'Complementary & Alternative Medicine' (CAM)

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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 30 Number 2 2016 pp 60–62

doi:10.1111/bioe.12243

EDITORIAL

COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM): ETHICAL AND POLICY ISSUES CAM encompasses a wide range of therapeutic modalities, including acupuncture, chiropractic, herbalism, homeopathy and osteopathy. It occupies a paradoxical position in modern medicine and healthcare: the plausibility and evidence base of many CAM treatments is very limited, and CAM approaches have been criticized and challenged by many scientists and physicians; despite this, some forms of CAM are popular among many lay people and a significant number of medical professionals. This raises fundamental ethical questions concerning the moral status of CAM. Substantive ethical arguments against the practice, promotion or toleration of CAM are manifold and include creation of risk through patients failing to seek effective healthcare, direct harm from intrinsically dangerous preparations or procedures, wastage of healthcare resources on ineffective therapies, promulgation of antiscientific perspectives in medicine and amongst the populace, and exploitation of poorly informed patients and vulnerable persons including children and non-competent adults. Counter-arguments from proponents of CAM include claims that placebo effects provide sufficient justification for the use of interventions which have no plausible biomedical basis or demonstrable biological effect, and that a CAM therapy can be justified if it subjectively pleases patients in everyday practice. Linked to such arguments are claims that CAM is cheaper and less invasive than conventional medicine, that non-conventional modalities are desirable or preferable on the basis that they are natural or holistic, and that patients autonomy is maximized by the provision of CAM to those who wish to receive it. We issued a Call for Papers for a special issue of the journal on the ethics of CAM. This generated a number of interesting contributions; ultimately, a total of four articles cleared the hurdles of editorial and peer review, and we are pleased to present these in the present issue of the journal. Definitions of CAM are varied and can be contentious, and indeed the articles published here define CAM in slightly varied ways. We consider that an acceptable definition of an alternative therapy would incorporate two key elements: (a) its efficacy is either unproven or disproved; and (b) the rationale for testing it in a trial cannot be expressed in acceptable scientific language. Regardless of definitional nuances, however, one precept should be clear: where robust evidence exists to demon-

strate the clinical efficacy of a therapeutic modality, and the proposed mechanistic basis of the modality does not violate fundamental scientific and logical principles, that therapy becomes (in principle) part of mainstream medicine and can no longer be considered as a form of CAM. In this context it is worth noting is that some of the initial submissions to the Special Issue were posited on claims of clinical efficacy and logico-scientific plausibility: had such claims been successful, the manuscripts subsequent ethical arguments – while possibly being of relevance to medicine more generally – would not be specifically relevant to CAM, and therefore could not be accepted for publication in the present context. However, it was somewhat dismaying to us – although perhaps not surprising, given our knowledge of the field – that some of the submitted manuscripts made poor use of, or misinterpreted, the published literature, and/or made claims for plausibility that virtually no serious scientist could accept, thus rendering the articles accompanying ethical argumentation invalid. Therefore, in such cases publication was not possible, and this contributed to a reduction in the number of articles eventually accepted for publication in this issue of the journal. The four articles published here deal in depth with several distinct areas of CAM, ranging from the public funding of homeopathy to notions of informed consent in CAM. Despite this specificity, many of the ethical arguments thereby developed have broad applicability across the spectrum of CAM modalities and contexts. Louise Crawford raises questions of ethical legitimacy in the context of a homeopathic hospital in the United Kingdom. A unique feature of Crawfords paper is the deployment of a well-established theoretical model from the accountability literature to the domain of bioethics. Crawford argues that homeopathy should be considered as a form of controversial industry, with an ethical status akin to that accorded to other controversial for-profit activities, for example armaments, gambling, pornography or tobacco. Her article identifies and analyses various legitimizing strategies used by homeopathy advocates in their attempts to secure moral legitimacy for homeopathy in the context of the Glasgow Homeopathic Hospital (GHH). She concludes that, in the case of the GHH, proCAM advocates have failed to maintain or repair moral legitimacy for homeopathy, resulting in a substantial probability that continued public funding for the GHH will cease. Crawford goes on to propose a number of broader lessons, including the concept that publicity can function as a crucial factor against attempts to secure undeserved moral legitimacy in the domain of CAM. C 2016 John Wiley & Sons Ltd V

Editorial Samuel Homola raises important ethical issues concerning the use of chiropractic spinal manipulation in children. Such techniques are commonly used by chiropractors on pre-adolescents – including infants and neonates – as treatment or preventative measures for a wide variety of ailments allegedly caused by vertebral subluxation. Such paediatric chiropractic techniques are supported by major chiropractic associations, and taught in chiropractic colleges. Homola identifies this situation as one of serious ethical concern on multiple grounds, including: credible evidence does not exist to support chiropractic subluxation theory; attempts to apply chiropractic manipulation to the immature spine presents a serious risk of physical harm to the child; and chiropractic care for children frequently conflicts with established medical guidelines. Subluxation-based chiropractors often genuinely believe (against the science and evidence) that spinal adjustment is required for the maintenance of health of all family members, and this carries the risk that such beliefs are transmitted to parents seeking chiropractic therapy for back pain, potentially resulting in children becoming captive victims of inappropriate treatment. Homola concludes that chiropractic manipulation of the immature spine of pre-adolescent children is dangerous, ineffective and unethical. Chris MacDonald and Scott Gavura consider CAM from the perspective of the ethics of commerce. CAM products and services are offered on sale as marketable entities, and as such ought to conform to the established tenets of commercial ethics. MacDonald and Gavura posit that trade in medical products and services is valuable in terms of maximizing consumer and vendor autonomy, and promoting diversity and competition within the healthcare sector. From this starting point, their article applies a formal framework for exploring the ethics of commerce to examine whether it is ethical, in general, to sell CAM products and services. Using this analytical framework, the authors firstly consider whether selling CAM violates the standard of merchantability – i.e. does the product or service fail to function as it should? The notion of what it means for a health product to work is not necessarily straightforward; for example, a consumer may purchase a CAM treatment not for its physiological effects but for its religious, spiritual or cultural significance. The authors explore the issues around merchantability in depth, and conclude that CAM violates this core tenet of commercial ethics. The articles analytical framework is additionally employed to establish that selling CAM entails deception on the part of the vendor, and may harm third parties, for example where parents fail to provide adequate care to their children by insisting on the use of CAM instead. MacDonald and Gavura conclude that central cases of CAM violate some or all of the core principles of commercial ethics.

C 2016 John Wiley & Sons Ltd V

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Arianne Shahvisi explores issues of informed consent in the context of CAM. The general demand for informed consent is, to a large extent, based on the notion that it promotes patient autonomy. To be effective in this regard, truly informed consent entails the patient sufficiently understanding the treatment – how it works (broadly), and why it (and not another treatment) is being offered for the patients medical condition. In reality, patients often simply rely upon physician authority as a proxy for personal understanding; in such cases there exists a wide – and ethically undesirable – epistemic disparity between patient and physician. But even in such cases, the physician should in principle be able to explain the treatment to the patient if so requested. Shahvisi argues that alternative medicine treatments fundamentally cannot be understood by anybody, including patients and physicians, because these modalities do not draw upon plausible physical causes, and may rely upon implausible mechanisms (e.g. acupuncture, homeopathy) or supernatural interventions (e.g. faith healing). Without understanding, or even the possibility of such understanding, informed consent is impossible. Shahvisi concludes that it is unethical for medical professionals to offer or endorse alternative medicine treatments. As guest editors we hope that these four articles will inform and motivate further debate around the ethics of CAM. The field of CAM ethics is young, however, it is already apparent that the majority of published papers in the field (at least those published in quality peerreviewed journals) reach negative conclusions concerning the ethics of CAM. It may be that the fundamental ethical arguments concerning CAM have by now been established, with the arguments reaching negative conclusions on CAM clearly trumping the opposing pro-CAM arguments. If this is indeed the case, the question becomes: what future forms of inquiry into the ethics of CAM will be of value? An answer may be found among the articles in this issue of the journal. Some of authors of these articles consider CAM ethics by focusing on a precise real-world case (the Glasgow homeopathic hospital, chiropractic spinal manipulation in children), and some apply analytical tools and ethical frameworks from outside the domain of bioethics (moral legitimacy theory, the ethics of commerce). In all four articles, an interdisciplinary perspective is evident. We suggest that future research and scholarship in CAM ethics would do well to take an interdisciplinary approach, bringing diverse intellectual tools to examine the ethics of specific realworld cases of CAM use or promotion. KEVIN SMITH (Abertay University) EDZARD ERNST (Exeter University) DAVID COLQUHOUN (University College London) WALLACE SAMPSON (Stanford University)

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Editorial

Kevin Smith is a bioethicist at Abertay University, Dundee (UK). His research focuses on CAM ethics, genethics and utilitarian bioethics. David Colquhoun held the AJ Clark Chair in Pharmacology at University College London (UK) until 2004. His main interest was the interpretation of single ion channel recordings. He worked both on experiments and on the stochastic theory needed to interpret them. Since 2004 he has specialised in the statistical interpretation of evidence, and in explaining this to the public via the media and his blog (dcscience.net). Edzard Ernst studied medicine and held professorial posts in Hannover (Germany), Vienna (Austria) and Exeter (UK). He has over 20 years of experience researching CAM. He has published 48 books and more than 1000 articles in the peer-reviewed medical literature, and his work has been awarded 15 scientific prizes. His latest book is A Scientist in Wonderland: A Memoir of Searching for Truth and Finding Trouble (Imprint Academic, 2015). Wallace Sampson practiced as a hematologist-oncologist, and headed the Division of Oncology at Santa Clara Valley Medical Center, San Jose (USA). He held a Professorship at Stanford University, and served as Chairman of the Cancer Advisory Council for the State of California and board member for the National Council Against Health Fraud. He published widely in the domain of CAM, and founded the journal The Scientific Review of Alternative Medicine.

POSTSCRIPT Sadly, one of the guest editors, Dr Wallace (Wally) Sampson, died during this publishing project, at the age of 85. A vigorous defender of scientific medicine, Wally was trenchantly opposed to pseudoscience and health fraud. He was academically active for decades, publishing widely and serving as founding editor of The Scientific Review of Alternative Medicine, amongst many other activities in defence of science and reason in medicine. He was particularly renowned for inspiring and nurturing younger academics and sceptics. Indeed, he was the first person to encourage and inspire me in this direction – specifically in terms of applying ethical analysis to CAM – and I consider myself very fortunate to have benefitted from his many deep insights and novel ideas. Wally will be sorely missed by a wide community of scientists, physicians, ethicists and others who have benefitted immeasurably from his great intellect and fine character.

KEVIN SMITH

C 2016 John Wiley & Sons Ltd V