CVAHEC Student Project Reports

Anne Dougherty
Freeman Scholar Program 2006

I began thinking about this project when a dear friend who is a CAM (complementary and alternative medicine) practitioner told me that as a physician I would not be able to legally incorporate CAM into my future medical practice. Since I had entered medical school with the idea that I would develop an integrative care clinic that would bring the most appropriate medicine to my patients regardless of modality or tradition, I was devastated by this notion. I needed to do some of my own research. For this reason, my project began with the seemingly simple question, can conventional physicians legally use CAM therapies in their treatment plans?

In trying to wrap my head around the question, I began to consider where we get our notions of what is legal in medicine. It is from the ethical concepts of beneficence, nonmalificence, autonomy and justice that the legal ideas grow. It seemed natural then to examine the ethical issues that CAM use presents to the conventional medical practitioner.

During the initial stage of my research, I found that there exists a burgeoning field of medico-legal study concerning CAM and integrative medicine. My literature review turned up multiple articles specifically discussing legal or ethical issues with the use of CAM in conventional medical practice as well as studies of when it is appropriate to apply CAM modalities pertinent to certain medical specialties (eg. cardiology, oncology). The latter articles outlined a framework which can aid a physician in evaluating a CAM treatment for safety and efficacy based on current studies. I believe that use of such objective criteria will become standard as CAM is increasingly integrated into conventional care plans. It will serve to guide ethical clinical decision making as well as provide basis for protecting a physician using CAM from liability.

From that literature review, I was able to begin answering my question, "Can a conventional physician use CAM?" The simplest answer seems to be - yes, probably. In a legal sense, since CAM is outside of the standard of care for a conventional physician, it is conceivable that if a patient sustained injury from the treatment regardless of whether it was suggested appropriately or recklessly, a physician could be liable. However, theory and reality are often different, especially in law. There have not been any court cases that suggest that the act of using CAM constitutes liability in and of itself. Furthermore, the Federation of State Medical Boards (FSMB) has issued a position statement saying,

"[The] standards of [medical licensure] allow a wide degree of latitude in physicians' exercise of their professional judgment and do not preclude the use of any methods that are reasonably likely to benefit patients without undue risk...a licensed physician shall not be found guilty of unprofessional conduct for failure to practice medicine in an acceptable manner solely on the basis of utilizing CAM." 1

This statement was approved by member delegates to the FSMB, but must be adopted on a state by state basis. At this time, Vermont has not adopted this resolution. Still, the fact that CAM is considered integral enough to the medical system that FSMB would consider creating a resolution indicates some degree of acceptance for the rational and appropriate use of CAM by the medical community. In such a milieu, it is unlikely that one would be held liable simply for the use of CAM or referral to a CAM practitioner. Even so, the Vermont Medical Society should be encouraged to adopt some form of what is being called a "medical freedom" act.

The next natural question becomes, what CAM treatments are okay? Is there a way to decide if a treatment will benefit the patient without doing harm and keep the physician at least somewhat protected from liability? Unfortunately, many CAM modalities that are popularly used do not have much well-executed, evidence-based study to bolster their use. The reasons for this include lack of funding and the inability to attract talented researchers away from more profitable conventional medical research.2 Without adequate study, it is difficult to know whether the use of the CAM therapy is ethical, that is, that the patient is getting the best care and the physician is protecting the patient from undue harm. Perhaps in some instances, such uncertainty would be considered acceptable (if the condition is less severe), but in other situations knowing the risks and benefits is clearly essential.

As mentioned previously, criteria have been established (though not universally accepted) that seek to concretely outline what treatments are acceptable and which should be discouraged. Weiger et al have published their systems guided by evidence-based research which is widely used by integrative clinics and physicians. (Weiger, table 1 4)

As a side note, it should be recognized that conventional methods for studying medical interventions do not always work well when applied to CAM therapies. CAM generally operates on the priciple of holism - treat the whole patient in inextricable relationship to his or her environment. No one and no thing operates in isolation according to CAM philosophies. It is often a combination of factors that contribute to the efficacy of a CAM treatment and therefore a systems-based approach to research (rather than reductionist techniques that seek to isolate and test one variable at a time) would be the most productive method of study.3 It will be intersting to see how the movement toward a systems-based approach to medical research develops.

As I moved into my second phase of the project, I progressed beyond my personal question, "Can the physician use CAM?" I began to think more about how the use of CAM affects all physicians, not just those who are CAM-minded. Patients are increasingly using CAM therapies on their own as adjuncts to or as substitutioni for conventional treatment. The topic of legal and ethical issues involved with the use of CAM in conventional medical settings is universally pertinent regardless of a physician's specialty or attitude toward CAM.

Firstly, physicians must be aware that their patients are using CAM, and they must ask each patient what treatments s/he are using or have used. Thankfully, this line of questioning is increasingly part of the conventional medical culture. Beneficence and nonmalificence can only be achieved if the physician knows what possibilities there are for interactions between CAM and conventional medicine.

It becomes a little more complicated once a physician asks the patient about CAM therapies. In order to fulfill his or her ethical obligations to the patient, the physician must understand something about the CAM modality being used. Legally, if a patient gives a piece of clinically relevant information, the physician must evaluate it fully and determine if there are possible interactions or contraindications. This means that no matter how a physician feels personally about CAM, s/he must be somewhat educated about the possible modalities a patient might be using. It, therefore, makes good legal and ethical sense for physicians to at least familiarize themselves with CAM treatments pertinent to their area of practice and to know where to seek supplemental information. The physician no longer has the option of dismissing out of hand the use of CAM by patients. It must also be said that respect for patient autonomy requires that physicians at least consider the patient's rational and appropriate use of CAM therapies.

Conventional medicine has moved into a new age where multiple healing modalities may be used side by side. This is largely uncharted territory legally and ethically speaking but many of the same concepts and clinical decision making skills apply whether conventional medicine is used by itself or in a more integrated model. The physician must continue to evaluate his or her ethical obligations of beneficence, nonmalificence, autonomy and justice. S/he must continue to have open and frank discussions with patients through the informed consent process. It is possible that CAM therapies will begin to enter into that process as evidence-based support for the therapies grows.

Much more work needs to be done, however. Physicians need to be increasingly educated about how the courts are dealing with the use of CAM in conventional medical settings in order to understand how to protect themselves from liability. CAM education needs to become a more prominent part of CME so that physicians can engage in meaningful dialogue with their patients when CAM use is mentioned. Meta-analyses of past CAM research studies need to be done to guide physician and patient use of specific CAM modalities. States need to adopt "medical freedom" acts that will allow physicians the protected right to use rational and appropriate CAM therapies in their treatment plans without fear of reprisal.

This project is an initial step in my exploration of this topic. I have produced:

It is possible that I will take this project a step further during my required scholarly project. I am thinking about designing a survey to gauge local physicians' understanding of the legal and ethical issues involved with the use of CAM in conventional medical settings. The results of such a survey would be a useful starting point for education projects on the topic.

As I said before, the world of conventional medicine is changing; we must review where we are and continue the discussion of where we are going if we are to provide the best possible care for our patients.

1 Model guidelines for the use of complementary and alternative therapies in medical practice. Approved by the House of Delegates of the Federation of State Medical Boards of the United States, Inc., as policy April 2001. Available from: http://www.fsmb.org/pdf/2002_grpol_complementary_alternative_therapies.pdf

2 Ernst E, Cohen MH, Stone J. Ethical problems arising in evidenced based complementary and alternative medicine. J Med Ethics 2004; 30:156-159.

3 Hyman MA. The evolution of research, part 2: the clinician's dilemma - treating systems, not diseases. Alt Ther in Health Med 2006; 12(4):10-13.

4 Weiger W, Smith M, Boon H. Advising patients who seek complementary and alternative therapies of cancer. Ann Intern Med 2002; 137:889-908.

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The views expressed in the Student Project Reports are those of the authors and do not necessarily reflect the views of Champlain Valley Area Health Education Center.