Use of complementary medicines: scientific and ethical issues

We need to address questions of effectiveness, safety and regulation

MJA 1998; 169: 180-181

This article has been cited in
Rey JM, Walter G. Hypericum perforatum (St John's wort) in depression: pest or blessing? MJA 1998; 169: 583-586.

The widespread acceptance of complementary medicines in Australia raises important scientific, social and ethical issues. The expression "complementary medicines" covers a diverse range of practices, from historically well-established therapies, such as traditional Chinese medicine, to more exotic forms, such as colour therapy and psychic healing.1 Taken together, the precise extent of their use is unknown. Certainly, the industry is a very large one: in the United States and Australia about one-fifth of the population visit alternative practitioners each year, and in Australia up to half the population have visited them at some stage.2-4 In the United States, expenditure on complementary therapies in 1990 was about $14 billion;3 for Australia, precise data are not available, but the figure is likely to be in the hundreds of millions of dollars.2,4 The use of complementary medicines is increasing. Again, data are scanty. However, over the last five years the number of raw medicinal substances imported for use in Australia has increased fourfold, and there are now about 300-400 individual medicines available.5 Since the introduction of a Medicare rebate for acupuncture in 1984, use of acupuncture by medical practitioners has increased greatly. By analysing one of the few reliable sources of data available, Health Insurance Commission records, Easthope et al,6 in this issue of the Journal, show that the number of Medicare claims for acupuncture services by general practitioners grew by nearly 50% in 12 years, to almost one million in 1996-97. Medicare reimbursements to doctors for acupuncture increased during this period from $7.7 million to $17.7 million, and in 1996 about 15% of general practitioners presented Medicare claims for acupuncture. Evidence regarding the clinical effectiveness of most complementary treatments, and the risks associated with them, is extremely limited.7,8 Randomised clinical trials have been few; indeed, it has been argued that complementary therapies in general, and traditional Chinese practices in particular, are in principle not susceptible to assessment using randomised-trial designs.7 In the case of acupuncture, significant insights have been achieved into physiological mechanisms of action; however, the few clinical studies that have been performed have often been flawed by poor design, inadequate measures and statistical analysis, and lack of follow-up data.7,8 Notwithstanding this, rigorous trials are possible, as has been shown by studies that support the use of acupuncture in the treatment of pain and nausea, and suggest possible applications in other areas, such as hypertension and asthma.7,8 It is important to recognise that complementary medicines, like orthodox ones, are not without risk. There is the possibility that use of complementary treatments might lead to withdrawal from appropriate medical therapy or to delays in diagnosis or treatment of underlying conditions. In addition, physical treatments can cause adverse effects, and herbal therapies can be either intrinsically toxic or contaminated with toxic substances. As recent discussions in the Journal have highlighted, serious reactions and even death can occur.8-11 Complications of acupuncture have included pneumothorax and puncture of other vital organs, spinal cord lesions, and infections (including HIV and hepatitis B),12,13 again associated with possible death.14 A National Health and Medical Research Council working party in 1989 found that complications occurred most frequently with acupuncturists without medical training.14 The widespread use of complementary medicines, and especially the application of acupuncture by general practitioners demonstrated by Easthope et al, raises some interesting social and ethical questions: It is widely accepted that individuals should be free to make their own choices with respect to healthcare; however, are not claims of cures matters of public interest affecting public health? Should the application of public funds be directed by consumer demand, or should it be limited to practices -- orthodox or complementary -- for which reasonable evidence of effectiveness and safety can be provided? Should the training and right to practise of complementary therapists -- at present largely unrestricted -- be subject to a formal system of regulation? Does the community have an obligation to protect vulnerable citizens from exploitation by practitioners holding uncertain qualifications, who apply practices with dubious benefits and unknown risks? Should special measures be introduced to protect children, especially from practices that may lead to their being denied conventional therapies of proven efficacy?15 Why have risk and lack of evidence not deterred potential patients and practitioners? The question of why people use complementary therapies is an important one which may have ethical implications of its own. There is evidence that people turn to alternatives because they are disillusioned with orthodox medicine. This may include dissatisfaction with doctor-patient interactions or dissatisfaction with medicine in general.16 Declining public support for hospitals and the introduction of economic practices such as managed care, which promote cost-saving at the risk of reducing the quality of service, may well exacerbate this process. Some form of regulation of complementary medicines seems to be necessary, but a delicate balance needs to be struck between control and consumer choice. A possible model, referred to as "protection of title", is presently under consideration in Victoria, following a government-sponsored inquiry into the practice of traditional Chinese medicine. It is believed that legislation will be introduced to limit the use of the titles "acupuncturist" and "practitioner of traditional Chinese medicine" to individuals who have been accredited by specified registration bodies. This approach would contribute to the establishment of standards of practice and training and provide avenues for aggrieved consumers to have their complaints addressed. Unregistered therapists could continue to practise as long as they did not claim to hold specific qualifications to do so. It is quite likely that some form of protection of title will eventually be adopted as a general approach to the regulation of various forms of complementary therapy throughout Australia. This approach, however, represents only a partial solution. It will still be necessary to consider whether therapies work and are safe -- and, indeed, whether this question can be answered at all. It will still be necessary for us to understand the cultural meaning of complementary medicines and what they have to teach orthodox practitioners. For these questions to be addressed, detailed research will be needed into not just the scientific but also the sociological, ethical and philosophical aspects of complementary medicines. It is to be hoped that such research will be undertaken, and that it will promote much-needed dialogue between practitioners of orthodox and complementary medicine. Paul A Komesaroff Associate Professor, Department of Medicine, Monash University and Director, Eleanor Shaw Centre for the Study of Medicine Society and Law Baker Medical Research Institute, Melbourne, VIC Eagle R. Alternative medicine. London: Futura, 1978. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. N Engl J Med 1993; 328: 246-252. Ban E. Australian alternatives. Nat Med 1998; 4: 8. Myers S, Bensoussan A. Towards a safer choice: the practice of Chinese medicine in Australia. Sydney: Faculty of Health, University of Western Sydney, Macarthur, 1996. Easthope G, Beilby JJ, Gill GF, Tranter BK. Acupuncture in Australian general practice: practitioner characteristics. Med J Aust 1998; 169: 195-198. Vincent C, Furnham A. Complementary medicine: a research perspective. London: Wiley, 1997; 181-182. National Institutes of Health. Acupuncture. NIH Consensus Statement, April 1998. Mullins RJ. Echinacea-associated anaphylaxis. Med J Aust 1998; 168: 170-171. Kelly S. Aconite poisoning [letter]. Med J Aust 1990; 153: 499. Drew AK, Myers SP. Safety issues in herbal medicine: implications for the health professions. Med J Aust 1997; 166: 538-541. Halvorsen TB, Anda SS, Naess AB, Levang OW. Fatal cardiac tamponade after acupuncture through congenital sternal foramen [letter]. Lancet 1996; 345: 1175. Norheim AJ, Fønnebø V. Adverse effects of acupuncture [letter]. Lancet 1995; 345: 1576. National Health and Medical Research Council, Acupuncture Working Party. Acupuncture. Canberra: NHMRC, 1989. Neeley GS. Legal and ethical dilemmas surrounding prayer as a method of alternative healing for children. In: Humber JM, Almeder RF, editors. Alternative medicine and ethics. New Jersey: Humana Press, 1998; 163-194. Siahpush M. Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies. J Sociology 1998; 34: 58-70.