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Complementary medicine is popular, yet ethical issues are rarely discussed. Misleading information, informed consent, publishing, and confidentiality are discussed in the light of medical ethics. The message that emerges is that, in complementary medicine, ethical issues are neglected and violated on a daily basis.
Several articles have been written about ethical problems related to complementary medicine, such as those by Ernst,1 Kerridge and McPhee,2 and Miller et al.3 These articles address ethics in the abstract; discussions that focus on practical day-to-day issues are largely missing. This article is aimed at filling the gap by alerting readers to ‘real-life’ ethical problems in the area of this increasingly popular form of health care.
Misleading patients or consumers is unquestionably wrong and can be unethical. Yet, in complementary medicine, this is precisely what happens on a daily basis. Misinformation is extremely widespread but, for the purpose of this article, only a few recent examples are provided.
A survey of promotional leaflets distributed by US and Canadian professional chiropractic organisations showed that all of those sampled claim chiropractic services that ‘have not been scientifically validated’.4 The authors concluded that this ‘reinforces an image of the chiropractic profession as functioning outside the boundaries of scientific behaviour’.4
The ethical code of The Royal Pharmaceutical Society of Great Britain informs UK pharmacists that they ‘must assist patients in making informed decisions by providing them with necessary and relevant information’ when purchasing homeopathic medicines,5 yet UK pharmacies distribute misleading promotional material that fails to inform customers that homeopathy is biologically implausible and not supported by convincing data on clinical effectiveness.6
The Code of Ethics and Practice of the UK Society of Homeopaths (the professional organisation of British non-doctor homeopaths) states that ‘all speculative theories will be stated as such and clearly distinguished’,7 yet the website of that society (www.homeopathy-soh.org) is full of speculative theories about the mode of action of homeopathic remedies without the slightest attempt to differentiate between fact and fiction.
The code of ethics of chiropractors of Britain and most other nations make it clear that chiropractors must not use the title ‘doctor’ such that clients might get the impression they are registered medical practitioners.8 However, there is much evidence that the majority of UK chiropractors do precisely that.9,10 In addition, a recent survey from New Zealand found that 82% of chiropractors in that country use the title ‘doctor’,11 a practice that was called ‘legally dubious’ by the Medical Council of New Zealand.12
Informed consent is an essential prerequisite for both research and clinical practice. Yet there is much anecdotal evidence that many practitioners of complementary medicine fail to obtain informed consent before treating a patient. For instance, in January 2003 the UK General Medical Council (GMC) dismissed a medical homeopath from the medical register, the main reason being that she had not obtained informed consent from her patients before administering homeopathic and other complementary treatments.13
British chiropractors recently published a survey of 150 practising chiropractors. Of those who responded, 25% reported not informing their patients of physical examination procedures prior to commencement, 6% did not fully explain the proposed treatment, over a third did not advise patients of alternative therapeutic options, 7% reported not always discussing minor risks, and 77% failed to discuss serious risks.14 The last point is particularly poignant as several hundred cases of serious adverse events after spinal manipulations are on record.15
Adequate ethical standards are an essential prerequisite for medical research in any area. This article shows that complementary medicine seems to be an important exception to this rule. These issues urgently need to be addressed to ensure that complementary medicine complies with the same standards as the rest of health care.
In 2005, a survey of 37 US professional organisations of complementary medicine revealed that only 57% had any informed consent policy or standards.16 Only 16% demanded that their members routinely obtain informed consent from their patients.
In research of complementary medicine, informed consent might also be suboptimal. Miller and Kaptchuk showed that, in acupuncture trials, patients are often deliberately misled by the investigators.17 Instead of getting the information that they may receive a sham treatment, researchers frequently tell patients of sham-controlled trials that several types of acupuncture are being compared and that they will receive one of them. Miller and Kaptchuk argue that this deceptive disclosure ‘violates the ethical requirement to obtain informed consent’.17
It is not difficult to find published studies of complementary medicine where informed consent was not obtained. For instance, Li et al published a clinical trial of qigong for detoxification of Chinese heroin addicts.18 The trial participants were from a ‘mandatory drug treatment centre’ and no informed consent was sought for the purpose of that study.
Using a systematic comparison of published articles, it was attempted to assess whether differences exist between the reporting of ethical aspects of clinical trials of complementary and conventional medicine.19 The results suggested that the former studies reported ethical approval less frequently. The situation was similar when the frequencies of disclosing conflicts of interest and sponsorship were compared.
Conflicts of interest can be ‘personal, professional or financial; and they can be actual (do influence judgement) or potential (could affect judgement)’.20 In complementary medicine research, financial interests are usually far less pertinent than in pharmacological research, but personal and professional influences can often be powerful. The vast majority of complementary medicine research is currently being performed by enthusiasts who aim to prove that their therapy is effective. This can constitute a conflict of interest that might be as influential as a financial conflict, yet it is hardly ever disclosed in publications.
The UK GMC, along with virtually all other healthcare organisations worldwide, stipulates confidentiality as an essential ethical obligation that can only be breached in certain, well-defined circumstances.21 Patients consider confidentiality to be crucial; if anything, they believe it is more important than doctors do.22 To the best of the author's knowledge, there is no systematic research into the question as to how rigorously complementary practitioners adhere to confidentiality. Anecdotally, the impression is that breaches occur frequently.
Considering the currently widespread use of complementary medicine, it is remarkable how rarely the ethical implications of this area of health care are being discussed. Many practitioners receive little or no ethical training during their education. Even the most voluminous standard texts, like the 1500-page Textbook of Natural Medicine, do not include a chapter on medical ethics.23 As a consequence, important issues continue to be neglected, ethical guidelines are violated, little research is being done, and crucial questions remain unanswered. It is time to change this deplorable situation.
The author has stated that there are none.
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