An Ethical Framework for Complementary and Alternative Therapists

Julie Stone

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134468331
• Topic: Medicine
• Subtopic: Health Care Delivery

As growing numbers of patients turn to complementary and alternative medicine (CAM), the focus of attention has largely been on whether these therapies work and whether they are safe. These questions are central to further integration of CAM with orthodox medicine. But in the absence of formal regulation, it is equally critical to consider the ethical dimensions of the CAM therapeutic encounter.
In this book, Julie Stone demonstrates that ethical issues are no less relevant to CAM therapists than they are to doctors or any other group of health professionals. She provides CAM therapists with a detailed framework of the specific ethical issues which affect CAM practice to help practitioners think constructively about how ethics underpin their therapeutic work.
An Ethical Framework for Complementary and Alternative Therapists encourages critical and reflective practice, suggests practical problems to common problems, includes illustrative scenarios of ethical dilemmas faced by therapists and summarises key points. This timely book offers a comprehensive guide to this important area. Its challenging conclusions are as relevant to experienced practitioners as to students and newly qualified therapists. This book will also interest policy makers and professional bodies interested in strengthening and enhancing CAM's potential.

1
INTRODUCTION

Given the growth in the last twenty years of the professional literature on bioethics, readers might legitimately ask whether it is necessary to devote an entire book to the ethics of complementary and alternative medicine (CAM). After all, the side effects and risks of complementary medicine are generally perceived to be lower than in conventional medicine. So many people now consult CAM practitioners that this would suggest high levels of patient satisfaction. To the extent that ethical issues arise, are these any different to the issues arising in other health care relationships? Could an ethically curious therapist not simply extract the necessary information from a conventional health care ethics text, substituting the words ‘complementary therapist’ for ‘doctor’ or ‘nurse’?

Given the growing awareness of ethical responsibilities amongst other health care professions, a strong argument needs to be made as to why CAM therapists should be treated differently from other health care professionals as far as ethical responsibilities are concerned. Arguably, the more that CAM practitioners organise themselves professionally like orthodox practitioners, and the greater the level of integration within orthodox health care systems, the closer any model of ethics for CAM practitioners should resemble that which pertains to other health professionals. If we accept the basic premise that patients consult health professionals with a desire to be healed, and that all health carers, in whatever way, seek to benefit patients, should there not be a single ethical framework which applies to all health care practitioners, be they spiritual healers or surgeons?

At first sight, this seems to be an attractive proposition. If one takes the example of sexual abuse of a patient by a practitioner, it ought to make little difference in regulatory terms whether the abusing practitioner is a physiotherapist or an acupuncturist. Creating and maintaining safe boundaries is critical whatever the therapeutic orientation of the practitioner. Similarly, a patient needs to be informed of the risk of serious injury from neck manipulation no less than the risks of spinal surgery since in each case, the information will be vital to the patient’s ability to make an informed choice as to whether to proceed with the treatment. Yet, despite the seeming similarity, CAM practice raises profound and novel questions for ethicists. The very features which differentiate CAM therapeutic encounters from relationships with conventional health care practitioners create unique ethical dilemmas. An ethical investigation of theCAMtherapeutic encounter needs to ask the following:

• Should the normal risk/benefit analysis be applied to the last resort patient who has exhausted every available conventional form of medication, and now wishes to seek complementary approaches, however outlandish and untested? Should parents be entitled to make that decision if their child is dying and the parents have lost confidence in conventional medicine?
• What complaints mechanism can realistically compensate a patient who has paid $100 to have their aura cleansed but feels no different at the end of the session than at the start? Should we give people the freedom to spend their money as they wish or protect potentially vulnerable patients from exploitation?
• What ethical principles should apply when the client is not ‘ill’ as conventionally defined, and views the therapeutic encounter as an opportunity to enhance their well-being? If the therapeutic encounter is reconceptualised as being about health improvement or enhancement as well as treating ill health, should the same ethical principles apply? If a patient views their weekly aromatherapy massage or reflexology session on a par with a visit to the hairdresser or manicurist, should the former be subject to a more restrictive ethical framework and if so, why?
• How can therapeutic outcomes be measured or compared to conventional medicine when a central goal of CAM therapy is to prevent the patient from getting ill?
• ; Can the ‘competencies’ of a psychic healer, for example, be discussed within the same discourse as a discussion of the competencies of a surgeon?
• If successful therapeutic outcomes depend, in part, on active patient involvement and patient self-responsibility, does this mean that patients must agree to become informed about what the therapist is doing to them, and participate in shared decision-making? Can CAM therapists work with patients who refuse to help themselves and prefer to be a passive recipient of treatment given by the therapist?
• If self-responsibility is essential to the healing process, does that mean that different ethical principles should apply in relation to the treatment of children and mentally incapacitated patients who are unlikely to be able to bring about the substantial lifestyle changes recommended by therapists?

These examples demonstrate that the content and context of the CAM therapeutic encounter may require a very different ethical analysis. An important preliminary point is that not all aspects of the therapeutic encounter are morally controversial. Ethicists tend to focus on worst-case scenarios and may even go looking for dilemmas where none exist. Indeed, formalised study of bioethics may falsely lead one to think that there is a ‘right thing to do’ in any given situation.¹ Many practitioners, when asked, say that they have never encountered an ethical dilemma in practice. Perhaps a generous interpretation of such a claim is that ‘good’ practitioners instinctively act ethically and resolve tensions before they escalate. It is not the purpose of this book to go looking for problems where none exist. A probable reason why very few people sue or complain about CAM practitioners is that therapists are genuinely more in tune with their patients. Hopefully most CAM practitioners do practise ethically. The levels of high patient satisfaction with CAM would surely bear this out.

Nonetheless, it is equally possible that practitioners who claim they have never encountered an ethical dilemma have an insufficiently developed awareness as to what constitutes an ethical issue. Gut instincts may currently guide practitioners through the complexities of therapeutic relationships, but these are not an adequate substitute for rigorous, reflective analysis of the ethical basis of the therapeutic encounter. CAM relationships do clearly give rise to a range of ethical issues, and hopefully all practitioners, however experienced, will find useful tools in this book to help them to refine their moral sensibilities and to reflect on how better to resolve ethical dilemmas whichmay arise in the future. Patients also have to exercise self-responsibility, since they too share some of the moral responsibility within the therapeutic exchange, an issue often overlooked in duty-based bioethics which concentrates on the practitioner’s duties towards the patient. Deciding what is ethically appropriate cannot be divorced from the principles and values that underpin practice and the needs and expectations of clients. These will now be explored.

Are there shared CAM values and characteristics?

A useful starting point for analysis is to ascertain whether there are any shared values which underpin CAM practice. To the extent that CAM comprises nearly two hundred different therapeutic modalities, are there any common themes that characterise the practice of complementary and alternative medicine which will influence the ethical implications of these sorts of therapeutic encounters? Is it possible to find statements which cover all therapists when the range of complementary and alternative therapies is so diverse, ranging from whole systems (such as Traditional Chinese Medicine, Ayurveda and homoeopathy and herbalism), to diagnostic methods (such as iridology and kinesiology), and self-help methods (such as yoga and biofeedback)?

The Chantilly Report², produced as a result of a US workshop involving more than two hundred experts on CAM, divided therapies into seven broad categories of holistic practice, namely: (1) mind/body interventions; (2)

bioelectromagnetics applications in medicine; (3) alternative systems of medical practice; (4) manual healing methods; (5) pharmacological and biological treatments not yet accepted by mainstream medicine; (6) herbal medicine; and (7) treatments focussing on diet and nutrition in the prevention and treatment of chronic disease. This gives some idea of the diversity of interventions under discussion. The question is whether these different categories share common values or approaches to health and healing which may better direct our inquiry of the ethical issues which their practice might raise.

Until recently, the only common link between CAM therapies was their absence from the orthodox medical school curriculum and the unwillingness of health insurers to reimburse patients for using these therapies. Indeed, the Harvard definition of alternative medicine is one of exclusion from mainstream medicine. Recent studies, however, demonstrate that this definition of exclusion can no longer be relied upon. As Eisenberg et al.’s 1997 follow-up study reveals, an increasing number of US insurers and managed care organisations now offer alternative medicine programmes and benefits³, and the majority of US medical schools and health care institutions elsewhere now offer courses on alternative medicine.⁴

For our current purpose, Eskinazi offers a more fruitful definition of alternative medicine:

I propose that alternative medicine be defined as a broad set of health care practices (ie, already available to the public) that are not readily integrated into the dominant health care model, because they pose challenges to diverse societal beliefs and practices (cultural, economic, scientific, medical, and educational). This definition brings into focus factors that may play a major role in the a priori acceptance or rejection of various alternative health care practices by any society. Unlike criteria of current definitions, those of the proposed definition would not be expected to change significantly without significant societal changes.⁵

This is a useful definition because it demonstrates the full extent to which CAM poses a threat to prevailing orthodoxies. In highlighting the various challenges alternative medicine poses, Eskinazi clarifies the point that acceptance or rejection by the medical profession is no longer the main or sole issue, because alternative medicine challenges a far broader range of beliefs. For this reason, integration of CAM and conventional medicine will never be a matter of mere therapeutics.

Given that there is rarely consensus even amongst members of the same therapy, is it realistic to hope to find values which cut across CAM as a whole? In order to make a meaningful transition from collective values to collective ethical precepts, we should not be lured into uncritical reliance upon some of the values therapists claim to possess. For example, we ought not to accept uncritically the contention that all complementary therapists work holistically, or that all therapists are patient-centred in their approach, without trying to establish what this might mean to individual practitioners and, perhaps more importantly, what patients think these terms mean.

The following is a possible list of shared values which might underpin the CAM therapeutic encounter. These values may apply to some therapies and therapists more than others and need to be discussed in turn. Perhaps no practitioner would identify with all of the following characteristics, but each raises issues that impact on the ethical relationship between practitioners and patients.

The holistic view of patients and of illness

The vast majority of CAM practitioners use the term ‘holistic’ to describe their practice. The most common use of the term holism refers to treating the patient as a whole person. Thus, illness is not just a physical phenomenon, but an indication of an imbalance which may relate to the patient’s mind, body and spirit. Because of this, many practitioners might start by working on physical symptoms, but would also seek to find and treat the underlying problem. The holistic approach is starkly at odds with the reductionist biomedical model which views the ill patient in similar terms to faulty machinery and seeks to remove physical symptoms rather than treating underlying causes. If the concern is with the whole person, then it becomes more realistic for a single practitioner to treat a patient, rather than the system of specialisation within orthodox medicine, where a patient may be referred to several specialists who only treat bits of the person. As Sharma asks:

If the patient is a whole person, then does it make sense to have completely different teams of people dealing with his/her musculo-skeletal system, digestive tract, mental health etc.?⁶

Interrelated aspects of holism are that the whole amounts to more than the sum of its parts and that individual health cannot be seen in isolation, but as part of society and the environment. Although the notion of holism has extended beyond the practice of alternative therapies, Douglas asserts that true holism is ‘a philosophy of the body which does not grow out of the history of western medicine’. She maintains that there is a distinct difference between what a complementary practitioner means by working holistically and what a western-trained physician who claims to work holistically means. She describes the difference thus:

Our doctor’s holism stops at the boundaries of the body and stays within the boundaries of the medical profession, whereas holistic medicine takes global account of the patient’s whole personality and spiritual environment.⁷

The holistic dimensions of the CAM relationship may raise ethical issues not present in a relationship which takes a more mechanistic view of patients and their illness. One concern is the tendency of practitioners to give advice on their patient’s lifestyle and emotional well-being, even if they have not been specifically trained to do so.

A recently qualified herbalist is treating a woman for depression. Over the course of several sessions, it emerges that his patient feels trapped within her arranged marriage, and is a victim of psychological and physical abuse. The herbalist, who is trying to be supportive, encourages his patient to leave her husband, and provides her with information about refuges. She is grateful for his help and leaves home. Subsequently, he is horrified to read in the local paper that his patient has been tracked down by her husband and savagely attacked. The herbalist receives a threatening phone call telling him to mind his own business or face the consequences.

This example shows what can happen when practitioners impose their personal values on their patients, in this case his belief that women have a right to be free from a violent husband. Although the therapist is not directly responsible for the attack, this case illustrates the dangers of offering directive advice, without the training to do so, and without taking into account cross-cultural difficulties, specifically about women’s right to autonomy, a value prized in the west, but interpreted differently in more traditional cultures.

Ideally, a holistic relationship will be one in which the views of the individual are given considerable prominence, as the patient’s emotional and spiritual issues are less readily measurable by external forms of observation and rely on the patient communicating his/her subjective experience to the practitioner. Where practitioners work in co-operation with patients, there will hopefully be less scope for the practitioner to tell the patient what to do, and more opportunity for active listening on the part of the practitioner and negotiating an appropriate course of action.

Holistic practice is not unique to complementary and alternative medicine. Many conventional physicians would ...

Table of contents

• Cover page
• Title page
• Copyright page
• Preface
• 1 Introduction
• Part I understanding ethics
• Part II ethical issues common to all therapists
• Part III ethics in practice
• Bibliography