Does a patient have the right to access to non-Western forms of medical treatment? Anh Tran, S.J., Markkula Center for Applied Ethics Associate Director of Health Care Ethics, discusses the issues in this case of a doctor’s refusal to refer a patient for acupuncture.
Mr. Chen, a 40 year-old patient originally from China, has had lumbar problems for one year. The condition includes dull pain in his right leg and the inability to sit still for long periods. X-ray examination reveals a prolapsed lumbar disc. He has been treated with conventional pain medication with minimal effect.
His physician, Dr. Robert Olson, recommends back surgery, but Mr. Chen is reluctant to take this option. Instead, he asks the doctor to refer him to an acupuncturist because his insurance coverage requires physician's approval for "alternative" therapy. He mentions to the physician that he has tried acupuncture before, and it has helped him.
But Dr. Olson is skeptical about any kind of alternative therapy. This derives partly from his belief that allopathic medicine, the approach taught in Western medical schools, is the most efficacious because it has been scientifically proven through clinical trials. He has also had extensive positive experience with surgical treatment for Mr. Chen’s condition. In his view, other forms of medicine are at best placebos, and he does not see it as his duty to recommend them. He refuses to order the acupuncture.
Did the physician act ethically?
This case illustrates a common scenario in doctors’ offices. Many patients seek alternative therapies because conventional medicine has not brought them satisfaction. Must their physicians make these referrals? As you answer the question, you might consider these ethical issues:
Cultural Sensitivity
First, it is important to define what is "conventional" and what is "alternative." Dr. Olson has overlooked the fact that for Mr. Chen, as for many of his Asian patients, acupuncture and herbal therapy are considered conventional treatment. In East Asia (China, Japan, Korea, and Vietnam), there is a dual system of medicine – Oriental, or "traditional," and Western, or "modern." Each type of medicine has its sphere of influence, and they are not considered mutually exclusive.
Although acupuncture and Chinese medicine have been a part of the regular health care system in East Asia for millennia, they did not become popular in the United States until the 1970s. Since then, acupuncture has been used by millions of American patients and performed by thousands of health care professionals, including physicians, dentists, and acupuncturists.
After two decades of researching and reviewing the body of knowledge on acupuncture, the U.S. Food and Drug Administration recently removed acupuncture needles from the category of "experimental medical devices"; it now regulates them just as it does surgical scalpels and hypodermic syringes. In 1997, the National Institutes of Health published a consensus statement recognizing the efficacy of acupuncture as a therapeutic intervention for conditions ranging from post-operative pain and chemotherapy nausea to addiction and stroke rehabilitation. According to the NIH report, acupuncture "may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program."
While acupuncture is now readily available in the United States, there can still be cultural differences in the way American and Asian patients approach this treatment. People who grow up in an environment where Chinese medicine is a regular part of health care tend to value it for what it’s worth, but they will not hesitate to use Western medicine whenever necessary.
On the other hand, many non-Asian patients who seek alternative treatments are often unhappy with conventional medicine. They want a more relational style of health care; they wish to alleviate symptoms gently or with fewer side effects; they wish to prevent disease or enhance wellness. Some of them look at Chinese medicine as the answer to all their problems. These patients are in a more vulnerable position because they often are desperate to try anything. They are less critical of alternative therapies and expect more out of them. As a result, they are often victims of medical frauds that can cost them money, time, and health.
Medical Need Vs. Desire
Dr. Olson does not want Mr. Chen to become such a victim. Despite agreement on the efficacy of acupuncture for conditions like Mr. Chen’s, Dr. Olson believes that his patient would be better served by back surgery. Is he obligated to accede to Mr. Chen’s wishes? Should the patient’s desire for alternative treatments always be respected?
This question touches on the issue of patient autonomy. To what extent should a person control his or her own care? Here, physicians face a dilemma: A patient might want all kinds of treatments and therapies, some of which might be effective and some of which might actually be harmful. Must the physician automatically comply?
Some doctors refuse to consider any form of alternative therapy as a serious option for their patients. This is shortsighted. At minimum, physicians should educate themselves about the benefits and limitations of alternative therapies so they can be a good source for referrals. Acupuncture, for example, is not an appropriate treatment for every disease, but it has proven effective for complaints like Mr. Chen’s. By informing himself about what acupuncture can and can’t do, Dr. Olson would be better able to act in his patient’s best interests rather than simply protecting his turf.
In addition, many health insurance companies only cover alternative therapies if there is a doctor’s referral. If the patient’s insurance company is willing to pay for acupuncture, the physician’s refusal to refer will create an unnecessary financial burden on the patient.
Dr. Olson is still not obligated to recommend acupuncture if, in his considered opinion, it is not the best option. He can, however, explain his position to Mr. Chen and offer to refer him to another physician who is more open to considering alternative therapies. Patients are entitled to a second opinion and options when it comes to major (and irreversible) medical interventions such as surgery.
Evaluating Risks
Obviously, a physician’s decision-making process about referrals to alternative therapies must weigh the risks. Because in the United States a licensed acupuncturist is also often a Chinese herbalist (the reverse is not true), it is important to consider the risks vs. the benefits of acupuncture as a part of Chinese medicine, which might include herbal therapy. In any type of treatment, there is always a certain level of risk. The question is how much?
Chinese medicine has minimized risks, but it is not risk-free. Reported problems include delayed diagnosis or treatment from a conventional point of view, allergic reactions caused by interactions between prescription drugs and herbal remedies, and possible infections or physical injury associated with acupuncture treatment.
These risks are often linked to the education and experience of Chinese medicine practitioners. It is important for the patient-consumer to check the credentials and training of these health care providers. In California, as of 2000, there were 4378 active acupuncturists whose licenses were regulated by the Medical Board of California; at least 300 of these were physicians. At this writing (June 2001), herbalists—Western or Chinese—were not regulated by any government agency.
Patients should beware of an acupuncturist who claims to treat any and every disease. While these treatments are efficacious for many conditions, some practitioners tend to exaggerate the therapeutic effects. Physicians and patients should consult the 1979 World Health Organization list and the 1997 National Institutes of Health list for conditions that are appropriate for acupuncture treatment.
If patients turn to acupuncture for these approved indications, are the risks acceptable? And who should decide, the patient or the physician? This evaluation is a shared responsibility. Physicians should educate themselves and patients on the benefits vs. the risks of acupuncture. Patients have an obligation to disclose to their physicians what type of therapy they undergo so that risks can be minimized. This can be achieved if there is mutual trust between physicians and patients. Physicians should be open-minded but critical. Patients should be willing to consider the physician’s recommendation seriously.