Nov 10 2008
Kimball Atwood has an interesting series of posts on the ethics of alternative medicine which I strongly encourage you to read. He does a great job examining the ethical implications of certain alternative medicine practices, and has a terrific dialog with Peter Moran, a frequent commenter here. At my other online locale, I make frequent forays into the morass of medical ethics, with an emphasis on specific clinical scenarios. Today, though, I’d like to take a step back and examine the nature of medical ethics as they apply to so-called alternative medicine.
First, and perhaps most important, I am not an ethicist. I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics. What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.
Ethics are not static. They are not a divine gift bestowed on each of us as we don our white coats. They are a living part of our specific cultures, and of the profession we serve. Some of the modern principles of medical ethics are newer than others. Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today. Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician. These ethics must be mutable, as the profession itself is ever-changing. Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.
Alternative medicine poses real challenges to the principle of medical ethics. First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics.
Who is a physician?
The identity of “physician” in North America is generally understood as referring to someone who has completed medical school, other requisite training, and is practicing medicine. In other cultures, there are other types of healers (such as curanderos) and how our ethics may apply to them is unclear.
What about people who present themselves as doctors, but do not practice the science-based medicine that we teach and practice? They may have an M.D. or D.O. degree, they may even be board-certified, but if they are practicing outside of the standard of care, are they still bound by the same system of ethics as their more traditional colleagues?
Absolutely. Anyone who presents themselves as a doctor must behave in a way concordant with medical ethics. A patient seeking help should expect the same ethical treatment from all practitioners. No doctor is exempt from our ethical principles.
What about a doctor who believes in the implausible medical claims that they practice? Since they believe that they are helping the patient, aren’t they behaving ethically?
If intention were the only principle of medical ethics, well, sure. But good intentions do not excuse incompetence, and one of our responsibilities as physicians is to strive for excellence in our knowledge and practice. This means maintaining our science-based education.
What about non-physicians who offer quasi-medical services? Professionals such as nurse practitioners have their own codes of ethics, but often enough non-professionals such as homeopaths, acupuncturists, and others present themselves as healers. Patients have a responsibility to educate themselves and protect themselves from harm, but people who are suffering are vulnerable, and non-professional healers take advantage of this vulnerability. While they are not bound by the same medical ethics that I am, they are bound by the same ethical principles that all of us are as members of a larger society. As a society, we generally frown upon folks pretending to be experts and futzing around with people’s health and hopes. We only tolerate “alternative healers” because their deceptions extend beyond their victims—we sometimes believe they are doing good, even if they are not.
Alternative medicine is prima facie unethical
To the extent that alternative practitioners are bound by medical ethics, alternative medicine is unethical. It violates most of the commonly agreed-upon precepts of our profession. Medicine is based on the humane application of science-based practices. Standards of care are based on either what has been shown to work, or when insufficient data is available, what we as a profession agree is likely to work. There are written resources that any doctor can look up in minutes. Altmed practitioners don’t “slip” away from real medicine, they intentionally turn away from it, sometimes with good intentions, sometimes not. So-called alternative medicine practices are ethical failures on many levels. As to the principle of beneficence, the most benefit they may offer is emotional comfort, something real medicine could just as easily offer. When it comes to non-maleficence, it fails miserably, in that it often deprives patients of real treatments, or subjects them to ineffective ones.
When it comes to patient autonomy and truthfulness, however, it really hits a wall. For a patient to exercise autonomy, they must be as informed as possible. If an altmed practitioner were to truthfully inform patients that the wares they are peddling have never been shown to be useful, are shunned by real doctors, and may in fact harm, patients would knock each other down to get out the door. But they don’t. When they do give lip service to the unproven nature of their practices, it is always with a wink and a spiteful nod to those silly non-believers at the hospital.
Even the most heartfelt modern shaman is an unethical sham. Alternative medicine, that is medicine that is outside the embrace of science-based practice, is inherently unethical, and it’s time to call it what it is—a blight on our profession, and so far as we tolerate it, a blight on us all.
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