Sunday, February 04, 2007

The ethics of complementary and alternative medicine: where the rubber meets the road

I’ve gone on and on about how the promotion of pseudoscience by us in mainstream medicine is unethical. But how are those ethics applied in the real world? It’s a safe bet there are woo consumers in your practice, since 34% of patients in one survey reported using alternative medicine, and the vast majority of patients who use alternative medicine also use conventional medicine. (Doctor, have you looked in your spouse’s medicine cabinet lately?)

There may be risks in telling such patients the uncompromised scientific truth about their treatment choices. They may become offended and leave your practice. If you come across as dismissive about herbs they’ll feel uncomfortable discussing them and may even conceal their use. What’s a doctor to do?

I can recall patients so deep into woo it was a way of life. It had become a major part of their world view, holding together their precariously balanced psychological defenses. In such cases a debunking from me might have caused psychological trauma. I saw no point in driving those patients away. Although likely to reject much of my advice they often needed my services. I usually felt I could help them in some way. How could I be honest without harming them?

A common justification by mainstreamers for their pseudoscience promotion is that doctors must respect patients’ beliefs and choices. Implicit in that argument is the tired canard that telling the truth about unproven methods and respecting patients’ choices are mutually exclusive. My own experience with patients is different. It is possible to tell the truth with respect and agree to disagree. If the patient is deeply steeped in woo I simply acknowledge our opposing world views and explain that in order to maintain a sense of professionalism I must remain true to the world view I believe in and was trained in and in which is western science. In this manner it is possible to respect patients’ beliefs without agreeing with them. It is not necessary to promote quackery, even implicitly, to treat patients with respect. I’ve found that even patients who are extremely into woo accept this approach.

The November 17 issue of Medical Economics addresses this problem in What would you do? Alternative Medicine. Doctors were asked how they would handle a patient who, after two unpleasant rounds of chemotherapy for colon cancer with metastasis to regional lymph nodes, sought treatment at an alternative medicine center. 8% said they would agree to collaborate with the alternative medicine center, no questions asked. 71% indicated they would “work with” the alternative medicine center even though they could not support its methods. 21% said they would refuse to collaborate with the center and urge the patient to continue with conventional treatments. I would have difficulty answering this survey. How does one “collaborate” with an alternative medicine center? One respondent put it well: "Patients may choose their treatment, but my collaboration implies my endorsement, and I can only endorse treatments that have some likelihood of success. Even if patients don't demand some scientific basis for treatments, it's my duty to require it for anything I recommend."


james gaulte said...

I believe you are so right.It is not necessary to promote-or condone-quakery to respect your patients.A great post.

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