'Alternative' Medical Treatments Raise Ethical Questions for Managed Care
John La Puma, M.D.
John La Puma, M.D.
Alternative medicine is the politically acceptable term for nonallopathic health practices, usually unavailable in physicians' offices or hospitals, that are very popular among our patients.
Alternative medicine encompasses mind-body interaction, homeopathy, naturopathy, chiropractic, botanical medicine and more. Diagnostics range from detailed examination of the pulses and tongue in Oriental medicine to long personal, medical, environmental and social histories in homeopathy. Therapeutic modalities can include art therapy, the postures and exercises of Chinese tai chi, and the herbs, purgatives and rubbing oils of the ancient Hindu medical system ayurveda.
Many physicians believe alternative medicine is unproven at best, and unsafe at worst. Stanislaw Burzynski, M.D., has used "antineoplastins" derived from urine to treat some neoplasms, and the FDA's raid on his Houston clinic last year was reported in the press. Nearly every physician has a story to tell about excess radiographs ordered by chiropractors, or the wildly varying quality of botanical medicines.
What issues does alternative medicine present for clinicians? What ethical questions does it raise? What can we learn from it?
The big question in alternative medicine is "What works safely?"
The ethical principle is beneficence, or "How should we do good for this patient?"
Acupuncture is 5,000 years old; the Chinese undergo major operations with it. Self-help support groups plus nicotine patches are a more successful smoking cessation intervention than nicotine patches alone. The University of California Berkeley Wellness Letter, a conservative publication, recommends that patients with heart disease ask their cardiologists about Coenzyme Q-10.
To begin to discover what works, the National Institutes of Health's Office of Alternative Medicine, established in 1991, has given more than 40 pilot research grants. Can electrochemical treatment help malignant tumors? Can intercessory prayer ameliorate drug abuse? Are certain Chinese herbs useful in patients with HIV infection?
Research methods in alternative medicine, however, generally do not follow the Western randomized, controlled trial ideal. Many prac-titioners have been unwilling to subject their therapies to double-blinded analysis. A focus on the individual, along with nuanced variation in diagnosis and therapy, makes the systematic application of the same protocol to all enrollees seem foreign to many alternative practitioners.
Consumer interest drives this field. The ethical principle here is autonomy, or "What does this patient want and why?"
One in three Americans reportedly used some sort of alternative therapy in 1990. A 1994 federal law, the Dietary Supplement Health and Education Act, deregulated the sale of herbs, vitamins, supplements and extracts. Now, every Wal-Mart and Walgreen's has racks full of supplements and slips of paper explaining their use. Patients buy them by the fistful.
Patients prefer "personal" care. But American physicians and medicine as a whole are not viewed as personal. Contrast this with the image of a practitioner interested in holism and balance, not diseases and drugs. A practitioner who wants to know you and your needs, not just know what you don't have. Someone who will not scoff at your visits to a colonic therapist or think of the 1960s when you mention macrobiotics.
To many patients, it does not seem to matter that alternative medicine's assumptions are not based in Western science, or that its methods appear unorthodox. Actually, some of its methods are standard in other cultures. The Berkeley Letter, for example, notes that 15 million Japanese take Co-Q 10 daily.
The ethical principle here is justice, or "How should we treat this patient, given the needs of others?"
Eisenberg's study ("Unconventional Medicine in the United States," New England Journal of Medicine 1993; 328:246 — 252) estimated 1990 expenditures on alternative medicine at $13.7 billion. Hospitalizations in 1990 cost Americans $12.8 billion.
Most alternative medicine is paid for out of pocket, but managed care may begin to cover certain treatments and practitioners.
Kaiser Permanente reportedly operates a successful pilot center for alternative medicine in Vallejo, Calif. It offers acupuncture, massage, meditation and yoga.
The state of Washington's insurance commissioner recently ordered access to and coverage for visits to "different state-certified providers for treatment covered by their insurer ... [including] physicians, acupuncturists, naturopaths, midwives, nurse-practitioners, massage therapists and others," according to American Medical News.
Reimbursement for services is a very hot button. Nonphysicians have established the market for alternative medicine and want to be included in managed care settings. Many allopathic treatments are also unproven, yet are reimbursed. Which "alternative" expertise is special? Should alternative treatments meet allopathic cost-effectiveness criteria?
The ethical principle here is nonmaleficence, or "Do no harm," because quality-of-life factors are determined by the patient. The ethical question is "How should we treat this patient so that no harm results?"
Alternative medicine is not harmless. There have been reports of deaths from the herb ma huang, an ephedrine-like substance promoted for asthma. The Annals of Internal Medicine published a report of four cases of pennyroyal toxicity this year, one of which was fatal. Pennyroyal is a sweet-tasting herb with abortifacient qualities.
Prudent practitioners know the power of the doctor-patient relationship and use the trust patients invest to help them get better. Alternative practitioners rely on trust, too. Medicine is a largely self-regulated profession with checks and balances, which holds its practitioners to reasonable medical standards that are socially sanctioned. Can the same be said for alternative medicine?
Physician referral to a stress management expert or biofeedback center does not seem unusual — these centers appear unlikely to cause harm. But who is a reliable hypnotist, or an expert naturopath? What are their credentials? When should primary care physicians be responsible for a naturopath's recommendations?
The challenge alternative medicine presents is to find and test those practices that are better than allopathic practices, and to integrate these practices into medical care. We can — and should — learn a lot from practitioners who welcome our most difficult patients.
John La Puma, M.D., practices internal medicine at North Suburban Clinic in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is the co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).