The context in which Western health care is delivered and consumed has changed considerably in the past half century. Arguably, complementary and alternative medicine (CAM) has re-emerged, after being quelled for centuries by the rise of orthodox medical dominance. CAM was originally thought to be the preferred treatment model for fringe segments of contemporary society such as the New Agers, the “cultural creatives,” and other groups believed to be rejecting traditional Western models of treatment for philosophical or spiritual reasons. This belief was dispelled in the early 1990s following a landmark study by Eisenberg et al. (Reference Eisenberg, Kessler, Foster, Norlock, Calkins and Delbanco1993) showing that approximately 40 per cent of the American population were using CAM and were spending billions of dollars annually on it. This research further revealed that patients were not fully communicating their use of CAM to their doctors.
With more than 3,000 citations to its credit, the Eisenberg et al. (Reference Eisenberg, Kessler, Foster, Norlock, Calkins and Delbanco1993) study continues to be a common point of departure for the proliferation of CAM research accumulated since. Much of this research clearly indicates that CAM is rarely used as an alternative to conventional medical care but, rather, typically complements conventional medical care. It is this dual use of CAM and conventional medicine that concerns much of the traditional medical community.
Perhaps the most pressing challenge facing the medical community is the ethical treatment of patients who also use CAM, and whether these same principles can and should be reciprocal. Lois Snyder and seven other contributors tackle these issues in Complementary and Alternative Medicine: Ethics, the Patient, and the Physician. It is the most recent edition from the Biomedical Ethics Reviews series, which, since 1983, has explored a number of significant biomedical issues from stem cell research to physician-assisted death. This book sets out to explore and debate the theoretical, clinical, and policy aspects of CAM as it pertains to medicine and the traditional doctor-patient relationship. The extent to which the book debates the theoretical aspects of CAM is indeed questionable, although clinical and policy aspects are solidly examined.
Early chapters establish the framework for a contemporary examination of CAM by describing its history, how and by whom it is defined, and prevalence of use. Later chapters focus on the ethical challenges of advising and educating patients about CAM from both the practitioner and researcher perspectives. Chapters flow logically, although the lack of introductory and concluding chapters leaves the reader wanting. A chapter dealing with CAM use in mid to later life would also help to elucidate many of the issues raised, considering that research has just begun to highlight the relationship between age and regular use of CAM for illness or wellness.
Of the book’s seven chapters, two merit particular analysis. Chapters 3 and 7 are well written and appropriately analytical, focusing on the purported heart of the issue – how realistic is it to expect integration between CAM and conventional medicine in the medical encounter, among health professions and in health research? Is it even possible, considering that both health systems adhere to contrasting worldviews and paradigms? Vaught opens Chapter 3, “The Physician’s Ethical Obligations”, with a vignette of a patient who, in her 32nd week of pregnancy, is trying to organize her birth plan. Her plan is met with resistance from one of her obstetricians who opposes and belittles her request to integrate CAM with her otherwise conventional birth plan. This story specifically addresses the ethical obligations of medical doctors whose patients “force” integration, but Vaught also acknowledges that growing numbers of doctors are, by their own volition, bringing CAM into their practice (p. 47).
Vaught reduces the issue of integration to two schools of thought: the supporters (conventional bioethics) and the critics (contemporary bioethics). Supporters of the former believe that CAM should comply with the traditional bioethics of autonomy, non-malfeasance, beneficence, and justice, while critics argue that integration requires new ethics as the traditional ones are outdated, claiming medicine must embrace CAM’s holistic, cultural, and spiritual aspects to develop truly contemporary bioethics. The author eloquently counters this argument by suggesting that the issue is perhaps less about CAM values, per se, than it is about an “imperfect reflection of the values inherent in mainstream medicine” (p. 49). Using parallels between Western and non-Western value systems to drive this point home, Vaught hints that mainstream medicine should be less ethnocentric and more pluralistic or diverse in its approach.
Perhaps Vaught asks too much of physicians. He suggests that “in addition to the duty to learn about CAM and to question patients about its use, physicians should also foster an environment that encourages a fair and thorough evaluation of CAM” (p. 57). Fostering an environment of fairness is a reasonable suggestion, but how fair is it to make learning about CAM an obligation? Doctors already struggle with staying current in an accelerated information age in which health information changes rapidly. Furthermore, to say that all non-Western values reflect CAM values is short-sighted and ignores CAM professions that strive to be “Westernized” and seek legitimacy relative to mainstream medicine by aligning their curricula closely with the biomedical model. In fact, chiropractic, the most commonly used CAM therapy, evolved in a Western context and the training curriculum is modeled on the traditional Western medical degree.
Chapter 7, “Whose Evidence, Whose Methods”, opens with research citing public and professional demand for evidence-based CAM research. Author Jon Tilburt, a medical doctor, describes the conundrum facing publicly funded research agencies that question whether CAM is worthy or even capable of being subject to clinical research. He proceeds masterfully to integrate examples of policy and practice to illustrate the difficulties with applying clinical values to CAM research. Drawing on the Institute of Medicine (2005) Policy Report on Complementary and Alternative Medicine, Tilburt shows that the values the Institute recommends for CAM research are not easily translated into practice. He poses questions about the ethical challenges of research design, such as subjecting CAM to randomized controlled trials (RCT) – the gold standard of biomedical clinical research – and the ethical aspects around the use of placebo controls, common in CAM research.
These are not new issues. The idea that CAM or other medical interventions are less valuable because they do not fit established standards of clinical research has been tackled by others before Tilburt. Smith and Pell (Reference Smith and Pell2003), for example, provided a humorous illustration of this in their systematic review of RCT on parachute use. Parachutes save lives, they argue, but we know this only because of observational data. They continued by noting that an accepted condition of observational data is that it must be verified by RCT before it can be considered credible in the medical world and deemed an effective medical intervention. Smith and Pell could not find a published RCT on the effectiveness of the parachute during gravitational free fall, so they posed the question, Does this make the intervention any less effective As the parachute study and others indicate, different types of evidence may satisfy causal conditions in the contested grounds for “evidence-based medicine”.
Complementary and Alternative Medicine: Ethics, the Patient. and the Physician is best suited for health practitioners, medical students, and those in the general population who would seek out such materials. The book is well referenced, timely, and provides a useful – if not overly paternalistic – guide for patients and doctors on how to communicate about the use of CAM. Yet, the book has gaps. Examination should not be limited to how the medical community should come to terms with CAM, but why. CAM use is widespread, growing, and the long-term trends indicate that it is here to stay (Kessler et al. Reference Kessler, Davis, Foster, Van Rompay, Walters and Wilkey2001).
This book also missed the opportunity to discuss chronic illness, which is unfortunate given the almost unequivocal finding that chronic illness is a strong and consistent predictor of CAM use (see systematic reviews by Bishop & Lewith, Reference Bishop and Lewith2008; Harris & Rees, Reference Harris and Rees2000). Whereas most research indicates that use of CAM is neither an outright rejection of medicine nor an unrealistic search for cure, this book, at the very least, could have entertained the notion that the complex relationship between CAM and chronic illness warrants attention. Examining the relationship would be worthwhile particularly given criticisms, from afar and from within medicine itself, that in its current form the conventional health care system is ill-equipped to address the needs of an aging population in an era of chronic illness. Whether and to what extent CAM can complement medicine rather than be integrated into it is open to debate. This book makes an effort at elucidating the complexity of this issue.
