Professionalism and Ethics in Complementary and Alternative Medicine

Many health care providers within the mainstream are fearful and distrustful of the motives and outcomes of complementary and alternative medicine. Many complementary and alternative medicine practitioners share the same depth of fear and loathing toward mainstream health care. Despite the fact that many consumers use both complementary and mainstream health care either sequentially or concurrently, they typically do not disclose their use of complementary and alternative medicine to mainstream providers, because they are mindful of devaluation and ridicule.

Given the widespread use of complementary and alternative medicine, consumers of health care would benefit from increased cooperation from both camps. This perspective is clearly expressed in Professionalism and Ethics in Complementary and Alternative Medicine, by John K. Crellin and Fernando Ania. Crellin is the John Clinch Professor of the History of Medicine at Memorial University of Newfoundland, and Ania is the founder and president of the Homeopathic College of Canada. These authors recognize a need to identify the place, role, and value of complementary and alternative medicine as partner and mentor of more traditional medicine and have written this book to fill that gap.

Part 1, called "The Current Scene—Public and Professional Issues," juxtaposes current standards of complementary and alternative medicine with those of scientific medicine in such areas as licensure and external oversight, standards of care, education, legislative protections, and outcomes research. The authors go into great detail describing two separate and distinct cultures of health care and document the antipathy that currently exists between them from both historical and sociocultural perspectives. Part 2, on professionalism, includes discussions of authority and power, the role of oaths and codes in medicine, and a brief discussion of biomedical ethics and its relevance to practice.

Despite the implication of the title, this volume would be improved by expanding the discussion of ethics in practicing complementary and alternative medicine, which is dealt with in a rather cursory fashion. Here the authors give the standard principles (1) of autonomy, beneficence, nonmaleficence, and justice relatively little attention and proceed to question whether "principlism" is relevant to complementary and alternative medicine. Instead, they offer consequentialism and social utilitarianism as alternatives. Part 3 is a series of case studies and readings that are used to illustrate the promises and pitfalls of complementary and alternative practice and stimulate discussion.

The authors strive to describe how complementary and alternative medicine might proceed to truly "complement" traditional medical care. A primary goal of the volume is that it seeks to improve the standing of practitioners of complementary and alternative medicine vis a vis physicians of a traditional bent. In many places the authors struggle mightily to maintain a balanced and objective stance. They do succeed in providing insight into how some providers of complementary and alternative medicine perceive the world around them. However, their description of mainstream medicine is somewhat stereotypically negative and does not adequately reflect the variety of methods that are currently used and the depth of concern most providers have for those they treat.

The authors are insightful when they call for better training in the methods of science and outcomes research for students of complementary and alternative medicine, and they realize that as evidence-based practices continue to emerge among mainstream providers, complementary and alternative providers will be called upon to do the same. Careful examination of complementary and alternative medicine and construction of an evidence-based set of such practices will no doubt continue to prove many to be safe and effective. However, what is absent is a discussion of what should be done when complementary and alternative practices fail to produce positive outcomes. That traditional providers are slow to adopt new practice patterns is well established, and changing established practices among providers of complementary and alternative medicine may prove equally difficult. The authors discuss a lack of regulatory mechanisms or licensure for many complementary and alternative practitioners, and this may further exacerbate any efforts to change practice patterns on the basis of evidence.

There are defenders of complementary and alternative medicine who argue that only a small subset of practices in mainstream medicine are actually evidence based and cite widespread iatrogenesis in mainstream practice to support complementary and alternative medicine, which is seen as safe and effective at best and benign at worst. However, this argument is specious, because complementary and alternative practices also have the potential to produce iatrogenic illness. Indeed, many herbal remedies are in fact drugs; they can interact with prescription medications. Furthermore, the use of complementary and alternative medicine may delay access to more effective treatments when it fails. The authors of Professionalism and Ethics in Complementary and Alternative Medicine discuss some of these pitfalls to varying degrees.

Crellin and Ania should be commended for taking on the tremendous task of describing comprehensively the professional and ethical issues in complementary and alternative medicine in all its diversity. As they note, the methods and practices of chiropractors, homeopaths, herbalists, acupuncturists, and others are wide ranging. Most of the book focuses on guild-oriented issues and provides models for their organization. The discussion of standards of care and regulation is primary theoretical and fairly diffuse, in part because the practices in complementary and alternative medicine are so broad. Of particular relevance to health services research would be an expanded discussion of how evidence-based practices could be integrated into complementary and alternative medicine where the culture may not be welcoming to data-driven enterprise. Of particular relevance to mental health care is that many seek out complementary and alternative medicine as a response to hopelessness and lack of access to mainstream services and unacceptability of services they received.

Criticism of the hegemony of scientific medicine as paternalistic, sexist, and lacking humanism and cultural competency; as failing to really embrace an evidentiary base; and as a destroyer of hope and optimism do not belong exclusively to purveyors of complementary and alternative medicine. Indeed, some of the harshest critiques of traditional medicine have come from within the pages of its most-esteemed journals. Clearly there are cultural and social challenges associated with the integration of complementary and alternative medicine with traditional medicine, challenges that will require mutual understanding and appreciation of differing perspectives both within and between various healers. Fear and loathing among providers present a formidable obstacle in meeting these challenges by stereotyping practices and minimizing potential. This volume takes a first step in overcoming this barrier, and despite its shortcomings, is valuable for readers using a variety of approaches.

Dr. Blank is assistant professor of psychology in psychiatry at the University of Pennsylvania in Philadelphia. Dr. Eisenberg is a psychologist at Research By Design in Doylestown, Pennsylvania.