m sorry to hear just how far CAM has invaded Nursing School. I graduated in 1994 and we only had one “lab” that dealt with it. During the lab we were trying to manipulate “energy fields”, needless to say most of the class was very uncomfortable and many just thought the exercise silly. Fortunately the teacher for this one said “this isn’t for everyone if you don’t want to use it, don’t”.

    Almost my entire career has been in the O.R. so I’ve been spared most of the woo infiltration, everyone is too busy trying to keep up the newest technology. Although I have noticed that our last employee health fair was about 60% woo offerings. I was surprised they were still offering blood pressure checks and PFT’s.

    All I can say is hang in there, we need good nurses that aren’t easily swayed by this nonsense. Give them the answer they want on the test. You don’t have to incorporate the garbage into your practice. And while I applaud your attitude of wanting to challenge it, nursing school isn’t the place (maybe graduation if you get to give a speech). You will have a much stronger voice out in the “real world”. We need nurses who can communicate well, something it looks like you can do. So many nurses can’t spell and don’t have even passable grammar skills and unfortunately don’t care to work on correcting the problem. Most of the ones I know with terrible skills in this area think it doesn’t matter. They really can’t grasp the concept that looking illiterate and spouting nonsense makes them look extremely unprofessional.

    Good luck with your education.

  5. JMB says:

    Thanks for the post, I have been looking forward to it.

    “maggot therapy”
    Maggot therapy has a reverse placebo effect. Patients are happy about the objective results, but unhappy with the subjective repulsion of the treatment. It keeps being rediscovered as a more effective and less painful way to debride open wounds of necrotic tissue. Even though it is more effective than the surgery intern using a scapel to debride the wound, it keeps disappearing from the treatment armatorium, only to be rediscovered 10 years later.

    “personal experience with a CAM therapy”
    One fallacy in using personal experience to argue for CAM based on practice experience is that doctors practices are subject to patient selection bias. There is variation in strength of placebo effect that may be attributed to the behavior of the healthcare provider, the nature of the treatment (big pill versus small pill), the nature of the condition being treated (chronic pain may exhibit the largest placebo effects), and the attitude of the patients. Patients looking for CAM treatments may have already learned their own susceptibility to placebo effects, and seek out IM practitioners. An IM physician is more likely to have a larger proportion of patients with higher susceptibility to placebo effects. So while Dr P may observe a large benefit in his patient population, providers in other situations may witness a lower response to placebo effects. Furthermore, patients who received no benefit from the CAM might not return to Dr P to give the negative feedback. That may also skew Dr P’s observations.

    Diane Henry gave us this quote from her nursing training, “we’re finally realizing that we need to treat the WHOLE patient and not just their symptoms”.

    30 years ago in my medical training we were taught that we must treat the WHOLE patient, which meant treating the disease process as well as the patient’s illness. The patient’s illness is the emotional response to the disease process as well as the social consequences. The only difference I can see between what we were taught 30 years ago and what you are being taught is in the names (medicine versus integrative medicine and placebo effect versus CAM). You don’t have to use CAM to treat the WHOLE patient. Use of pseudoscience explanations was apparently more frowned upon back in my day. But don’t let the teaching of CAM dissuade you. Just focus on the idea that it is important to communicate with your patients and provide reassurance. Someone with good social skills usually doesn’t have to use the trappings of CAM to achieve that.

    From the article,
    “Dr. P pointed out that CAM providers are very rarely sued because they tend to have very good relationships with patients. ”

    He’s right about that. There was a case of a chiropracter in a small western town that killed 13 or 14 patients undergoing colonic treatments. Inadequate sterilization resulted in the transmission of shigellosis between patients. There was not one malpractice lawsuit filed.

    From the article,
    “In the aforementioned (real-life) case of the coma patient treated with hyperbaric oxygen,”

    At one time, I was a certified tank diver for hyperbaric medicine (doctors had to accompany patients inside the hyperbaric chamber). I got hazardous duty pay in the military for that. I am mystified how you could help a comatose patient clear their ears to prevent rupture of the eardrums. I guess if nothing else, that amount of pain would have been more effective at awakening someone from a coma than traditional methods.

  6. # DevoutCatalyston 08 Apr 2010 at 9:00 am
    “Can the same be said for antibiotics? Patients want these. There is a poster on the wall at the local urgent care telling the patient they are worthless for certain indications and not to ask the doctor for them. Actually there are two such posters, side by side.”

    The overuse of antibiotics can lower their efficiency for everyone. I don’t see a way that the use of Reiki by someone else will lower the efficiency of my conventional medicine.

  7. Actually, I have to say that reading about the experiences in nursing schools saddens me more than those in medical schools. My sister is a nurse anesthetist. Before she got her masters and started working in Anesthesia, she worked in Cardiology ICU, then moved on to one of the top burn units in the Country. Comparing her accounts of school and her work experience to the accounts of training of nurses here (reflexology, reiki, energy fields?!?) is depressing. What a terrible degradation of the field.

  8. windriven says:

    “personal experience with a CAM therapy”

    1. To quote the distinguished and erudite puscaster, “the three most dangerous words in medicine are ‘in my experience.’”

    2. The plural of anecdote is not ‘fact.’

  9. Diane Henry says:

    @Skeptinurse,
    Thank you so much for the words of encouragement and advice. I will keep my head down, for now. And work my butt off to be a good nurse who uses critical thinking!

  10. Versus says:

    It is both infuriating and sad that medical and nursing education tolerates this nonsense. Perhaps my view is simplistic, but administering any treatment that has no plausible basis in science is fraud and should be treated as such. I do not understand the notion that because the patients “wants” a CAM treatment the MD has to participate in getting it for him. Why would one ever “refer” (Dr. P’s term) a patient to a CAM provider? Nor do I understand why an MD would ever put herself in the position of “monitoring” CAM use by the patient. If a patient asks about, for example, reiki, the MD can, in a kind and caring manner, tell the patient she understands that reiki is being advertised to the public as beneficial by practitioners who make money off of it but reiki doesn’t work and she would hate to see the patient waste his money on it.

    As useful test to apply when considering becoming a part of your patient’s CAM use is “How will I explain this to the jury?”

    As for CAM practitioners not being sued for malpractice as often as MDs, perhaps this is because their patients are often the “worried well” and the treatments are inert. In addition, their own kooky beliefs are the “standard of care.” You’d have to work hard to commit malpractice in that situation.

  11. windriven says:

    @Versus

    “As (sic) useful test to apply when considering becoming a part of your patient’s CAM use is ‘How will I explain this to the jury?’”

    An excellent point. Dr. Kreider pointed out in his post that many sCAMsters enjoy excellent relationships with their patients because of the ‘touchy-feely’ nature of the therapy. Still, a high profile lawsuit against a licensed MD who drifts into the weeds of woo might well sober of few of his or her colleagues. Somewhere there will be a spouse whose mate has died as a result of this malpractice and who did not share the mate’s belief in magic. With well over 1 million attorneys practicing in the US (statistic: ABA 2007) this seems to me a loaded gun looking for a hapless MD.

  12. BillyJoe says:

    “Why would [an MD] ever “refer” a patient to a CAM provider? ”

    In Australia, Medicare and the Dept Veterans Affairs covers chiropractic provided the patient’s GP provides a referral letter.

  13. baldape says:

    Here’s a spoof I’d love to see: videotape an unexpecting person as they take their car to a Complementary and Alternative Mechanics shop. One can imagine the expression on the face of the customer as the “Eastern Mechanics” dismiss the notion of treating the symptoms (e.g. that annoying whining noise when they back up), and instead explain that it is necessary to treat the whole car. Amusement would ensue as the car is put through the works:

    Feng shui experts working out why the energies aren’t flowing properly, and adjusting the contents of the persons trunk accordingly.
    Homeopaths successing / diluting some dirt into gasoline a few dozen times before adding a few drips to the gas tank, fawning over their like-cures-like principles.
    Reiki experts wafting away the bad energies around a small dent in the fender.
    Crystal experts hanging various rocks at obnoxious locations in the car.
    A magnetic bracelet being placed around the exhaust pipe.
    A toxin expert doing a full engine-oil flush using some absurd concoction of, say, garlic juice an peanut oil, to remove all the nasty toxins of the car.
    A chiropractic expert who spends hours disconnecting and reconnectinging bundles of wires in the car, removing hardly perceptible twists and bends in the wires (muttering something about “subluxations”) to allow unimpeded flow of data and electricity throughout the cars components.
    An acupuncturist methodically sticks small needles into the car upholstery, correcting the bad flow of qi by following a guide of energy meridian lines sketched out on a piece of paper.

    After hours of such holistic treatments, we can see a followup test, and observe the customer complain that the whiny noise has gotten no better (perhaps getting a tad worse), only to be met with enthusiastic proclomations that the “bad humours” are fighting their last fight and the treatments are “surely working”. Then, while everyone walks off congratulating themselves and the customer reviews his bill in stunned silence, “Ted” the Western Mechanic guy can walk up, pop the hood, swat aside one of the dangling crystals, tighten a loose nut, and voila, the sound disappears.

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