As complementary and alternative medicine (CAM) practices continue to increase in popularity, many practitioners in the traditional medical community demand adherence to scientific proof as a measure of efficacy and clinical legitimacy. This is a problematic demand due to proven resistance, under-funding, and lack of suitable research methodologies, as well as a double standard, compared to the levels of evidence in conventional medicine (Clark-Grill, 2007). Guinn (2001) argued that traditional bioethics (i.e., autonomy, beneficence, non-maleficence, and justice) does not apply with equal validity to integrative medicine practices due to fundamental differences from conventional medicine, including values. A more adequate framework would expand on the basic principles to incorporate holistic, naturalistic, and spiritual characteristics of CAM. Guinn (2001) suggested the following 5 core values: integrated humanity, ecological integrity, naturalism, relationalism, and spiritualism.
The concept of integrated humanity states that people are a united whole of their bodies, minds, and spirits, influenced by their relationship with the world and others (Guinn, 2001). Ecological integrity describes the effect of the social, political, and natural environments that can either support or hinder an individual’s wellness, as seen by the effects of poverty and racism on health. Naturalism, on the other hand, points to an understanding of life and health as an inherently complex and dynamic process and that the body is instinctively oriented toward the norm of health. Guinn (2001) defines relationalism as the importance of respect and engagement between the patient and caregiver to facilitate a mutually beneficial interaction. Lastly, spirituality recognizes that humans as oriented toward the transcendent or something greater than the individual alone (Guinn, 2001).
Ethics of Complementary and Alternative Medicine Use in Children
Overview
Children with life-threatening and chronic illnesses are among the highest users of CAM. However, excluding religious choices, it could be considered abusive or neglectful if substituted for a known effective life-saving therapy (Vohra & Cohen, 2007). Additionally, issues of autonomy are complicated by conflicts between parent and child values, particularly in adolescence when they have a right not only to confidentiality and privacy but respect for their treatment decisions. Therefore, conventional pediatric healthcare providers must be knowledgeable about CAM, promote open, nonjudgmental discussion, refer to a specialist if they lack the expertise, and communicate with their patients’ CAM providers (Vohra & Cohen, 2007).
Example
In 2019, Florida Judge Thomas Palermo ruled against the parents of Noah McAdams and ordered that he be placed in the custody of his maternal grandparents after Joshua McAdams and Taylor Bland-Ball failed to bring the child to scheduled chemotherapy treatment (The Associated Press, 2019). The couple expressed the desire to treat their 4-year-old’s acute lymphoblastic leukemia, a cancer of the blood and bone marrow, with natural remedies including CBD oil, diet changes, vitamins, and alkaline water. The ruling included a requirement that Joshua McAdams and Taylor Bland-Ball undergo a psychological evaluation before consideration of being reunified with their child (The Associated Press, 2019).
Best Practice
Many observations regarding the ethical and legal issues of using CAM apply to both adult and pediatric patients, including fostering respectful relationships, communication, and informed consent (Gilmour et al., 2011). In pediatric cases, the child’s best interest must also be clarified about the parent’s decision-making authority. Gilmour et al. (2011) suggest including the child in discussions and decisions to the greatest extent possible, particularly when treating young people who can understand the consequences of proposed treatments and alternatives.
Challenges in the Ethical Complementary and Integrative Medicine (CIM) Research
Institutional Review Boards (IRBs), also known as research ethics committees, are responsible for approving studies involving human subjects by analyzing concerns inherent to the research (Cooper et al., 2016). Cultural differences and competing stakeholders often complicate IRBs' review of complementary and integrative medicine (CIM) studies. Impartial analysis requires overcoming conventional Western conceptions of health, disease, medicine, and evidence. The World Health Organization and the National Center for Complementary and Integrated Health (NCCIH) have been influential in promoting clinical trials of herbal products and regulation of integrating CIM into conventional practice (Cooper et al., 2016).
Example
Carl Hart, Ph.D., is a behavioral neuroscientist, professor, and chair of the psychology and psychiatry departments at Columbia University. His work challenges traditional theories on addiction and drug policy (Winerman, 2014). In his book High Price: A Neuroscientist's Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society, Hart goes beyond the science of addiction to discuss the political meaning of drug policy in the United States and the groups who are being disproportionately impacted. Some of the studies that have received the most attention involve cocaine and methamphelogicallycting in a logical way if you give them the choice between the drug and a reward. In an interview, Hart suggests that the treatment receives limited attention because his methods did not include brain imaging (Winerman, 2014).
Best Practice
CIM research requires a balance of ethical obligations to patients with the desire to advance understanding of treatment possibilities. Challenges including conflicting health cultures, competing stakeholders, and achieving meaningful ethical review should be addressed by the essential role of IRBs to safeguard human subjects (Cooper et al., 2016). Additionally, as proposed by Guinn (2001), an expansion on the basic principles to incorporate holistic, naturalistic, and spiritual characteristics would support equitable consideration and approval of CIM research.
Liability for Referrals to Complementary and Alternative Medical Providers
Although patients have the right to refuse conventional care, medical practitioners remain ethically and legally obligated to provide patients with adequate information to make informed healthcare decisions and consent to treatment. However, the current lack of regulation of CAM leaves patients vulnerable to fraudulent practices, deceptive information, improper diagnosis, inappropriate treatments, and consequently severe patient injuries (Raposo, 2019).
Example
The medical license of Dr. Kenneth N. Woliner, MD was revoked by the Florida Board of Medicine after he was found responsible for the death of a patient previously diagnosed with cancer. He argued that the patient’s symptoms were caused by allergies and recommended that she discontinue conventional chemotherapy treatments. Dr. Woliner’s defense was that he was not required to use the allopathic standard of care, but instead, standards that are specific to holistic medicine (Raposo, 2019).
Best Practice
The standard of care describes the typical actions that a reasonable practitioner of a given specialty would perform in a particular medical circumstance (Raposo, 2019). Whether practicing conventional or integrative medicine, practitioners will be judged against the standard of care in a court of law. Therefore, regulation and licensure not only protects the general public but also CAM providers and conventional practitioners who may refer their patients to them.
References
Clark-Grill M. (2007). Questionable gatekeeping: Scientific evidence for complementary and alternative medicines (CAM): response to Malcolm Parker. Journal of Bioethical Inquiry, 4(1), 21–28.
Cooper, J. A., Borasky, D., Rosenfeld, S., & Sugarman, J. (2016). Challenges in the ethical review of research involving complementary and integrative medicine. Therapeutic Innovation & Regulatory Science, 50(3), 337–341. https://doi.org/10.1177/2168479015620246
Gilmour, J., Harrison, C., & Vohra, S. (2011). Concluding comments: Maximizing good patient care and minimizing potential liability when considering complementary and alternative medicine. Pediatrics, 128, S206-12. https://doi.org/10.1542/peds.2010-2720K
Guinn, D. E. (2001). Ethics and integrative medicine: moving beyond the biomedical model. Alternative Therapies in Health & Medicine, 7(6), 68–72.
Nour, M. M., Evans, L., & Carhart-Harris, R. L. (2017). Psychedelics, personality, and political perspectives. Journal of psychoactive drugs, 49(3), 182–191. https://doi.org/10.1080/02791072.2017.1312643
Raposo, V. L. (2019). Complementary and alternative medicine, medical liability, and the proper standard of care. Complementary Therapies in Clinical Practice, 35, 183–188. https://doi.org/10.1016/j.ctcp.2019.02.009
The Associated Press. (2019). Judge: No custody for parents who didn’t want chemo for their son. In AP Regional State Report - Florida. Associated Press DBA Press Association.
Vohra, S., & Cohen, M.H. (2007). Ethics of complementary and alternative medicine use in children. Pediatric Clinics of North America, 54(6), 875–887.
Winerman, L. (2014). Paying a high price for the war on drugs. Monitor on Psychology, 45(3). http://www.apa.org/monitor/2014/03/war-drugs