Duke Physicians: Clinicians Have Ethical Obligation To Consider Alternative Medicine

November 10, 1998

DURHAM, N.C. -- Even physicians who subscribe to only conventional medical therapies have an ethical obligation to help their patients who are considering non-traditional treatments, Duke University Medical Center physicians say in Wednesday's (Nov. 11) edition of the Journal of the American Medical Association.

In the article, described as a "policy perspective," Drs. Jeremy Sugarman and Larry Burk tackle the question of the traditional clinician's role in a patient's use of alternative medical treatment. The issue focuses on alternative medicine.

"We have taken a hard look at the current role of the clinician -- the doctor practicing conventional medicine -- in relation to alternative medicine. That is, what do we know from the perspective of good medical care ... and what role, if any, do clinicians have regarding alternative therapy?" said lead author Sugarman, a physician and medical ethicist.

The answer, he said, is that in individual cases, physicians should apply medicine's longstanding ethical principles: respect for persons, nonmaleficence, beneficence and justice.

But they emphasize that clinicians' obligations regarding alternative medicine center on whether those therapies have been shown through rigorous examination to be safe and effective. If the therapies are not tested and proven, doctors don't have the same obligation, Sugarman said.

With the rising interest in alternative methods of care, Sugarman and Burk, a radiologist and director of Duke's office of integrative medicine education, said it is important to examine the principles of care common to both conventional and alternative treatment. Clinicians following conventional medicine rely on scientific method in making decisions about appropriate therapy, while practitioners of alternative medicine treatments, such as acupuncture and therapeutic touch, generally do not. But the health-related goals of the two approaches may not differ radically, they said. For instance, both promote prevention of illness and relief of pain or suffering.

Alternative therapies aren't necessarily foreign to clinicians adhering to the conventional practice of medicine. Adjustments to diet and recommendations of exercise to reduce stress can be seen as alternatives to medicine, but are accepted parts of patient treatment by both conventional and alternative practitioners.

Since more patients are embracing alternative therapies, there's a need for clinicians, within the scope of the ethics of their practice, to find a way to bridge the gap between their reliance on conventional practice and their patients' needs, Sugarman said.

In approaching the issue, the authors assumed that practitioners of alternative medicine have the patient's best interest at heart and practice according to high ethical principles.

The first principle to consider, he said, is respect for persons -- the patients' right to autonomy in choosing care. Clinicians must respect their patients' right to be informed so patients can make the best decisions regarding their treatment. While clinicians' knowledge of an alternative medicine may not be expansive, Sugarman said they are obligated to help patients understand issues of the safety of treatments and how to get more information on options they are considering.

"It may be easier for clinicians to accept a patient's choice of alternative therapy if there are no known effective conventional ways to treat a condition. And there are cases when we would be remiss as physicians if we didn't counsel a patient to avoid alternative therapies in specific cases," Sugarman said, such as a case where a patient wanted to self-treat with herb tea for an infection that is a serious threat to health.

Nonmaleficence, or the principle of "doing no harm," clearly stands as an enduring obligation of physicians, Sugarman said. Besides offering information, doctors must take a careful history to determine any alternative therapies the patient is using to screen for possible adverse effects. For example, a patient may be taking St. John's Wort on her own, something which could influence a clinician's decision to prescribe an antidepressant. Without eliciting information about the patient's alternative therapy choices, the patient's health could be jeopardized.

Clinicians also are obliged to help patients reach their health-related goals, which is the essence of the principle of beneficence, Sugarman said. In following that principle, doctors may feel the need to learn to prescribe known beneficial alternative medicine therapies. Pursuing adequate and appropriate training would be another professional obligation for the conventional clinician who wanted to include alternative methods in medical practice.

Finally, clinicians are bound by the principle of justice that dictates patients should have fair access to alternative therapies, as well as conventional treatments, that are known to be safe, effective and appropriate for their particular condition.

The authors did not call for physicians to learn all alternative therapies. "But they do need to learn enough to understand what the patient is doing to reach health related goals," Sugarman said.

Duke is developing a center for integrative medicine that will include both research on alternative medicine and education on alternative therapies for physicians, medical students and the lay public, Burk said. "For us to make ethical decisions, we need a lot more information. That's part of the reason we're working on the center."

Duke University Medical Center

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