Nature, nurture, or nuisance: The ethical issues that surround alternative medicine.

Case Scenario

Meadow, a 15-year-old female patient, returns to Dr. Medical Derm (MD) with her father for severe nodulocystic acne that has been treated over many months. She has been compliant with the use of topical treatments (retinoid and benzoyl peroxide) and an oral antibiotic medication but the acne has not improved. The patient and her father are worried about scarring around her jawline. During the last visit, Dr. MD discussed oral isotretinoin as a treatment with Meadow and her father. During today’s appointment, Meadow’s father is frustrated and will not allow Meadow to start treatment with oral isotretinoin due to the potential side effects. He has researched alternative therapies and plans to have Meadow start a ketogenic diet in conjunction with barberry extracts and topical tea tree oil instead of her current medications.

Dr. MD should a) explain to Meadow and her father that the efficacy of the alternative therapy they are considering has not been proven and because of concerns of scarring, they should seriously consider treatment with oral isotretinoin despite the potential risks; b) discharge the patient from the practice because the family is noncompliant and unreasonable; c) refer the patient to a university colleague because they are too much trouble to deal with; or d) suggest the family use a combination of alternative therapies with current conventional treatment.

Discussion

Thirty-eight percent of adults and 12% of children use some form of complementary and/or alternative medicine (CAM) in the United States (National Center for Complementary and Integrative Health, 2016b). Alternative refers to therapies used in place of conventional medicine, complementary suggests use as an adjunct to traditional treatment, and integrative implies a blended approach that brings conventional and complementary therapies together in a coordinated way (National Center for Complementary and Integrative Health, 2016a).

Despite the assumption by many patients that CAM is natural and therefore always safe, there are risks associated with many CAM therapies. Yet, they are often insufficiently researched to accurately weigh the risks and benefits (Ernst et al., 2004). Additionally, patients may be unaware of the less rigorous standards that are applied to the alternative therapy industry in terms of premarketing testing for safety and efficacy as well as postmarketing surveillance of adverse effects.

Our case invokes the conflict that can occur among the bioethical principles of autonomy, beneficence, and nonmaleficence when a patient decides to pursue unproven alternative therapies in place of conventional treatment. The case also raises the question of the primacy of autonomy versus beneficence from which the additional ethical issue of paternalism arises (Beauchamp and Childress, 2009).

Autonomy involves the obligation to honor a patient’s freely made medical choices (Cohen, 2008). In the therapeutic relationship between patient and physician, respect for autonomy is a two-way street (Jonsen et al., 2010). Physicians must respect a patient’s preferences for self-determination but also have the right to respect their own autonomy with regard to clinical judgment. Thus, tensions can arise between patient and physician when a patient is adamant about pursuing alternative treatments in lieu of conventional therapy.

When there is little risk of harm, it is reasonable to support the patient’s wishes for complementary therapy (Ernst, 1996). However, when harm is likely to result from the decline of medically indicated treatment, physicians need to advise patients of the risks they are undertaking by this decision (Kaptchuk and Miller, 2005), and it would be clearly unethical for the physician to condone a treatment plan that could potentially harm the patient. Rather than dismiss a patient’s questions about alternative treatments, it is important to set aside personal beliefs and communicate openly about various potential therapeutic approaches (Jacobson and Cain, 2009). This tactic decreases the potential for physician paternalism in which the physician dismisses a patient’s preferences with the intention of benefiting or preventing harm to that patient. In addition, maintaining the therapeutic relationship through nonjudgmental discussions may encourage the patient to return for conventional treatment if their disease progresses or recurs (Kaptchuk and Miller, 2005).

Situations may become even more complex when parents desire a nontraditional treatment for their child. Physicians should insist on evidence with regard to safety and efficacy before endorsing such therapies (Ernst, 1999). Although true informed consent can only be given for oneself, a similar process of parental informed permission in conjunction with child assent is endorsed for medical decision-making in the pediatric population (Ladd and Forman, 2010). Nonetheless, parental authority is limited compared with the liberties that are given to competent adults who make decisions with regard to their own health (Katz and Webb, 2016). Physicians may be presented with anecdotal reports of unproven treatments by parents for the care of their children, in which case a reasonable minimal ethical standard for cooperation entails strong evidence of no risk of harm along with the possibility of benefit (Yeoh et al., 1994).

Analysis of case scenario

In the current case scenario, option A is the best choice. Dr. MD should avoid paternalism by initiating a nonjudgmental discussion with regard to the alternative therapies that Meadow’s father is considering, clearly explaining the risks and benefits, and encouraging them to continue conventional therapy. Dr. MD should investigate alternative treatment research for acne rather than dismiss the therapies as quackery, which could diminish the patient’s trust. There have been studies to demonstrate that certain CAMs for acne (low glycemic load diet, topical tea tree oil, and oral barberry extract) may reduce total skin lesions (Bagherani and Smoller, 2015, Cao et al., 2015, Fouladi, 2012).

Option D, which allows the family to utilize some of the alternative therapies while continuing the current conventional treatment, would be a reasonable approach if Meadow’s acne was not scarring despite months of traditional therapy. Severe nodulocystic acne that results in significant scarring could have a profound impact on the patient’s psychological wellbeing (Zaenglein et al., 2016). Neither the continuation of conventional therapies that have been employed to date nor the proposed alternative therapies are likely to be effective in this clinical situation. Therefore, Dr. MD should direct Meadow and her father away from alternative therapy in favor of treatment with oral isotretinoin. Although oral isotretinoin has potential adverse effects, the other options confer a much greater risk of potential harm.

Option B, discharging the family from the practice, is drastic and could cause harm to Meadow by precluding a discussion on the risks and benefits of alternative and conventional therapies and making it even more likely that Meadow will not receive the medical care she requires. If Meadow and her father decide to pursue only alternative therapies after this discussion, then maintaining the therapeutic relationship through communication increases the chance that they will return for conventional treatment if the acne continues to progress and potentially minimizes the amount of harm to Meadow.

Option C, referring the patient to a university colleague, is inappropriate as written because it has the same effect as discharging the patient and may not address the patient’s immediate needs. This option merely shifts the responsibility to someone else. Offering the patient the opportunity to have a second opinion would be reasonable if they are receptive.

Bottom line

When we encounter patients who use or consider the use of complementary and/or alternative medicine, we should respect their autonomy while also fulfilling our obligations of beneficence and nonmaleficence. Physicians should become more knowledgeable about research on CAM therapies and approach discussions in an open, nonjudgmental manner to enhance patient trust. In situations where there is little risk of harm and the possibility of benefit, supporting a patient in their interest in complementary therapies can strengthen the patient-physician relationship. However, when a patient’s desire to utilize alternative therapies poses a health risk, physicians have the ethical obligation to skillfully counsel the patient toward those therapies that are medically appropriate.