II. ETHICAL AND LEGAL ISSUES

Alternative medicine covers a dizzyingly heterogeneous group of medical theories and practices. Alternatives range from the different forms of faith healing, Christian Science, and folk medicine to allegedly scientific systems like homeopathy, chiropractic, and visualization therapy. Also included under the term are acupuncture; herbalism; iridology; the traditional medicines of India, China, Japan, the Philippines, and indigenous peoples; holistic medicine; naturopathy (treatment using agents or elements found in nature); shamanism; yoga; radiesthesia (therapy based on detection of natural waves of force emanating from nature); color healing; aromatherapy; transcendental meditation; crystal therapy; thalassotherapy (treatment based on sea bathing, sea voyages, etc.); massage therapy; midwifery; and many others. Certain shared negative elements justify lumping together such diverse medical theories and practices. They include marginal social standing or fringe status; exclusion from mainline professional journals and public funding for research; exemption from mainline licensing requirements; and opposition to conventional medicine. The essential ethical and legal considerations raised by alternative medicine are veracity and nonmaleficence. Because false claims of healing efficiency can cause direct and indirect harm to patients, any such claims violate the essential ethical standards of all medical practice, whether alternative or conventional practice.

The Meaning of Alternative and Conventional

"Alternative" implies alternative to orthodox, regular, mainline, or conventional medicine. These latter adjectives refer to a medical theory, based on modern science, that began to emerge in the Renaissance with medical innovators such as Andreas Vesalius (1514–1564) and Paracelsus (1493–1541), and to scientifically validated medical therapies that blossomed in the twentieth century. If alternative medicine is characterized by an enormous variety of different medical theories and practices with little in common either conceptually or culturally, conventional medicine has the appearance of a single powerful system based on a narrowly conceived biology and focused primarily on the organic needs of sick people. Besides being scientific and materialistic, conventional medicine is also rationalistic: a system that relies on hard data, observation, controlled experimentation, logical argument, and a somewhat outdated view of causality. Alternative and conventional medicine actually help to define one another by contrast and opposition.

What is now classified as either conventional or alternative medicine was not always so designated. Formerly alternative medical theories and practices have moved into conventional standing; for example, the use of antioxidant vitamins and other dietary remedies for both prevention and therapy (Steinberg; Stampfer et al.; Rimm et al.). Formerly conventional medicine is in the alternative category; this includes most nineteenth-century therapies like baths, massage, and purgatives. Between the Renaissance beginnings of modern orthodoxy and its dominance in the twentieth century, conventional medicine was practiced by relatively few university-trained physicians. Most sick people during these centuries got along on remedies developed under older theories. Even university physicians used bleedings and purgings, sweating, and vomiting in addition to quinine and digitalis; not much separated scientific orthodoxy from nonscientific alternative practice when it came to therapeutic interventions. In the nineteenth and twentieth centuries, university-educated physicians established their own medical associations, adopted updated ethical standards, reformed their educational systems, proved that microorganisms cause infectious disease, developed vaccines to control them, employed technologies to improve both diagnosis and therapy, and finally gained legal status for their practice, along with monopolistic control of healthcare institutions. The line between a unified, socially supported, conventional medicine and separate, alternative medical practices became much more clearly drawn.

Differences between conventional and alternative medicine are accentuated by a continuing polemic. The term alternative is still used by conventional physicians as synonymous with quackery, falsehood, uselessness, and dishonesty. Alternative is frequently used to mean foreign or antiquated, or to emphasize the different cultural origins and ancient practices of alternative medicine. In literature favoring alternative therapies, conventional medicine is characterized by toxic and addictive drugs, high costs, aggressive procedures, impersonalness, unnecessary surgeries, economic monopoly, and iatrogenic (physician-induced) illnesses. For their part, orthodox critics create the impression that alternative medicines are products of prescientific cultures, but that conventional medicine is purely scientific and transcends historical and cultural influence.

What constitutes disease and illness, however, as well as how they are understood and treated by any medical system, is necessarily historical and cultural. Contemporary culture's medical–industrial complex, for example, has as much influence on mainline medicine as the military–industrial complex has on modern warfare. Indeed, the historical and cultural content of conventional and alternative medicines is an important consideration wherever legal and ethical issues are addressed. What is ethically right cannot simply be reduced to what is culturally dominant. Cultural dominance does not equate with ethical correctness; minority status or identification with another culture does not reduce to moral incorrectness. Only when cultural and historical factors are identified on both sides can ethical and legal questions about alternative medicine be clearly addressed. Then dialogue can be substituted for hostility and common ethical standards can be developed for both types of practice.

Conventional Allopathic Medicine: Justifying Its Preferred Status

Conventional medicine is known as allopathy. This term sets it apart from homeopathy, a nineteenth-century theory and practice that treated disease by administration of minute doses of a remedy that would, in healthy persons, produce the same symptoms as the disease being treated (similis similibus curantur). Allopathy, in contrast, is a system that counteracts disease by the use of remedies that produce effects different from those produced by the disease (contraria contrariis curantur). Allopathic medicine by definition combats, counteracts, and aggressively opposes specified disease entities. Today's conventional allopathic medicine has its own history and is the product of strong cultural influences. The allopathic approach, originating in ancient Greece with the Hippocratics, was reinforced in the nineteenth century by opposition to the homeopathic alternative. Another important historical influence was a high school teacher from Kentucky, Abraham Flexner, who wrote a book on U.S. medical practice that laid the foundations of what we call medical orthodoxy.

The Flexner Report, published in 1910, not only criticized medical education and practice in North America but also held up a model of ethical medicine grounded on hard laboratory science and universal laws. For Flexner, ethical medicine targeted disease objects rather than patient complaints, and like engineering was founded upon hard science. Under his influence, nineteenth-century German medicine came to be orthodox medicine in the United States, and a new medical school at Johns Hopkins University was held up as the model for the way orthodox medicine should be taught and practiced. Doctors William Welch (1850–1934), William Osler (1847–1919), William S. Halsted (1852–1922), and Howard Kelly (1858–1943) at Johns Hopkins became the architects of mainline orthodoxy, and all four were products of German training (Ackerknecht). Because Flexner applied the images of war to medical practice, orthodox medicine became an aggressive, hands-on science. Engineering and military science shaped mainline medical attitudes and procedures, while biology, histology, embryology, anatomy, physiology, pathology, and bacteriology provided the substance of orthodox medical understanding. For Flexner all other approaches were both unscientific and unethical.

What over several centuries came to be orthodox medicine enjoys great power and prestige in so-called developed societies because it alone of the classic professions (law, medicine, ministry) wrapped itself in the mantle of hard science. Alternative medicine is alternative because it lacks that mantle. If alternative medicine is ethically suspect, it is because hard science became the ethical as well as the epistemological standard in twentieth-century culture. Being unscientific or deficiently scientific amounts to being irresponsible in medicine. All alternative medicines are not the same in this regard, but in general, alternative medicine's moral weakness can be traced to an absent or weak science.

Some alternative medicines claim to use "a different science." They adopt the stand that modern science is just another cultural variable or another historical belief system. Some defenders of alternative medicine argue that one cultural variable or belief system is as good as another. No rational grounds exist, they claim, to prefer one medical system to another or to assign to one a greater social and ethical standing. From the fact that mainline science is itself cultural and historical, radical advocates for alternative medicine make their basic argument for equal legal and ethical status. Patients, they insist, must be totally free to make their own choices about treatment. Their argument is strengthened by calling attention to the theoretical flaws in modern science.

Karl Popper's work, The Logic of Scientific Discovery (1939 German edition; 1959 English edition), on the concepts of verifiability and falsifiability undermined claims about what is proved in science. He argued that the best science can do is demonstrate what is false, not prove what it true. Later, Popper's claims about falsifiability were themselves shown to be flawed. Then Thomas Kuhn (The Structure of Scientific Revolution, 1962) showed how what he called a paradigm defines what counts as admissible evidence in science, and how these paradigms change. The foundations, then, on which modern medical orthodoxy bases its claims to ethical and social superiority are strongly influenced by cultural-historical factors.

Modern science and mathematics may have rational and conceptual flaws, but all flaws are not equal. Despite the flawed epistemological foundations of science and mathematics, they still can be used to build bridges that work and spacecrafts that arrive at their destinations. Modern medical science too has real explanatory power. The rigor of scientific explanation, however, is often absent in alternative medicines. Mainline scientific research is much more credible than unscientific and unsubstantiated claims. Admittedly, alternative medicines lack the government funding to carry out sound research, which is expensive, but many alternative medicines ignore research and have unrigorous standards for subjecting therapeutic claims to critical review. If a medicine is ethical and earns preferential social status because it bases its claims and practices on publicly confirmable evidence and continuing critical review, then orthodox scientific medicine warrants the ethical and legal priority it enjoys.

Some Alternative Medicines

CHRISTIAN SCIENCE. All alternative medicines do not have the same relationship to modern science. Christian Science is an alternative to conventional medicine in the most radical sense: denying the existence of matter as well as disease, illness, pain, and death. Mary Baker Eddy (1821–1910) was a sickly person who had a healing experience in 1866, which she understood as the discovery of Christian Science, a religion centered on healing and health. Her book Science and Health: With Key to the Scriptures (1875) is read at all Christian Science services along with the Bible, thereby continuing her healing ministry. It contains her metaphysical beliefs about disease, death, matter, spirit, and God, one famous synopsis of which is as follows:

Question. What is the scientific statement of being?

Answer. There is no life, truth, intelligence, nor substance in matter. All is infinite Mind and its infinite manifestation, for God is All-in-all. Spirit is immortal Truth; matter is mortal error. Spirit is the real and eternal; matter is the unreal and temporal. Spirit is God, and man is His image and likeness. Therefore man is not material; he is spiritual. (Eddy, p. 469)

Christian Science healing is not like the "miracle cures" of faith healers. Ministers who claim to heal acknowledge the existence of disease and evil, but Mary Baker Eddy did not. Her religion trains "practitioners," who devote their energies to healing in a different sense. They are called upon by believers just as non-Christian Scientists seek out physicians when they are ill. The practitioner talks to people on the phone, visits them at home, and heals by restoring patients to the spiritual plane of thinking that according to Christian Science is reality. Healing, then, is actually reeducation, in which the patient is brought to exchange mental errors and delusions for God's truth and God's reality, where evil, illness, disease, and death have no place.

Christian Science is a radical alternative because it is founded upon a worldview at odds with the theoretical base of conventional medicine. According to this metaphysical theory, disease, pain, sickness, and death only seem real because people believe them to be so, and practitioners heal by stripping away these false beliefs. Conventional doctors in this view are engaged in "un-Christian and sinful" activities; indeed, they live in an unreal world. And yet a certain civility characterizes the debate between orthodox medicine and Christian Science. The latter belief system may be too bizarre for most mainline physicians to take seriously. Christian Science apologists, however, tend to be middle-class and well educated, and they respond to objections with reasoned discourse.

This civility has been strained by several legal cases involving parents whose children died after being treated by Christian Science practitioners instead of by conventional physicians. Following the court decisions, calls were issued in the Journal of the American Medical Association and New England Journal of Medicine for stronger child-protection legislation and stronger penalties for "parents who use the pain and anguish of their children to demonstrate the strength of their belief in Christian Science." Conventional physicians warned against child-neglect legislation in Colorado, Texas, and Louisiana that provides religious exemptions for Christian Scientists. In some places Christian Science has become in effect the legal equivalent of conventional medicine. Mainline doctors object to this as well as to the fact that Christian Science practitioners have legal standing comparable to their own. Blue Cross and Blue Shield pay practitioners in some states, as do major insurance companies and Medicare. Practitioners may even sign certificates for sick leave and for disability payments. According to conventional physicians, this policy creates a double standard. Practitioners, they insist, should be required to meet much higher standards if they are to receive comparable medical responsibilities (and benefits).

In 1989 the parents of a seven-year-old girl were convicted of third-degree murder and child abuse in connection with her death from diabetes. A Sarasota, Florida, jury rejected the parents' claim that they had not sought medical treatment for their daughter because of Christian Science belief. This was the first case in the United States since 1967 in which Christian Scientists were held criminally responsible for relying on the practices of their faith alone to cure a child's illness.

In July 1990, a Boston jury convicted Christian Science parents of manslaughter because they relied on the services of practitioners rather than conventional medical care to treat their two-year-old son, who had died of bowel obstruction in 1986. The parents were sentenced to ten years' probation and ordered to take their other children for periodic medical checkups. This case aroused unusual interest because it took place in Boston, the headquarters of the Christian Science Church. Both cases reflect a pattern in U.S. courts, which have ruled that competent adults have a right to refuse treatment—even life-saving treatment—for themselves, but not for their children. The same response was made regarding Jehovah's Witness children whose parents refuse blood for them based on religious belief.

Official Christian Science response to these decisions has been reserved and moderate. In an official publication (First Church of Christ, Scientist), church officials recognize that the state has an interest in and a responsibility to protect children against abuse, including the possibility of their being used by parents to prove the strength of their faith. They acknowledge that the death of a child treated by practitioners alone is a tragedy, but counter with examples of thousands of children cured from certified illnesses by Christian Science practitioners and many deaths resulting from treatment with conventional medicine. They also recognize the distinction between unrestricted First Amendment freedom of belief, on the one hand, and restrictions on behavior or acting on belief, on the other. Still, church officials argue against any law that would radically restrict Christian Science treatment of children. Like advocates of alternative medicine generally, they argue for a right to unrestricted practice on the basis of the patient's right not to be interfered with in private matters. It would, however, be more ethically responsible for Christian Scientists to make explicit the childhood conditions where practitioners can cooperate with physicians, instead of forcing parents to make an either-or choice. This same solution could apply to other alternative practices; it would require increased communication and cooperation between conventional physicians and alternative practitioners.

Cases involving children put at risk because of parents' religious beliefs pose questions that can be addressed either by ethics or by law. In the language of ethics, these cases create a conflict between a negative individual right—not to be interfered with in private matters like religious belief and healthcare decisions—and a positive societal right or obligation: to protect vulnerable people. Put differently, they reflect a conflict between the principle of individual autonomy and the principle of justice. If the principle of autonomy is respected, justice is compromised, and vice versa.

In the history of Western ethics, individual rights and autonomy concerns are late arrivals—dating from the eighteenth-century Enlightenment period. Societal rights to protect life and the duties of citizens to obey societal norms are much older. Dilemmas involving the two types of ethics are worked out by emphasis on the importance of societal rights and justice, but restriction and limitation of their implementation by reference to individual rights and autonomy. Societal rights (justice) in effect are balanced with individual rights (autonomy), and the only justified degree of societal influence is that which is necessary to accomplish basic justice. In ethical language, the state has an interest not only in justice but in the protection of individual autonomy; therefore it has an interest in balancing the two goods. In legal language it is the balancing of negative constitutional rights—founded on the Bill of Rights (freedom of religion)—and a positive legal obligation of parens patriae. The particulars of the legal balancing are worked out through common law decisions in Anglo-Saxon systems. Statutory laws and policies that in effect deny a child access to effective treatment for serious illness can be considered both ethically and legally deficient.

LAETRILE. Alternative medicine is used by most patients for prevention and as an adjunct to conventional treatments. Alternative medicine, however, also flourishes where conventional medicine is weak, inattentive, or an outright failure. When conventional medicine has nothing more to offer and the patient faces death, many people look to alternatives. Cancer at certain stages of development provides a case in point. Because of devastating side effects associated with conventional cancer treatment (chemotherapy and radiation), alternative approaches are particularly attractive. Ten billion dollars is spent annually on unproven alternative cancer treatments, in many cases by affluent and well-educated patients. One such alternative that generated great public debate, court cases, and then finally involvement by the federal government was laetrile, a controversial drug derived from apricot pits and held up as the last hope for terminal cancer patients.

In the 1970s this drug, which had been around for decades, received wide publicity not only because of claims made about its effectiveness but also because the U.S. Food and Drug Administration (FDA) had banned its interstate shipment and sale. This created another conflict between an individual negative right not to be interfered with in choosing treatment and the positive social right to protect vulnerable people against exploitation. In 1979, the U.S. Supreme Court ruled that the FDA could legally inhibit the distribution of the drug, based on the agency's powers to establish "safe and effective" standards; this ruling validated the agency's positive social right. In Rutherford v. United States (1979), the Supreme Court remanded the case to the U.S. Tenth Circuit Court of Appeals for reconsideration of other arguments. The appeals court held that the FDA ban did not violate the individual negative right to privacy of cancer patients.

Responding to public pressure, the FDA on January 3, 1980, gave approval for the National Cancer Institute to initiate scientific trials to study laetrile. First, animal studies would be conducted, then stage-one toxicity trials on six human patients, and finally a clinical trial involving 200 to 300 advanced cancer patients who volunteered for the laetrile treatment. The studies were delayed by debate over the money and time required to test an allegedly ineffective drug and over who would perform the tests. Although some alternative practitioners were board certified in conventional medicine, most conventional physicians and scientists resisted involvement with an "alternative" therapy.

On April 30, 1981, the National Cancer Institute announced that it had found laetrile, or amygdalin, to be ineffective as a cancer treatment. The announcement was made at a meeting of the American Society of Clinical Oncology. Over half the patients given the alternative therapy had died and the rest had not responded to the treatment. Charles G. Moertel, director of cancer treatment at the Mayo Clinic, who gave the report, added that he hoped the study would end "the exploitation of desperate cancer patients" by doctors prescribing the drug in twenty-three states where its use was legal despite the FDA ban on interstate sale and shipment. (This apparent contradiction is rooted in the fact that federal regulations are often imperfectly coordinated with state statutes, which may allow the use of federally banned drugs.) Laetrile advocates claimed that the test was rigged and that a less than optimum form of laetrile was used. The contemporary debate over alternative therapies—especially for cancer—continues, although one hears little about laetrile (Cassileth et al.).

HOMEOPATHY. Homeopathy originated in Germany at the end of the 1700s in the work of Samuel Hahnemann. By the end of the next century, one in every seven physicians in the United States was a homeopath. The nineteenth- and twentieth-century successes of allopathic medicine considerably reduced the influence of homeopathy. As the limits of allopathic medicine have become better recognized, homeopathy has begun to make something of a comeback. About 1,500 homeopaths practice in the United States, and medical practitioners use homeopathy in Australia, the United Kingdom, Germany, India, Brazil, and Argentina.

Included under conventional allopathic practices are drug therapies in the process of scientific trial but not yet officially approved (unproven or nonvalidated therapies), and fully approved and scientifically validated drugs being used in novel ways (innovative therapies). Homeopathy uses its own special brand of unproven and innovative "drugs." Homeopathic medicines or remedies are available in many health and natural food stores in the United States. Because mainline pharmacy and professional pharmacists are strongly aligned with the allopathic system and conventional physicians, they have few incentives to become involved with homeopathic practices. Licensed conventional pharmacists would have little understanding of homeopathic preparations and little economic motivation to add these to their stock. Homeopathic pharmacists/practitioners prepare their own medications; a large part of the homeopathic doctors' work involves modifications (dilutions) of these remedies for each individual illness or patient.

If interest in alternative medicine continues, mainline drug stores may begin to carry some over-the-counter homeopathic remedies. Then, presumably, mainline pharmacists will learn about homeopathic background theories in order to explain these preparations to customers. Would doing so compromise the scientifically trained pharmacist's belief system because of the appearance of endorsement? Ordinarily not. Pharmacists as a group learn about natural remedies and understand the importance of patient belief in such products for therapeutic effectiveness. Pharmacists have their own professional code (American Pharmaceutical Association, 1981; see the Appendix) and standards of practice. These would be compromised only if an alternative therapy were known to be harmful.

VISUALIZATION THERAPIES. The biological sciences of orthodox medicine are materialistic (i.e., founded on physical realities and quantifiable data) and are ill-equipped to handle many of the problems listed as disease categories in psychiatry's diagnostic manual (American Psychiatric Association). A narrowly focused conventional psychiatry relies on chemical therapies and restricts practice to drug prescriptions and medication reviews. Beyond this narrow range of orthodoxy, psychological and social theories have added a broad assortment of nonchemical approaches to conventional practice—from classical psychoanalysis (through cognitive, behavioral, and group treatments) to visualization therapies.

Hypnosis, guided imagery, and biofeedback are all forms of visualization therapy often used in orthodox treatment centers. Practitioners may be conventional physicians, psychologists, social workers, or nurses. The conditions addressed by these techniques include everything from mental and emotional illness to immunological disorders, childhood hyperactivity, and cancer and senility. On the theoretical level, practitioners and advocates work to demonstrate just how the mind controls the brain and immune system (the mechanisms of psycho-neuro-immunology). The effect of biofeedback on psyche (stress reduction) and physiology (temperature, heart rate, blood pressure) is well documented. Advocates of visualization therapies argue that they can enhance the functioning of the immune system. Controversy about this last use of visualization therapies has centered on its scientific status. Whether it will be considered an alternative therapy or an extension of conventional medicine, in the sense that it broadens conventional medicine's positivistic base to include psyche, will depend on whether the visualization techniques can generate satisfactory scientific proof of effectiveness in this important area. Advocates of mainline medicine, such as Norman Cousins, Bernie Siegel, and Andrew Weil, testify to the need for a wider theoretical base for mainline practices, one that includes a place for the mind's influence on bodily healing (Cousins; Siegel; Weil).

CHIROPRACTIC. Chiropractic is probably the best-known alternative medicine in the United States. Practitioners call themselves doctors and complain bitterly about being excluded from mainline medical institutions. The effectiveness of manual manipulations, they insist, is based on scientific studies, but it is difficult for hands-on chiropractic manipulation to eliminate placebo effect and to satisfy double-blind requirements. Back pain could be called the chiropractic specialty, and orthopedic physicians the mainline competition. One double-blind scientific study of the effectiveness of chiropractic versus conventional treatment conducted in 1990 strongly favored chiropractic therapy (Meade et al.). Conventional physicians attacked the study's science, attempting to show that the statistics were unreliable because the study's method was not rigorous enough. Most chiropractors feel discomfort about requiring that any claim of effectiveness satisfy a double-blind requirement, because doing so would throw doubt upon many of their own scientific studies of effectiveness, which are statistical but not double-blind. Some chiropractic medical schools have their own research institutes and are continuously involved in effectiveness or outcome studies; one example is the ongoing research of the Palmer College of Chiropractic Graduate School in Davenport, Iowa. Despite extensive use of chiropractic in certain parts of the United States, serious dialogue and cooperation with mainline practitioners are limited.

Orthodox Public Health and Alternative Practices

No practice has been more orthodox since the nineteenth century than public-health medicine. When microscopic technologies aided in the discovery of bacterial causes of infectious diseases, public-health physicians began energetic application of laboratory science on behalf of societal health. Public-health physicians were laboratory science's strongest advocates. They insisted upon strict quantitive standards of proof for what they considered ethical medical practice. Only what could be shown quantitatively to be effective (e.g., vaccine) commanded their respect and endorsement. Laboratory science alone was the ground for real medicine. They used the police power associated with public health (health laws and their enforcement) to support the narrow positivistic foundation of conventional medicine. Medicine for them was narrowly focused on microbes and they tended to leave broader cultural and environmental issues out of consideration. We know that an adequate science does not leave ecology out of consideration, and it does not ignore sociocultural influences on behaviors that spread disease.

The new public-health practice requires "cultural competence," that is, an understanding of the culture of the people to whom public-health policies are applied. Ethnic ways, which include particular attitudes and practices related to health and disease, have to be taken into consideration in order to provide the most effective public-health services. Cooperation between conventional physicians and alternative practitioners, we know, may make the difference between compliance and noncompliance in minority populations.

The World Health Organization (WHO) has strongly advocated cooperation between conventional physicians and alternative practitioners because neither one is likely to disappear. In the United Kingdom in 1995, one in seven people visited alternative practitioners. In the Netherlands, a survey of 293 conventional generalists showed that many believe in the efficacy of certain alternative practices: manual therapy, yoga, acupuncture, hot baths, and homeopathy. In Germany, a distinction is made between scientifically supported alternatives such as naturopathy, which stimulates the body's own healing resources, and unscientifically based alternatives. The former are covered by some insurance policies and the state plan pays a subsidy to patients using them. In Norway, a group of conventional physicians and alternative practitioners are meeting to promote closer cooperation (Rankin-Box).

Because the use of alternative treatments continues to increase both in the United States and in Europe, new studies of alternative approaches have been initiated. In 1993, the National Institutes of Health (NIH) created an office of alternative medicine, where alternative approaches are tested; the public will be kept informed of research results. The U.S. Congress mandated the creation of this project and required that NIH spend two million dollars of its annual budget on it. An oversight committee includes both conventional physicians and alternative practice advocates. They have agreed that alternative practices will be evaluated with the same methods and standards as conventional therapies (outcome research, relative efficiency, double-blind where possible). This is an important development because ethical considerations of alternative practices have to start from reliable information about their effectiveness. This project has added ethical importance because the projects funded require cooperation and collaboration between alternative and conventional practitioners wherever possible.

Ethical Standards and Alternative Practice

Alternative medicine is governed by ethical obligations derived from what medical practitioners of any variety publicly profess and what societies have always required of them: to heal, to relieve pain, to restore function, and to comfort and accompany their dying, when patients are beyond treatment. In the Hippocratic tradition this basic ethical standard was encapsulated in the imperative "to help and not to harm." Early twenty-first century medical ethics talks about the same basic ethical obligation in terms of the principles of beneficence and nonmaleficence.

Alternative or conventional interventions that harm patients without providing offsetting benefits are unethical. Alternative treatments that are harmless may not violate either individual or social ethical standards—especially if patients have strong faith in them or if the illnesses for which they are used are self-limiting and conventional treatments are either expensive, have serious side effects, or have proven ineffective. When diseases being treated are more serious, however, harmlessness is not enough to satisfy individual and social ethical standards. If harmless alternative remedies prevent patients from seeking an effective treatment available from conventional medicine, then individual alternative practitioners would actually be preventing patients from being helped, and just social policy would require that such practice be curtailed. Although alternative remedies are most often adjuvant and complementary to mainline remedies, it remains important to respect the social and professional ethical requirement that treatment actually provide some benefit to patients. Patient benefit is a complicated concept that sometimes involves unquantifiable quality of life considerations, but patient benefit cannot be permitted to slip beyond empirical proof entirely. Societies have to make laws that use rigorous empirical standards for approval of treatment modalities. Anecdotal evidence of therapy effectiveness or claims of effectiveness dependent upon depth of commitment to an alternative belief system are not enough to satisfy basic individual and social medical ethical obligations.

Modern medical-ethical standards add another basic obligation derived from patient rights, that is, that the patient has the right to consent to treatment or to refuse consent. Alternative practitioners, like conventional doctors, are ethically obligated to provide patients with information relevant to their decisions and to protect patients against coercion, fraud, or manipulation. If patients are not competent, informed consent or refusal must be provided by surrogates—either family members or, in their absence, a guardian. Even decisions of competent patients, however, must meet professional standards, so that an irrational choice or insistence upon a treatment that is ineffective or futile or economically devastating might not—perhaps should not—be respected. The modern principle of patient autonomy must be balanced with the ageless principle of beneficence/nonmaleficence, which protects patients against irrational or incompetent decisions that involve harm without offsetting benefit. Care must be exercised, however, in judging irrationality so as not to confuse it with decisions based on value systems different from those of the treating physician or practitioner. Patients have their own values, and these cannot be set aside because they differ from what a scientifically focused specialist may think is organically best for a patient. True patient benefit requires consideration of both personal and scientific interests.

A competent adult may refuse an effective conventional treatment associated with real burden and choose instead an unproven or ineffective alternative therapy. Similar choices, made for children or for incompetent adults without advance directives, however, are neither ethically nor legally acceptable. Justice and autonomy, beneficence and nonmaleficence are broad, abstract ethical standards. Agreement about these standards in their abstract form is possible even in pluralistic and heterogeneous societies. But principles can come into conflict with one another. Respect for patient autonomy may mean not providing patient benefit or violating principles of justice and equality. When such conflict occurs, ethics at a more pragmatic level of discourse is required: concrete norms and rules that attempt to offer compromise, or to effect a balance between the conflicting principles. Working out the relationship between mainline conventional medicine and alternative practices involves just this form of concrete ethics. Appeal to abstract principles only in a situation of conflict between conventional and alternative medicine can turn an ethics discussion into an exchange of slogans. One important test of an ethics that addresses the relationship between alternative and conventional medicine is whether it encourages a needed dialogue between different practitioners and whether it can generate concrete norms and public policies to handle interaction between the two traditions (Eisenberg et al.).

Ethics has been intimately associated with mainline medicine since its beginning in Hippocratic times. Hippocratic physicians were distinguished from other healers not only by their emphasis on science but also by their commitment to patient benefit rather than to selfish goals. Medicine of any variety derives its ethics from obligations generated by a doctor-patient relationship in which a healer commits himself or herself to help someone in need by cure or pain relief or function restoration. Unselfishness and altruism are at the core of medicine's professional ethics. Truthfulness traditionally was not part of medical ethics, but recently it has been added in order to fulfill the obligations associated with patient autonomy. This essential and structural medical ethics is applicable to alternative and conventional medicine alike.

Mainline medicine obliges physicians to high ethical standards but has been weak in policing deviant members and sanctioning ethical failures. Alternative practitioners are not as well organized as conventional physicians, and some lack the strong ethical emphasis of the mainline tradition. Both face a daunting challenge: developing and maintaining the character traits without which concrete moral rules and abstract ethical principles are ineffective, in a new economic climate that encourages profit making more than altruism.

james f. drane (1995)

bibliography revised

SEE ALSO: Autonomy; Emotions; Healing; Healthcare Professionals, Legal Regulation of; Jehovah's Witness Refusal of Blood Products; Medicine, Philosophy of; Public Health Law; and other Alternative Therapies subentries

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