Scand J Soc Med, Vol. 20, No.4
Ethical and professional aspects of the practice of alternative medicine Niels Lynoe From the Department of Social Medicine, University of Umed, Sweden
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Ethical and Professional Aspects of the Practice of Alternative Medicine. Lynoe, N. (Department of Social Medicine, University of Urnca, Sweden). Scand J Soc Med 1992,4 (217-225). The question of who should provide alternative medical treatment raises a number of different problems of both an ethical and a professional nature, Providing medical treatment, including alternative medical treatment, presupposes that the physician in question possesses diagnostic competence. It is in the best interests of society that medical care is safe. and therefore society must monitor the medical profession, c.g. in order to assure itself that the treatment provided is in agreement with the tenet of science and proven experience. The democratization of the patientdoctor relationship and the liberalization of the availability of medical and alternative medical treatments means that society also has an interest in ensuring that physicians offer alternative medical treatments or cooperate with practitioners of alternative medicine. A question is whether this is also of interest to the physicians? Another question touching on professional ethics is whether the doctor has the same responsibility to respect the desire of a patient to receive alternative medical treatment as he would have to respect the patient's right to forgo ordinary medical treatment. These questions are analysed here against the background of the perspective of the relevant interest groups and arc graded with regard to the disease and treatment concerned, how far the disease has advanced, the age of the patient, and whether or not the patient is competent to make his These considerations arc relevant in a disown deci~ions. cussion of who is qualified to provide or prescribe alternative medical treatment. This study points out that the individual physician should have the possibility to compromise and improvise from case to case. In order to shed further light on these matters it is also pointed out that there is a need for empirical investigations of how patients/laymen consider the ethical dilemmas in specific situations. Key words: Alternative medicine, academic medicine, medical ethics, professional ethics, patient's right.
INTRODUCTION The assessment of a medical technology usually implies an assessment of the effectivity. safety and cost
of the particular technology (1). In the assessment of alternative medical technologies, the assessment entails a number of more complex considerations (2). In evaluating safety, a discussion concerning who should provide the alternative medical technology is actualized. The question is whether, from the perspective of society and the patient, it is justifiable that a physician should provide alternative medical treatment or refuse to cooperate with practitioners of alternative medicine. If a physician participates directly or indirectly by cooperating with a practitioner of alternative medicine, this would most likely lessen the risk that more adequate treatment might be neglected (3). However, is it defensible from the point of view of the medical profession and the supervisory authorities, to allow physicians to cooperate with practitioners of alternative medical treatments (4)? Alternative medical technologies may be defined as those measures whose aim is to medically prevent, diagnose and treat disease, but which have not be approved of by health and medical authorities (5). Regardless of whether the patient has or has not requested that his doctor should provide or prescribe an alternative medicine, the treatment is still not in accordance with science and proven experience (6). The matter of who ought or ought not to provide and/or prescribe alternative medical treatment actualizes conflicts of both an ethical and a professional nature. Professional interests have an ethical dimension in that they are prerequisites for proper care (7), as well as dependent upon whether the doctor has a duty to respect a patient's request to receive alternative medical treatment in the same way as he has a responsibility to respect the right of the patient to refuse ordinary medical treatment. There are at least four main groups of participants in these various interest conflicts: the patients, the physicians, society and the practitioners of alternative medicine (8, 9). Hidden just behind these main kinds of actors we can glimpse other participants Scand J Soc Med 20
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who are involved, including relatives of the patients, health services politicians, other health services personnel, individual doctors and nurses who already provide alternative medical treatment, medical associations, supervisory authorities, the pharmaceutical industry, the naturopathic industry, ctc. The conflicts of interest among these participants vary according to different factors, e.g. the type of disease in question, what stage of the disease the patient is in, the age of the patient, and the alternative medical treatment involved. In what follows below, the ethical and professional aspects of this will be focussed upon, the point of departure being the perspective of each of the main participants in turn.
(5). The rationale is that since people consciously take risks all the time (e.g. whcn choosing to take up mountain-climbing as a hobby), they should also be allowed to decide whether or not they wish to take a risk in connection with medical treatment (5). For example, one does not force a fully competent Jehovah's Witness to undergo a life-saving blood transfusion against his will (14). The tradition of the physician consulting with and informing his patient has not always existed. In 'ancient China a physician informed and consulted only his sovereign and other highlyplaced potentates (15). The democratization of the doctor-patient relationship has meant that the patient has become more aware of his options, and in certain cases chooses an alternative medical treatment over an academic THE INTERESTS OF THE PATIENT medical treatment. Considering his medical training In the case of a disease or discomfort, the primary a physician can perceive a request for alternative medical treatment as irrational and in some ininterest of the patient is usually to become healthy as soon as possible, which requires that the patient stances directly harmful (11, 16). However, against the background of his own values and circumstances, should receive adequate help. By "adequate help", is meant that the patient, on the one hand, should the patient's request may still remain entirely rationot be "over-examined", thereby risking to be exnal. posed to over-treatment, and, on the other hand, The physician is in danger of violating a patient's not be "under-examined", thereby risking to receive right to self-determination by not giving him adetoo little treatment. Therefore, one prerequisite for quate information, thereby robbing the patient of providing adequate treatment is that the doctor the opportunity for comparing the possibly different premisses, and thus of his chance of coming to a should possess sufficient medical competence to enable him to arrive at a correct diagnosis. Being medproper decision (17). The opposite situation may ically competent entails that the doctor is aware of also occur if the patient believes that the physician the limits of his competence. It means that in certain feels professionally wronged if the patient opts for cases he must refer the patient to another specialist alternative medical treatment. For that reason, the with more adequate diagnostic competence (to). patient may choose not to inform his doctor that he is undergoing an alternative medical treatment. According to the Swedish Regulations for Physicians, a physician is also required to consult with the Both sets of circumstances may contribute to the patient and inform the latter of the different types of disruption of the patient-doctor relationship, a contreatment available (6). However, this does not in- sequence which is.in the best interest of neither the clude information on methods of alternative medical doctor nor the patient. . As far as the individual patient is concerned, the treatment. Strictly speaking, the physician may only provide information and prescribe alternative med- fact that a particular treatment is in accordance with ical treatment when the patient himself requests it. the tenet of science and proven experience is most The myth which characterizes the patient who per- likely irrelevant. The patient is primarily interested haps chooses to forgo academic medical treatment-as' in receiving help which he perceives as effective; unenlightened or misinformed has recently been whether or not that effect is a placebo effect is of challenged (11-13). Patients who seek out alterna- little concern to him. However, it does matter if the tive medical treatment are often well-informed physician is of the opinion that the treatment is or about what they choose and what they may be recould be compared with placebo treatment. If a physician consciously administers a treatment that he jecting. It is likely that politicians are aware of this fact when they propose that the patients themselves considers to be tantamount to placebo treatment, should bc able to choose medical (or alternative then the patient has been deceived. A physician who medical) treatment, even if it implies taking a risk "deceives" his patients can justify such an action by Scand J Soc Med 20
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Alternative Medicine saying that he had the best interests of the patient in mind (17, 18). However, such a paternalistic act means that the decision-competent patient's right to make his own decisions has been disregarded, and the physician is thereby wronging the patient. Using judgements based on ethical consistency, this kind of action also comes into conflict with the interests of society and the medical profession if there is a risk that news of this procedure will become common knowledge, thereby jeopardizing the faith people have in the health care system (18, 19). THE INTERESTS OF SOCIETY That public health should be sound, and that diseases should be treated effectively, safely and as economically as possible is in the best interest of society. In curing sick individuals there is always a slight risk of harming them. As an insurance against incorrect treatment or harming the patient in the process of attempting to cure him, society places special demands on those whose job is to treat the sick. Society has delegated responsibility for health and welfare services primarily to those individuals who have received special education. Thus, only those who have completed medical school as specified and approved of by society are entitled to call themselves licensed physicians (6). The Regulations for Physicians require that a physician should inform and consult with hispatient and provide treatment in accordance with science and proven experience. The physician's preferential right of interpretation in the question of what is in the best interests of the patient when choosing the form of care and treatment has recently been challenged by the report of the Committee on Alternative Medicine (5). The report contains proposals concerning a relaxation of the socalled :'Quackery Law", thereby increasing the opportunities for patients to choose the form of care and treatment themselves in the future. When society provides practitioners of alternative medicine with increased opportunities for treating the sick, problems simultaneously arise for the supervisory authorities and for those physicians whose patients urge them to provide alternative medical treatment. On the one hand, society checks that doctors provide only those treatments found to be in accordance with science and proven experience through its supervisory bodies, while, on the other hand, a liberalization of practitioner and treatment availability implies that the physician finds himself either di-
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rectly or indirectly involved in alternative medical treatments. To the extent that society has an interest in seeing that the health of an individual should not be put at risk, it is in the best interests of both society and the patient that doctors either themselves provide or agree to prescribe alternative medical treatments. In that way, society can assure itself that the patient's risk of direct or indirect harm is minimized. Itis thus in the best interest of society to see to it that physicians act in accordance with science and \ proven experience. At the same time it may also be in its best interest that physicians should be allowed to provide or prescribe treatments which are not in accordance with these criteria. This seemingly paradoxical relationship is the result of a liberal ambition to give equal weight to individual freedom of choice and medical interests, and a socio-political ambition to provide for the safety of the individual in the health and welfare system (5). THE INTERESTS OF THE PHYSICIAN Through its educational and scientific ideal, the medical profession has contributed to the development of a health and welfare organisation which has gained the respect and trust of society. The medical profession has developed a cultural authority against the backdrop of this ideal, which has at the same time meant that the medical profession has achieved near hegemony over the question of who is qualified to treat the sick (10). Medical treatment is based on medical science, which may imply that the treatment is specific and that it has been proved that its effectivity differs from that of the placebo effect. By "placebo effect" is meant the so-called unspecific effect which is the result of a patient's psychological expectation of getting well. Placebo treatment has long been disdained as quackery (18). Providing or prescribing alternative medical treatment in those cases where the effect is not documented or where a more adequate treatment is available is contrary to the concept of science and proven experience. A physician who undertakes to provide or prescribe alternative medicine thus acts against his professional interests. If a physician provides alternative medical treatment it can be construed from the viewpoint of the profession as an indirect challenge to its educational and scientific ideals. One of the original reasonsfor creating e.g. the AMA, was the desire to prevent the creation of "sects" (10). As a result of this fear of sects, doctors who show an interest in Scand J Soc Med 20
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alternative medical treatments arc apprehended as a threat to the credibility and authority of the medical profession (to, 20). With the ambition of not depriving the patient of his hope, the individual physician may occasionally feel obligated to fulfil the patient's request to be given alternative medical treatment. If it is a question of a terminally ill cancer patient, the choice may be between providing cytostatics or alternative medical treatment. If the physician chooses the former, it is in this instance comparable to the so-called "active placebo treatment", with powerful secondary effects (19). An alternative medical treatment free from side-effects or one with few side-effects might in this context appear to be more considerate towards the patient. A study of a random selection of Swedish physicians showed that 65% agreed completely or on the whole with the statement that "it is defensible to employ placebo treatments in risk-free or incurable conditions, if one can thereby minimize secondary effects and risks to the patient" (21). In his effort not to harm the patient, the physician may also choose to provide alternative medical treatment or to cooperate with a practitioner of alternative medicine. If the patient insists on receiving an alternative medical treatment, towards which the physician (and the profession) adopts a negative attitude, the physician can thereby drive the patient into the arms of the practitioner of alternative medicine. The same study of attitudes displayed by Swedish physicians towards alternative medical treatment showed that 50% of them agreed completely or for the most part with the opinion that if alternative medical treatment is to be provided at all, it ought always to be provided by an accredited physician in order to assure that more adequate treatment has not been ignored (21). T'he physician's justification for providing or prescribing alternative medical treatments may also be a desire to adjust to a market where there apparently exists a growing demand for them. Adjusting to the market implies, among other things, that the physician wishes to remain competitive with practitioners of alternative medicine. In the above-mentioned study, 26% of those surveyed agreed completely or for the most part with the statement that physicians ought to attempt to satisfy their patients' demands for alternative medical treatment, in order to be able to compete more effectively with practitioners of alternative medicine (21). This must be seen in the
light of the fact that, for the most part, health care in Sweden is provided as a public service. In the case of those alternative medical treatments which are already on their way to becoming accepted, the practice is not as problematic in its relationship to the interests of the professions (21, 22). If, on the other hand, it is a question of a more general market adjustment, this conflicts with collective professional interests, since these interests are associated with educational and scientific ideals (10, 21, 23). Interest in acquiring knowledge and professional interests are closely related in the medical profession (2); a doctor who casts doubt upon its educational and scientific ideals runs the risk of ending up questioning his own and the medical profession's interests (10). In the study of Swedish doctors' attitudes towards the providing and prescribing of alternative medical treatment, 44% agreed completely or for the most part with the statement that accredited physicians ought not to provide or prescribe such treatments as this may damage the reputation of academic medicine in the long run (21). The propensity for doctors to adjust to market demands should be contrasted with the question of whether there is a professional right not to grant a patient's request to receive alternative medical treatment. THE INTERESTS OF THE PRACfITIONER OF ALTERNATIVE MEDICINE There are approximately 2,500 people practising some two hundred different forms of alternative medical treatment in Sweden today (5). This group of practitioners is heterogeneous both with regard to educational background and type of treatment offered, and includes everything from academically qualified and accredited physicians to autodidactic naturopaths completely lacking formal education (24,25). The treatments offered by them encompass everything from treatments on the verge of acceptance by the academic medical establishment to treatments which are completely incomprehensible and at variance with academic medical thinking (2, 5). The professionalization of physicians has brought with it specialization where respect for a colleague's specialist knowledge and skill is recognized in the procedure of referrals (10). Similar traditions are possibly developing within certain fields of alternative medicine, but practitioners generally claim that their particular treatments are universally applicable
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o all diseases and symptoms. Therefore, there is no call for specialization and cooperation between diferent groups of practitioners. Furthermore, some practitioners offer acupuncture, homoeopathic reatment and manipulation treatment, and it is simply up to the patient to choose the form of treatment which suits him best (23,25). This situation tends to make alternative medicine controversial. Some practitioners are eager to cooperate with accredited physicians, thereby lending credibility to heir own treatments, while others perceive such elationships as disadvantageous. Striving for "legitimacy" may be interpreted as a compromise by the patient who is searching for a genuine practitioner of alternative medicine. Cooperation is perhaps most nticing for those practitioners whose treatments are n the process of becoming accepted in order for hem to better hold onto their "share of the market". Such reasoning has been evident in discussions conerning manipulation treatment and acupuncture and the groups who will be allowed to offer such reatment (22, 26). For a physician with an academic medical educaion, it would be unethical and irreconcilable with he tenets of science and proven experience to provide a treatment, the effect of which is indistinguishable from the placebo effect. Ethically, placebo reatment presupposes that the patient is deceived, which is controversial both in terms of respect for he autonomy of the patient and the possible negaive consequences for public faith in the medical profession. On the other hand, a practitioner of alternative medicine might have a different view of how one gains knowledge about reality and about how that knowledge is structured. If it is a question of an alternative medical technology, bound to a pecificmedical cosmology, there is seldom a tradiion within which to test the technology empirically under controlled conditions. It is often part of the nature of the cosmology that knowledge of reality is divine in nature, and therefore eternal and immutable. Demanding empirical investigations can thus be perceived as superfluous or simply blasphemous, as f one demanded empirical proof of the existence of God. By referring to another scientific ideal, practitioners of alternative medicine can behave in an ethcally defensible manner, since the difference beween the actual effect and the placebo effect is not afforded any significance or is not documented. As ong as the practitioner himself assumes and believes
that a treatment is effective, the practitioner has no reason to feel that the patient has been deceived, and thus he has not violated the patient's right to self-determination. There has been much discussion as to whether using academic medical methods of measurement for assessing alternative medical technologies docs signify an ethnocentric attitude (27). A relativization of demands for the documentation of the effects of an alternative medical technology creates a disparity, not only with regard to the possibility of introducing new treatments, but also a disparity in how the physician and the practitioner of alternative medicine can relate in an ethically defensible manner towards their respective patients (18). TWO EXAMPLES From the perspective of the physicians, it becomes apparent that there arc numerous different conflicts of interest of an ethical, psychological, legal, epistomological, methodological and professional nature. These conflicts of interest are often interwoven and deeply integrated; exactly how interwoven is further underlined when they are related to varying factors, e.g. the age of the patient, whether the patient is capable of making his own decisions, the faith which the patient shows in, the health care system, the nature of the disease in question, the nature of the treatment, who is conducting the examination of the patient, and who is choosing and providing the treatment. In order to illustrate the complexity involved, we shall look more closely at the following two case histories. The elderly cancer patient 1) The patient is 82 years old and suffers from a malignant blood-cancer disease. The adequate treatment is cytostatics combined with radiation treatment. The treatment stretches over a relatively long period and demands numerous hospital visits. The prognosis after treatment is good. The treatment involves secondary effects in the form of nausea, diarrhoea, increased risk of infection, and hair loss. The patient, who is lucid and decision-competent, has refused the treatment offered and has chosen instead to try magnet therapy, which she had heard could help her. Magnet therapy of the proposed sort has no scientifically documented efficacy, but seems not to cause the patient any unpleasant side-effects. Obtaining the magnets necessary is a relatively exScand J Soc Med 20
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pensive proposition for the 82-year-old, and her family is opposed to her spending her money on this The young cancer patient 2) The patient is the 41-year-old head of a housetreatment. There is no risk of indirect harm in this case, for hold, suffering from diffuse back pains. The patient the patient has primarily sought academic medical sought help in the first instance from a practitioner care and the diagnosis is clear. The patient has cho- of alternative medicine who opined that the pains sen to refuse ordinary medical treatment after con- could be treated with acupuncture. He received a sidering the effects of the treatment, including the series of treatments and the symptoms abated. After influence of the sideeffects on the quality of her life some time the patient sought academic medical care, during her last few years, and the risk of death and was diagnosed as having a blood cancer disease localized in the bone marrow, including the verinvolved in the suggested treatment. Instead, the patient has chosen a treatment free of side-effects tebral column. The disease was diagnosed to be in an advanced stage, though treatable with available which she herself believes in, but one which accordmedical treatment. The prognosis for this treatment ing to physicians will have no effect beyond the is relatively positive, with a five-year survival of placebo effect. The patient in this case is a person whose decision 5()-{jO% (untreated the five-year survival is zero). the physician ought to respect, and it would be eth- Since adequate treatment had already been delayed, it was important that it should be initiated as soon as ically controversial for the doctor to attempt to perpossible. The treatment, as well as the pattern of suade her to choose ordinary medical treatment. However there is an ethically relevant distinction side-effects, were the same as in case 1). However, the patient had no faith in academic medical treatbetween the doctors' responsibility to respect the patient's right to refuse medical treatment and to ment, which he considered at odds with the laws of accept any and all proposals by the patient (28). You nature. Instead, the patient wished to be treated might ask: Docs the patient also have an obligation with a naturopathic preparation of anthroposophic to respect the doctor's refusal to provide a treatment origin, Iscador. which is not in accordance with the tenets of science The question now is how the physician should and proven experience? Even if rational grounds behave towards his patient. There are rational arguments here for him to attempt to convince (with exist for the physician to discourage the patient from magnet therapy, there are also reasons for the physi- rational arguments) the patient that he should cian not to distance himself actively from such treat- choose the academic medical treatment. However, the patient rejects the arguments, basing his rejecment. If the physician calls magnet therapy into tion on the theories of anthroposophy, which acquestion, it could cause its placebo effect to diminish. The placebo effect is a not insignificant part of . cording to the patient, are more in accordance with the effect of a treatment, even in instances of malig- the laws of nature. In such instances, it can be temptnant disease (29). Both physician and family may ing for the physician to attempt to persuade the feel that the patient ought to forgo it, even feel that patient to follow his advice. Aside from using arguthe practitioners of alternative medicine are exploit- ment, the physician might also refuse to participate in giving injections of Iscador, pointing out that its ing -the hopes of the patient. But considering the placebo effect and the degree of decision-making effect docs not differ from the placebo effect, competence of the patient there are reasons for the thereby placing it in conflict with the tenets of sciphysician both to respect the choice of the patient to ence and proven experience. Furthermore, the phyrefuse ordinary medical treatment and to accept her sician can also attempt to frighten the patient by opting for alternative medical treatment. The older a threatening him: if he chooses Iscador, he gives up his chance of receiving ordinary medical treatment. patient is and the more advanced the disease is, the The physician can also attempt to use more ethical more apparent the choice becomes for the physician. In order not to harm a terminally ill patient it might arguments - he can accuse the patient of acting be ethically defensible for the doctor to propose a irresponsibly towards himself and his family. His harmless placebo treatment. On the other hand, if children will be left fatherless and the family placed the patient in question is young, the physician's in financial difficulty if he should die. The patient counters, however, by stating that his spouse supchoice is no longer quite as simple. ports his beliefs and choice of treatment. Thus, if the Scand J Soc Med 20
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Alternative Medicine patient remains firm in his decision to be treated with Iscador, the question is whether or not the physician should desist in his criticism of the treatment in order not to counteract the placebo effect. Furthermore, should the physician in this situation offer to provide the alternative medical treatment? Just as the physician has a moral (and nowadays legal) obligation to respect the right of a decisioncompetent patient to forgo adequate medical treatment, the question is raised as to whether the patient docs not have an obligation to respect the physician who, for professional reasons, docs not wish to participate in alternative medical treatment. The patient's right of self-determination docs not automatically imply that the physician should also respect and comply with a patient's desire to take other measures, especially if these are contrary to the physician's professional "autonomy". Society respects a doctor's decision to refuse to comply with a patient's request for, e.g. euthanasia or the prescription of narcotic drugs for recreational purposes. Thus, the physician is not expected to agree to any and alI of his patients' requests, even when they are a part of a competent individual's social, psychological or medical life project. THE ROLE OF EMPIRICAL PARAMETERS These two examples illustrate the different dilemmas which may confront the physician and the patient when they hold diverging views of the choice of treatments. The dignity of the conflict varies with the character of the situation and the variables which define it. The variation can be depicted schematically as follows:
< ted20
15 Social Medicine
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Ethical and professional aspects of the practice of alternative medicine Niels Lynoe From the Department of Social Medicine, University of Umed, Sweden
.
Ethical and Professional Aspects of the Practice of Alternative Medicine. Lynoe, N. (Department of Social Medicine, University of Urnca, Sweden). Scand J Soc Med 1992,4 (217-225). The question of who should provide alternative medical treatment raises a number of different problems of both an ethical and a professional nature, Providing medical treatment, including alternative medical treatment, presupposes that the physician in question possesses diagnostic competence. It is in the best interests of society that medical care is safe. and therefore society must monitor the medical profession, c.g. in order to assure itself that the treatment provided is in agreement with the tenet of science and proven experience. The democratization of the patientdoctor relationship and the liberalization of the availability of medical and alternative medical treatments means that society also has an interest in ensuring that physicians offer alternative medical treatments or cooperate with practitioners of alternative medicine. A question is whether this is also of interest to the physicians? Another question touching on professional ethics is whether the doctor has the same responsibility to respect the desire of a patient to receive alternative medical treatment as he would have to respect the patient's right to forgo ordinary medical treatment. These questions are analysed here against the background of the perspective of the relevant interest groups and arc graded with regard to the disease and treatment concerned, how far the disease has advanced, the age of the patient, and whether or not the patient is competent to make his These considerations arc relevant in a disown deci~ions. cussion of who is qualified to provide or prescribe alternative medical treatment. This study points out that the individual physician should have the possibility to compromise and improvise from case to case. In order to shed further light on these matters it is also pointed out that there is a need for empirical investigations of how patients/laymen consider the ethical dilemmas in specific situations. Key words: Alternative medicine, academic medicine, medical ethics, professional ethics, patient's right.
INTRODUCTION The assessment of a medical technology usually implies an assessment of the effectivity. safety and cost
of the particular technology (1). In the assessment of alternative medical technologies, the assessment entails a number of more complex considerations (2). In evaluating safety, a discussion concerning who should provide the alternative medical technology is actualized. The question is whether, from the perspective of society and the patient, it is justifiable that a physician should provide alternative medical treatment or refuse to cooperate with practitioners of alternative medicine. If a physician participates directly or indirectly by cooperating with a practitioner of alternative medicine, this would most likely lessen the risk that more adequate treatment might be neglected (3). However, is it defensible from the point of view of the medical profession and the supervisory authorities, to allow physicians to cooperate with practitioners of alternative medical treatments (4)? Alternative medical technologies may be defined as those measures whose aim is to medically prevent, diagnose and treat disease, but which have not be approved of by health and medical authorities (5). Regardless of whether the patient has or has not requested that his doctor should provide or prescribe an alternative medicine, the treatment is still not in accordance with science and proven experience (6). The matter of who ought or ought not to provide and/or prescribe alternative medical treatment actualizes conflicts of both an ethical and a professional nature. Professional interests have an ethical dimension in that they are prerequisites for proper care (7), as well as dependent upon whether the doctor has a duty to respect a patient's request to receive alternative medical treatment in the same way as he has a responsibility to respect the right of the patient to refuse ordinary medical treatment. There are at least four main groups of participants in these various interest conflicts: the patients, the physicians, society and the practitioners of alternative medicine (8, 9). Hidden just behind these main kinds of actors we can glimpse other participants Scand J Soc Med 20
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who are involved, including relatives of the patients, health services politicians, other health services personnel, individual doctors and nurses who already provide alternative medical treatment, medical associations, supervisory authorities, the pharmaceutical industry, the naturopathic industry, ctc. The conflicts of interest among these participants vary according to different factors, e.g. the type of disease in question, what stage of the disease the patient is in, the age of the patient, and the alternative medical treatment involved. In what follows below, the ethical and professional aspects of this will be focussed upon, the point of departure being the perspective of each of the main participants in turn.
(5). The rationale is that since people consciously take risks all the time (e.g. whcn choosing to take up mountain-climbing as a hobby), they should also be allowed to decide whether or not they wish to take a risk in connection with medical treatment (5). For example, one does not force a fully competent Jehovah's Witness to undergo a life-saving blood transfusion against his will (14). The tradition of the physician consulting with and informing his patient has not always existed. In 'ancient China a physician informed and consulted only his sovereign and other highlyplaced potentates (15). The democratization of the doctor-patient relationship has meant that the patient has become more aware of his options, and in certain cases chooses an alternative medical treatment over an academic THE INTERESTS OF THE PATIENT medical treatment. Considering his medical training In the case of a disease or discomfort, the primary a physician can perceive a request for alternative medical treatment as irrational and in some ininterest of the patient is usually to become healthy as soon as possible, which requires that the patient stances directly harmful (11, 16). However, against the background of his own values and circumstances, should receive adequate help. By "adequate help", is meant that the patient, on the one hand, should the patient's request may still remain entirely rationot be "over-examined", thereby risking to be exnal. posed to over-treatment, and, on the other hand, The physician is in danger of violating a patient's not be "under-examined", thereby risking to receive right to self-determination by not giving him adetoo little treatment. Therefore, one prerequisite for quate information, thereby robbing the patient of providing adequate treatment is that the doctor the opportunity for comparing the possibly different premisses, and thus of his chance of coming to a should possess sufficient medical competence to enable him to arrive at a correct diagnosis. Being medproper decision (17). The opposite situation may ically competent entails that the doctor is aware of also occur if the patient believes that the physician the limits of his competence. It means that in certain feels professionally wronged if the patient opts for cases he must refer the patient to another specialist alternative medical treatment. For that reason, the with more adequate diagnostic competence (to). patient may choose not to inform his doctor that he is undergoing an alternative medical treatment. According to the Swedish Regulations for Physicians, a physician is also required to consult with the Both sets of circumstances may contribute to the patient and inform the latter of the different types of disruption of the patient-doctor relationship, a contreatment available (6). However, this does not in- sequence which is.in the best interest of neither the clude information on methods of alternative medical doctor nor the patient. . As far as the individual patient is concerned, the treatment. Strictly speaking, the physician may only provide information and prescribe alternative med- fact that a particular treatment is in accordance with ical treatment when the patient himself requests it. the tenet of science and proven experience is most The myth which characterizes the patient who per- likely irrelevant. The patient is primarily interested haps chooses to forgo academic medical treatment-as' in receiving help which he perceives as effective; unenlightened or misinformed has recently been whether or not that effect is a placebo effect is of challenged (11-13). Patients who seek out alterna- little concern to him. However, it does matter if the tive medical treatment are often well-informed physician is of the opinion that the treatment is or about what they choose and what they may be recould be compared with placebo treatment. If a physician consciously administers a treatment that he jecting. It is likely that politicians are aware of this fact when they propose that the patients themselves considers to be tantamount to placebo treatment, should bc able to choose medical (or alternative then the patient has been deceived. A physician who medical) treatment, even if it implies taking a risk "deceives" his patients can justify such an action by Scand J Soc Med 20
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Alternative Medicine saying that he had the best interests of the patient in mind (17, 18). However, such a paternalistic act means that the decision-competent patient's right to make his own decisions has been disregarded, and the physician is thereby wronging the patient. Using judgements based on ethical consistency, this kind of action also comes into conflict with the interests of society and the medical profession if there is a risk that news of this procedure will become common knowledge, thereby jeopardizing the faith people have in the health care system (18, 19). THE INTERESTS OF SOCIETY That public health should be sound, and that diseases should be treated effectively, safely and as economically as possible is in the best interest of society. In curing sick individuals there is always a slight risk of harming them. As an insurance against incorrect treatment or harming the patient in the process of attempting to cure him, society places special demands on those whose job is to treat the sick. Society has delegated responsibility for health and welfare services primarily to those individuals who have received special education. Thus, only those who have completed medical school as specified and approved of by society are entitled to call themselves licensed physicians (6). The Regulations for Physicians require that a physician should inform and consult with hispatient and provide treatment in accordance with science and proven experience. The physician's preferential right of interpretation in the question of what is in the best interests of the patient when choosing the form of care and treatment has recently been challenged by the report of the Committee on Alternative Medicine (5). The report contains proposals concerning a relaxation of the socalled :'Quackery Law", thereby increasing the opportunities for patients to choose the form of care and treatment themselves in the future. When society provides practitioners of alternative medicine with increased opportunities for treating the sick, problems simultaneously arise for the supervisory authorities and for those physicians whose patients urge them to provide alternative medical treatment. On the one hand, society checks that doctors provide only those treatments found to be in accordance with science and proven experience through its supervisory bodies, while, on the other hand, a liberalization of practitioner and treatment availability implies that the physician finds himself either di-
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rectly or indirectly involved in alternative medical treatments. To the extent that society has an interest in seeing that the health of an individual should not be put at risk, it is in the best interests of both society and the patient that doctors either themselves provide or agree to prescribe alternative medical treatments. In that way, society can assure itself that the patient's risk of direct or indirect harm is minimized. Itis thus in the best interest of society to see to it that physicians act in accordance with science and \ proven experience. At the same time it may also be in its best interest that physicians should be allowed to provide or prescribe treatments which are not in accordance with these criteria. This seemingly paradoxical relationship is the result of a liberal ambition to give equal weight to individual freedom of choice and medical interests, and a socio-political ambition to provide for the safety of the individual in the health and welfare system (5). THE INTERESTS OF THE PHYSICIAN Through its educational and scientific ideal, the medical profession has contributed to the development of a health and welfare organisation which has gained the respect and trust of society. The medical profession has developed a cultural authority against the backdrop of this ideal, which has at the same time meant that the medical profession has achieved near hegemony over the question of who is qualified to treat the sick (10). Medical treatment is based on medical science, which may imply that the treatment is specific and that it has been proved that its effectivity differs from that of the placebo effect. By "placebo effect" is meant the so-called unspecific effect which is the result of a patient's psychological expectation of getting well. Placebo treatment has long been disdained as quackery (18). Providing or prescribing alternative medical treatment in those cases where the effect is not documented or where a more adequate treatment is available is contrary to the concept of science and proven experience. A physician who undertakes to provide or prescribe alternative medicine thus acts against his professional interests. If a physician provides alternative medical treatment it can be construed from the viewpoint of the profession as an indirect challenge to its educational and scientific ideals. One of the original reasonsfor creating e.g. the AMA, was the desire to prevent the creation of "sects" (10). As a result of this fear of sects, doctors who show an interest in Scand J Soc Med 20
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alternative medical treatments arc apprehended as a threat to the credibility and authority of the medical profession (to, 20). With the ambition of not depriving the patient of his hope, the individual physician may occasionally feel obligated to fulfil the patient's request to be given alternative medical treatment. If it is a question of a terminally ill cancer patient, the choice may be between providing cytostatics or alternative medical treatment. If the physician chooses the former, it is in this instance comparable to the so-called "active placebo treatment", with powerful secondary effects (19). An alternative medical treatment free from side-effects or one with few side-effects might in this context appear to be more considerate towards the patient. A study of a random selection of Swedish physicians showed that 65% agreed completely or on the whole with the statement that "it is defensible to employ placebo treatments in risk-free or incurable conditions, if one can thereby minimize secondary effects and risks to the patient" (21). In his effort not to harm the patient, the physician may also choose to provide alternative medical treatment or to cooperate with a practitioner of alternative medicine. If the patient insists on receiving an alternative medical treatment, towards which the physician (and the profession) adopts a negative attitude, the physician can thereby drive the patient into the arms of the practitioner of alternative medicine. The same study of attitudes displayed by Swedish physicians towards alternative medical treatment showed that 50% of them agreed completely or for the most part with the opinion that if alternative medical treatment is to be provided at all, it ought always to be provided by an accredited physician in order to assure that more adequate treatment has not been ignored (21). T'he physician's justification for providing or prescribing alternative medical treatments may also be a desire to adjust to a market where there apparently exists a growing demand for them. Adjusting to the market implies, among other things, that the physician wishes to remain competitive with practitioners of alternative medicine. In the above-mentioned study, 26% of those surveyed agreed completely or for the most part with the statement that physicians ought to attempt to satisfy their patients' demands for alternative medical treatment, in order to be able to compete more effectively with practitioners of alternative medicine (21). This must be seen in the
light of the fact that, for the most part, health care in Sweden is provided as a public service. In the case of those alternative medical treatments which are already on their way to becoming accepted, the practice is not as problematic in its relationship to the interests of the professions (21, 22). If, on the other hand, it is a question of a more general market adjustment, this conflicts with collective professional interests, since these interests are associated with educational and scientific ideals (10, 21, 23). Interest in acquiring knowledge and professional interests are closely related in the medical profession (2); a doctor who casts doubt upon its educational and scientific ideals runs the risk of ending up questioning his own and the medical profession's interests (10). In the study of Swedish doctors' attitudes towards the providing and prescribing of alternative medical treatment, 44% agreed completely or for the most part with the statement that accredited physicians ought not to provide or prescribe such treatments as this may damage the reputation of academic medicine in the long run (21). The propensity for doctors to adjust to market demands should be contrasted with the question of whether there is a professional right not to grant a patient's request to receive alternative medical treatment. THE INTERESTS OF THE PRACfITIONER OF ALTERNATIVE MEDICINE There are approximately 2,500 people practising some two hundred different forms of alternative medical treatment in Sweden today (5). This group of practitioners is heterogeneous both with regard to educational background and type of treatment offered, and includes everything from academically qualified and accredited physicians to autodidactic naturopaths completely lacking formal education (24,25). The treatments offered by them encompass everything from treatments on the verge of acceptance by the academic medical establishment to treatments which are completely incomprehensible and at variance with academic medical thinking (2, 5). The professionalization of physicians has brought with it specialization where respect for a colleague's specialist knowledge and skill is recognized in the procedure of referrals (10). Similar traditions are possibly developing within certain fields of alternative medicine, but practitioners generally claim that their particular treatments are universally applicable
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o all diseases and symptoms. Therefore, there is no call for specialization and cooperation between diferent groups of practitioners. Furthermore, some practitioners offer acupuncture, homoeopathic reatment and manipulation treatment, and it is simply up to the patient to choose the form of treatment which suits him best (23,25). This situation tends to make alternative medicine controversial. Some practitioners are eager to cooperate with accredited physicians, thereby lending credibility to heir own treatments, while others perceive such elationships as disadvantageous. Striving for "legitimacy" may be interpreted as a compromise by the patient who is searching for a genuine practitioner of alternative medicine. Cooperation is perhaps most nticing for those practitioners whose treatments are n the process of becoming accepted in order for hem to better hold onto their "share of the market". Such reasoning has been evident in discussions conerning manipulation treatment and acupuncture and the groups who will be allowed to offer such reatment (22, 26). For a physician with an academic medical educaion, it would be unethical and irreconcilable with he tenets of science and proven experience to provide a treatment, the effect of which is indistinguishable from the placebo effect. Ethically, placebo reatment presupposes that the patient is deceived, which is controversial both in terms of respect for he autonomy of the patient and the possible negaive consequences for public faith in the medical profession. On the other hand, a practitioner of alternative medicine might have a different view of how one gains knowledge about reality and about how that knowledge is structured. If it is a question of an alternative medical technology, bound to a pecificmedical cosmology, there is seldom a tradiion within which to test the technology empirically under controlled conditions. It is often part of the nature of the cosmology that knowledge of reality is divine in nature, and therefore eternal and immutable. Demanding empirical investigations can thus be perceived as superfluous or simply blasphemous, as f one demanded empirical proof of the existence of God. By referring to another scientific ideal, practitioners of alternative medicine can behave in an ethcally defensible manner, since the difference beween the actual effect and the placebo effect is not afforded any significance or is not documented. As ong as the practitioner himself assumes and believes
that a treatment is effective, the practitioner has no reason to feel that the patient has been deceived, and thus he has not violated the patient's right to self-determination. There has been much discussion as to whether using academic medical methods of measurement for assessing alternative medical technologies docs signify an ethnocentric attitude (27). A relativization of demands for the documentation of the effects of an alternative medical technology creates a disparity, not only with regard to the possibility of introducing new treatments, but also a disparity in how the physician and the practitioner of alternative medicine can relate in an ethically defensible manner towards their respective patients (18). TWO EXAMPLES From the perspective of the physicians, it becomes apparent that there arc numerous different conflicts of interest of an ethical, psychological, legal, epistomological, methodological and professional nature. These conflicts of interest are often interwoven and deeply integrated; exactly how interwoven is further underlined when they are related to varying factors, e.g. the age of the patient, whether the patient is capable of making his own decisions, the faith which the patient shows in, the health care system, the nature of the disease in question, the nature of the treatment, who is conducting the examination of the patient, and who is choosing and providing the treatment. In order to illustrate the complexity involved, we shall look more closely at the following two case histories. The elderly cancer patient 1) The patient is 82 years old and suffers from a malignant blood-cancer disease. The adequate treatment is cytostatics combined with radiation treatment. The treatment stretches over a relatively long period and demands numerous hospital visits. The prognosis after treatment is good. The treatment involves secondary effects in the form of nausea, diarrhoea, increased risk of infection, and hair loss. The patient, who is lucid and decision-competent, has refused the treatment offered and has chosen instead to try magnet therapy, which she had heard could help her. Magnet therapy of the proposed sort has no scientifically documented efficacy, but seems not to cause the patient any unpleasant side-effects. Obtaining the magnets necessary is a relatively exScand J Soc Med 20
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pensive proposition for the 82-year-old, and her family is opposed to her spending her money on this The young cancer patient 2) The patient is the 41-year-old head of a housetreatment. There is no risk of indirect harm in this case, for hold, suffering from diffuse back pains. The patient the patient has primarily sought academic medical sought help in the first instance from a practitioner care and the diagnosis is clear. The patient has cho- of alternative medicine who opined that the pains sen to refuse ordinary medical treatment after con- could be treated with acupuncture. He received a sidering the effects of the treatment, including the series of treatments and the symptoms abated. After influence of the sideeffects on the quality of her life some time the patient sought academic medical care, during her last few years, and the risk of death and was diagnosed as having a blood cancer disease localized in the bone marrow, including the verinvolved in the suggested treatment. Instead, the patient has chosen a treatment free of side-effects tebral column. The disease was diagnosed to be in an advanced stage, though treatable with available which she herself believes in, but one which accordmedical treatment. The prognosis for this treatment ing to physicians will have no effect beyond the is relatively positive, with a five-year survival of placebo effect. The patient in this case is a person whose decision 5()-{jO% (untreated the five-year survival is zero). the physician ought to respect, and it would be eth- Since adequate treatment had already been delayed, it was important that it should be initiated as soon as ically controversial for the doctor to attempt to perpossible. The treatment, as well as the pattern of suade her to choose ordinary medical treatment. However there is an ethically relevant distinction side-effects, were the same as in case 1). However, the patient had no faith in academic medical treatbetween the doctors' responsibility to respect the patient's right to refuse medical treatment and to ment, which he considered at odds with the laws of accept any and all proposals by the patient (28). You nature. Instead, the patient wished to be treated might ask: Docs the patient also have an obligation with a naturopathic preparation of anthroposophic to respect the doctor's refusal to provide a treatment origin, Iscador. which is not in accordance with the tenets of science The question now is how the physician should and proven experience? Even if rational grounds behave towards his patient. There are rational arguments here for him to attempt to convince (with exist for the physician to discourage the patient from magnet therapy, there are also reasons for the physi- rational arguments) the patient that he should cian not to distance himself actively from such treat- choose the academic medical treatment. However, the patient rejects the arguments, basing his rejecment. If the physician calls magnet therapy into tion on the theories of anthroposophy, which acquestion, it could cause its placebo effect to diminish. The placebo effect is a not insignificant part of . cording to the patient, are more in accordance with the effect of a treatment, even in instances of malig- the laws of nature. In such instances, it can be temptnant disease (29). Both physician and family may ing for the physician to attempt to persuade the feel that the patient ought to forgo it, even feel that patient to follow his advice. Aside from using arguthe practitioners of alternative medicine are exploit- ment, the physician might also refuse to participate in giving injections of Iscador, pointing out that its ing -the hopes of the patient. But considering the placebo effect and the degree of decision-making effect docs not differ from the placebo effect, competence of the patient there are reasons for the thereby placing it in conflict with the tenets of sciphysician both to respect the choice of the patient to ence and proven experience. Furthermore, the phyrefuse ordinary medical treatment and to accept her sician can also attempt to frighten the patient by opting for alternative medical treatment. The older a threatening him: if he chooses Iscador, he gives up his chance of receiving ordinary medical treatment. patient is and the more advanced the disease is, the The physician can also attempt to use more ethical more apparent the choice becomes for the physician. In order not to harm a terminally ill patient it might arguments - he can accuse the patient of acting be ethically defensible for the doctor to propose a irresponsibly towards himself and his family. His harmless placebo treatment. On the other hand, if children will be left fatherless and the family placed the patient in question is young, the physician's in financial difficulty if he should die. The patient counters, however, by stating that his spouse supchoice is no longer quite as simple. ports his beliefs and choice of treatment. Thus, if the Scand J Soc Med 20
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Alternative Medicine patient remains firm in his decision to be treated with Iscador, the question is whether or not the physician should desist in his criticism of the treatment in order not to counteract the placebo effect. Furthermore, should the physician in this situation offer to provide the alternative medical treatment? Just as the physician has a moral (and nowadays legal) obligation to respect the right of a decisioncompetent patient to forgo adequate medical treatment, the question is raised as to whether the patient docs not have an obligation to respect the physician who, for professional reasons, docs not wish to participate in alternative medical treatment. The patient's right of self-determination docs not automatically imply that the physician should also respect and comply with a patient's desire to take other measures, especially if these are contrary to the physician's professional "autonomy". Society respects a doctor's decision to refuse to comply with a patient's request for, e.g. euthanasia or the prescription of narcotic drugs for recreational purposes. Thus, the physician is not expected to agree to any and alI of his patients' requests, even when they are a part of a competent individual's social, psychological or medical life project. THE ROLE OF EMPIRICAL PARAMETERS These two examples illustrate the different dilemmas which may confront the physician and the patient when they hold diverging views of the choice of treatments. The dignity of the conflict varies with the character of the situation and the variables which define it. The variation can be depicted schematically as follows:
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15 Social Medicine
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