Opposing views

Complementary therapies
Volume 195 - Issue 2

Is it ethical for medical practitioners to prescribe alternative and complementary treatments that may lack an evidence base? — Yes

Author:  Marie V Pirotta

Med J Aust 2011; 195 (2): 78. || doi: 10.5694/j.1326-5377.2011.tb03211.x
Published online: 18 July 2011
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Academic GP Marie Pirotta says some alternative therapies are worthy of consideration

Yes The use of complementary and alternative medicine (CAM) is hugely popular — each year, over half of the Australian population uses some form of CAM, at a total cost of $A1.8 billion.1 Importantly, most of this use of CAM is not a substitute for conventional therapy. Indeed, CAM is often used together with conventional therapies to treat particular conditions.

CAM is usually considered a homogenous static entity, or a creed, to be either believed in or not. However, the “CAM” label incorporates a disparate range of therapeutic approaches, from the esoteric and bizarre through to therapies with accumulating evidence of effectiveness, such as St John’s wort for mild to moderate depression.

If the first principle of medicine is to do no harm, is it ethical for general practitioners to actively recommend CAM? Indeed, how should the profession respond ethically to the challenge of CAM generally?

One apparent hurdle is that much CAM currently lacks high-quality evidence. However, this should not be taken as proof that a given CAM is ineffective or harmful. To place this in context, it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence.2

CAM research is slowly gaining momentum. It is hampered by factors including lack of financial reward for research investment for products already in widespread use, and few trained independent researchers. With increasing interest and research capacity, no doubt, evidence will accumulate for some CAM, which may be adopted into our armamentarium and become “mainstream”.

Yet we cannot ignore CAM while awaiting the results of these trials. A framework for responsible engagement with CAM is needed now: its use is already widespread, even among GPs, and patients want to get their information about CAM from GPs.3

Encouragingly, CAM is largely safe. In Australia, CAM is regulated to pharmaceutical standards by the Therapeutic Goods Administration, so the risk of poor-quality, contaminated or adulterated products is low. While side-effects and interactions do occur, CAM is generally safer than pharmaceuticals.4

So in the context of widespread use, a slowly developing evidence-base, patients’ wish for their GP to provide CAM advice and its relative safety, is it ethical for GPs to recommend CAM?

Ethical recommending of any treatment takes place within the framework of a careful history, examination and diagnosis. GPs contribute their clinical experience and scientific knowledge, while maintaining respect for patients’ preferences and values. Patients may value different aspects of treatment than their GP, such as “naturalness”. Together, patients and their GPs explore the risks and benefits of the proposed treatment, relative to other available treatments. Any treatment decision must be monitored for harm and benefit.

Discussion of CAM options (including recommending or discouraging use, as appropriate) can be ethically incorporated into this framework. Where evidence is lacking, GPs can turn to the accumulated knowledge over time (sometimes millennia) of the historical use and safety of the CAM. In fact, it is important for GPs to discuss CAM options with patients to ethically fulfil their role as trusted primary care providers.

Doctors who do not engage in discussion about CAM may harm the doctor–patient relationship in the longer term — use of potentially harmful CAM may remain undetected, and patients may seek information from less reliable sources. Further, it may be unethical not to inform patients in situations where evidence-based CAM options exist.5

Is it ethical to bill these consultations to Medicare? Of all CAM treatments, only medical provision of acupuncture has its own Medicare item number. Using the framework I describe for ethical, responsible discussion of CAM, I believe it is appropriate to bill Medicare.

There are certain circumstances in which recommending CAM would be unethical. These include: if the GP has inadequate knowledge to avoid harm;6 if the use of CAM causes delays in treating serious illness where evidence-based conventional therapies exist; if there is evidence that a CAM is not effective; or if (and this is unusual) unproven or ineffective practices are recommended to vulnerable patients for exploitative financial gain.

Further, potential for conflict of interest exists for GPs who recommend and sell CAM. The Australian Medical Council Code of Conduct provides clear guidelines, including declaring to patients one’s professional and financial interest in any product endorsed or sold from one’s practice, and not making an unjustifiable profit from the sale or endorsement.7

Ethical prescribing of CAM is possible within good general practice if GPs have an adequate knowledge of CAM and have their patients’ best interests at heart. Generally, GPs need to keep up-to-date as evidence grows about CAM, and maintain a respectful relationship with patients so they feel able to ask questions about CAM and thus maintain their enviable position as trusted primary care providers.

Author

  • Marie V Pirotta MB BS, MMed, PhD1
  • 1. Department of General Practice, University of Melbourne, Melbourne, VIC.

Correspondence: m.pirotta@unimelb.edu.au

Competing interests

None relevant to this article declared (ICMJE disclosure form completed).

References

Provenance: Commissioned; not externally peer reviewed.

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