Bioethics Discussion Blog: November 2004





Thursday, November 25, 2004

Medical Miracles or Misguided Media?

Continuing with the topic of blurring the line between medicine and "miracles", here is a link to a great analysis by Los Angeles Times Staff Writer David Shaw on how the media is, to the detriment of the public, blurring the line. ..Maurice.

Medical Miracles or Misguided Media?: "Science is both a methodical and a somewhat messy process, a gradual exploration of the unknown. It moves slowly, with each study building on the one before it--brick by brick by brick. Most discoveries are partial improvements, steps forward (or backward), subtle gradations and even contradictions. There's seldom a true end point in science. Almost invariably, the breakthrough that's published today is the final stage in a series of studies that began years, perhaps decades ago, and it, too, may still be subject to revision by future studies. Genuine breakthroughs, giant leaps forward--penicillin, for example, or the Salk polio vaccine--are rare."

Monday, November 22, 2004

Ad Tagline:"Blurring the Line Between Medicine and Miracles"

I know of a current advertising campaign to the public for a multi-specialty professional medical group to emphasize the uniqueness of the group from other groups. The tagline for the advertisements is: “Blurring the line between medicine and miracles”

Here is my opinion about the use of such a tagline. Though this may be thought as a "goodheaded" slogan from an advertising point of view, I find this tagline as misleading and ethically wrong. It simply adds irrational support to the confused idea that there really may be a relationship between medical practice and what many
define as "miracles". It sets up a concept about medical care which could in the
end lead to degrading attempts at patient beneficence, non-malificence and
justice for patients in general. Many of the conflicts brought to the ethics
committee have to do with confusion in the mind of patients and family about the
limits of medicine. Often, families want more diagnostic tests, treatment
and continued life-support in search of the "miracle".

Miracles to me are very rare medically unexpected and scientifically unclear
good-fortune. Doctors are not "miracle-workers". Hope is important as
presented to the patient and family but at some point physicians must be realistic
in their presentation as to what they can accomplish. Though it is likely that the physicians of the multi-specialty clinic deserve recognition of excellence, nevertheless the line between medicine
and miracles should be kept bright and clear and blurring should be avoided.

Do you think that miracles should not be looked upon as a medical result but due to something else, perhaps of spiritual origin? ..Maurice.

The Blogs of Two Beginning Physicians

I have found two blog sites which seem to complement what I have been writing about in the past few months. One is Chronicles of a Medical Mad House which is written by a medical resident in a city hospital and deals with his experiences there. The other is The Examining Room of Dr. Charles who is apparently a general physician who has just finished his residency and is starting up his new office practice. This blog also deals with the physician's trials and tribulations. They both appear to be worthy to link into. ..Maurice.

Monday, November 15, 2004

Breaking the Doctor-Patient Relationship: The Suing Patient

I would like to bring up an issue for discussion that has to do with a breakdown in the doctor-patient relationship. What should happen to the relationship if the patient initiates a malpractice suit against the doctor or the medical clinic and yet apparently has not terminated the professional relationship? This event has happened in the past. What could be the consequences if the relationship was to continue? Would each party have sufficient trust in the other to make the doctor-patient interaction therapeutically effective?

In a San Diego, CA case Scripps Clinic v. Superior Court (Thompson) (2003), Cal.App.4th [No.D040569. Fourth Dist., Div. One. April. 17, 2003], a physician-group practice rationalized the decision to transfer the patient to another clinic by arguing that a physician having received an intent to sue letter "irreparably compromises the physician-patient relationship, thereby potentially compromising the care rendered to the patient. Patient litigants might not be as forthcoming for fear that evidence or information would be used in their lawsuit. Further, patients may also believe that their physicians will not give them balancedcare...for example, they might believe that a physician who does not timely return a telephone call is punishing the patient." (Thanks to Lance K Stell, PhD, FACFE, Charles A. Dana Professor of Philosophy, Director, Medical Humanities Program, Davidson College, PO Box 7135,Davidson, NC 28036 for the reference.) Does the physician or clinic at this point have the right to decide not to continue treating the patient and transfer the patient to another physician or clinic, if the patient’s medical condition allows the patient to be safely transferred? What if the patient lives in a geographic area where transportation to another caregiver would be lengthy and inconvenient?

It is my understanding that as the patient has the legal right to sue and the physician or clinic has the legal right not to accept a patient except in an emergency and a right to terminate care, not to abandon the patient but transfer the patient safely to another equivalent healthcare provider. But in this particular situation what is your opinion? ..Maurice.

Sunday, November 14, 2004

Possible Conflict of Interest:Doctors Selling Products and Owning Stock

As a segue from complementary and alternative medicine, consider the physician selling to the patient, out of the office, potions and lotions of alternative medicine which may have equivocal efficacy. Consider, the physician selling pharmaceuticals which have proven benefit or other products which may also be found in drug stores. What do these action do to the doctor-patient relationship? If a doctor prescribes but also sells to the patient a medication, can the patient be sure that the doctor's prescription was not based on the doctor's self-interest rather than the interest of the patient? Would a cheaper medication that the doctor was not dispensing be equally as effective? Some have equated this action as equivalent to a physician referring the patient to a lab or X-ray facility of which the physician had financial interest. Are these behaviors on the part of the physician ethical?
One can also extend the ethical concerns to physicians who own stock in certain pharmaceutical companies or have been treated to some benefit by a pharmaceutical company. Should patients consider that the physician might be prescribing a particular brand of medicine because of this influence? Should each patient be made aware at the outset of all potential conflicts of interest that their physician bears? Or should the patient always assume that a physician's interest is always in the patient? Please write me your comments on this issue.

As a resource to learn more about the issue of the physician selling products from his or her office, read the position paper representing the Ethics and Human Rights Committee of the American College of Physicians titled "Selling Products Out of the Office" by
Gail J. Povar, MD and Lois Snyder, JD, for the Ethics and Human Rights Committee, Annals of Internal Medicine, 7 December 1999 | Volume 131 Issue 11 | Pages 863-864. Here is an abstract of that paper. ..Maurice.

The sale of products from the physician’s office raises several ethical issues and may affect the trust necessary to sustain the patient-physician relationship. When deciding whether to sell products out of the office and, if so, which ones, physicians should carefully consider such criteria as the urgency of the patient’s need, the clinical relevance to the patient’s condition, the adequacy of evidence to support use of the product, and geographic and time constraints for the patient in otherwise obtaining the product. Physicians should make full disclosure about their financial interests in selling the product and inform patients about alternatives for purchasing the product. Charges for products sold through the office should be limited to the reasonable costs
incurred in making them available.

Friday, November 12, 2004

Medical Ethics of Complementary and Alternative Medicine (6)

I am going to leave the issue of the ethics of CAM now.. but I do want to refer those who want to continue this thread to another blog, Complementary and Alternative Medicine Law Blog. This blog is devoted to CAM and presents news items and discussions of the legal implications as well as the ethical and many other aspects of CAM practice. You should find the site rewarding as another resource. ..Maurice.

Wednesday, November 10, 2004

Medical Ethics of Complementary and Alternative Medicine (5)

In order to best understand the benefits found in the use of the various modalities of alternative medicine, evidence-based conclusions need to be presented. These conclusions are based on careful review of as many research projects available in the literature done to look for benefits of a particular modality for a particular disease or disorder. The reviewer must be able to establish that the research trial was devised to meet scientific criteria and attempt to find statistically significant data. These projects are then compared and together, a conclusion about benefits as well as harms can be established. This review then becomes the basis for rational use of the alternative medicine modality in the specific disease.

There is a developing web-site that has begun such a review of CAM studies. It is called "Complementary and Alternate Medicine" and is an evidence-based resource from New Zealand about complementary and alternative medicine. Recently completed reviews include Arnica creams, gels and sprays for the treatment of soft tissue injury; Cranberry for the prevention of urinary tract infection; Acupuncture for smoking cessation; Horse chestnut seed extract for the treatment of chronic venous insufficiency; and Garlic for the treatment of calf pain when walking. The results are summarized and a conclusion is given. A description of the modality and a description of the medical condition is also given for visitor education.
The URL for this important resource is

Medical Ethics of Complementary and Alternative Medicine (4)

My view of complementary and alternative medicine is that the practice should be more complementary than alternative. What I mean is that I think that the very best treatment for the patient, if alternative treatment is considered, should be a carefully orchestrated combination of both alternative and conventional standard medicine with practitioners of both disciplines working together. There is no doubt that alternative medicine has something to offer patients. For one example is the attention that the alternative practitioner provides to the patient. There is something important provided to the patient with the “listening to the patient” by the chiropractor and others in alternative medicine or the “laying on of hands” by the chiropractor or those practicing “therapeutic touch.” Medical doctors are often criticized for such deficiencies in terms of their brief history taking and their perfunctory physical examinations.

With regard to the therapeutic benefits of the techniques or substances administered, there is certainly the possibility that they provide a benefit through the so-called “placebo” effect. This effect would not involve a direct physical or pharmacologic action but produce benefit indirectly through unknown or psychologic or behavioral mechanisms. Direct benefits must be proven by research studies.

What are the ethical implications of alternative medicine as integrated into conventional medicine? I agree with much of the concerns and conclusions written in the articles of the previous two postings. With regard to establishing a benefit beyond a placebo effect, many of the techniques or substances could be subjected to controlled studies with care taken to provide the same informed consent and protection to the subjects as research studies done in conventional medicine. When alternative medicine is used with conventional medical treatment, the orchestration mentioned above should include care that the patient is not harmed or burdened by either method, that the interference of the methods be minimized and that the patient should be informed about the all the risks and known benefits. There will be cases where conventional medicine has reached a dead end in terms of specific therapy for the illness. This is where conventional medicine must reach out with comfort care to the patient and not simply abandon the patient to alternative medicine. The medical doctor should not extinguish the little flame of “hope” which the patient holds but still be realistic in talking to the patient and support the patient if the patient wishes to try alternative medicine as long as this is part of a program of comfort care for which the medical doctor is managing.

As you see,in this posting,I am supporting the view of the patient always engaging in complementary medicine rather than going out and obtaining alternative medicine on their own. My rationale is that diseases are based on anatomical,physiologic,psychologic,biologic,pharmacologic,biochemical and physical principles and the practitioners who have the best education for treating diseases are the medical doctors (or modern osteopaths)and therefore they should never remain outside the care of the patient.You may hold a different view and I certainly would like to hear from you. Please write your comments on this subject. ..Maurice.

Monday, November 08, 2004

Medical Ethics of Complementary and Alternative Medicine (3)

JAMA -- Abstract: Ethical Issues Concerning Research in Complementary and Alternative Medicine, Franklin G. Miller, PhD; Ezekiel J. Emanuel, MD; Donald L. Rosenstein, MD; Stephen E. Straus, MD

JAMA. 2004;291:599-604.

The use of complementary and alternative medicine (CAM) has grown dramatically in recent years, as has research on the safety and efficacy of CAM treatments. Minimal attention, however, has been devoted to the ethical issues relating to research on CAM. We argue that public health and safety demand rigorous research evaluating CAM therapies, research on CAM should adhere to the same ethical requirements for all clinical research, and randomized, placebo-controlled clinical trials should be used for assessing the efficacy of CAM treatments whenever feasible and ethically justifiable. In addition, we explore the legitimacy of providing CAM and conventional therapies that have been demonstrated to be effective only by virtue of the placebo effect.

Thursday, November 04, 2004

Medical Ethics of Complementary and Alternative Medicine (2)

An issue which can be raised regarding complementary and alternative medicine is whether the physician’s advice to patients encouraging use of the modalities involved and their use is indeed ethical. Adams, Cohen, Eisenberg and Jonsen writing in the Annals of Internal Medicine present some criteria which if considered may pave the way to ethical use in appropriate patients. The following is the abstract from the Annals article. ..Maurice.

From the Annals of Internal Medicine, 15 October 2002 | Volume 137 Issue 8 | Pages 660-664

Ethical Considerations of Complementary and Alternative Medical Therapies in Conventional Medical Settings

Karen E. Adams, MD; Michael H. Cohen, JD, MBA, MFA; David Eisenberg, MD; and Albert R. Jonsen, PhD

Increasing use of complementary and alternative medical (CAM) therapies by patients, health care providers, and institutions has made it imperative that physicians consider their ethical obligations when recommending, tolerating, or proscribing these therapies. The authors present a risk–benefit framework that can be applied to determine the appropriateness of using CAM therapies in various clinical scenarios. The major relevant issues are the severity and acuteness of illness; the curability of the illness by conventional forms of treatment; the degree of invasiveness, associated toxicities, and side effects of the conventional treatment; the availability and quality of evidence of utility and safety of the desired CAM treatment; the level of understanding of risks and benefits of the CAM treatment combined with the patient’s knowing and voluntary acceptance of those risks; and the patient’s persistence of intention to use CAM therapies. Even in the absence of scientific evidence for CAM therapies, by considering these relevant issues, providers can formulate a plan that is clinically sound, ethically appropriate, and targeted to the unique circumstances of individual patients. Physicians are encouraged to remain engaged in problem-solving with their patients and to attempt to elucidate and clarify the patient’s core values and beliefs when counseling about CAM therapies.

Tuesday, November 02, 2004

Medical Ethics of Complementary and Alternative Medicine (1)

To begin this topic, first we should understand what is complementary and alternative medicine (CAM) and how it has been applied to treat patients including its use along with conventional medicine. To help explain CAM, the following is an informational fact sheet publication by the U.S. National Institutes of Health. (Please note that in this post, the URL resources listed have not been linked.) I will be presenting the ethical issues of CAM in later postings. ..Maurice.

What Is Complementary and Alternative Medicine (CAM)?

On this page:

* What is complementary and alternative medicine?
* Are complementary medicine and alternative medicine different from each other?
* What is integrative medicine?
* What are the major types of complementary and alternative medicine?
* What is NCCAM's role in the field of CAM?
* Definitions

There are many terms used to describe approaches to health care that are outside the realm of conventional medicine as practiced in the United States. This fact sheet explains how the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health, defines some of the key terms used in the field of complementary and alternative medicine (CAM).[These definitions are found at the bottom of this fact sheet.]

What is complementary and alternative medicine?

Complementary and alternative medicine, as defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.1,2 While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.

The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.

Are complementary medicine and alternative medicine different from each other?

Yes, they are different.

* Complementary medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery.

* Alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.

What is integrative medicine?
Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.

What are the major types of complementary and alternative medicine?

NCCAM classifies CAM therapies into five categories, or domains:

1. Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

2. Mind-Body Interventions

Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.

3. Biologically Based Therapies

Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements,3 herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).

4. Manipulative and Body-Based Methods

Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.

5. Energy Therapies

Energy therapies involve the use of energy fields. They are of two types:

* Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

* Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

What is NCCAM's role in the field of CAM?

NCCAM is the Federal Government's lead agency for scientific research on CAM. NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professionals.


1 Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Other terms for conventional medicine include allopathy; Western, mainstream, orthodox, and regular medicine; and biomedicine. Some conventional medical practitioners are also practitioners of CAM.

2 Other terms for complementary and alternative medicine include unconventional, non-conventional, unproven, and irregular medicine or health care.

3 Some uses of dietary supplements have been incorporated into conventional medicine. For example, scientists have found that folic acid prevents certain birth defects and that a regimen of vitamins and zinc can slow the progression of an eye disease called age-related macular degeneration (AMD).


Acupuncture ("AK-yoo-pungk-cher") is a method of healing developed in China at least 2,000 years ago. Today, acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

Aromatherapy ("ah-roam-uh-THER-ah-py"): involves the use of essential oils (extracts or essences) from flowers, herbs, and trees to promote health and well-being.

Ayurveda ("ah-yur-VAY-dah") is a CAM alternative medical system that has been practiced primarily in the Indian subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment.

Chiropractic ("kie-roh-PRAC-tic") is a CAM alternative medical system. It focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool.

Dietary supplements. Congress defined the term "dietary supplement" in the Dietary Supplement Health and Education Act (DSHEA) of 1994. A dietary supplement is a product (other than tobacco) taken by mouth that contains a "dietary ingredient" intended to supplement the diet. Dietary ingredients may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, and metabolites. Dietary supplements come in many forms, including extracts, concentrates, tablets, capsules, gel caps, liquids, and powders. They have special requirements for labeling. Under DSHEA, dietary supplements are considered foods, not drugs.

Electromagnetic fields (EMFs, also called electric and magnetic fields) are invisible lines of force that surround all electrical devices. The Earth also produces EMFs; electric fields are produced when there is thunderstorm activity, and magnetic fields are believed to be produced by electric currents flowing at the Earth's core.

Homeopathic ("home-ee-oh-PATH-ic") medicine is a CAM alternative medical system. In homeopathic medicine, there is a belief that "like cures like," meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses would actually cause those symptoms.

Massage ("muh-SAHJ") therapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being.

Naturopathic ("nay-chur-o-PATH-ic") medicine, or naturopathy, is a CAM alternative medical system. Naturopathic medicine proposes that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the patient with a goal of supporting this power, through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine.

Osteopathic ("ahs-tee-oh-PATH-ic") medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all of the body's systems work together, and disturbances in one system may affect function elsewhere in the body. Some osteopathic physicians practice osteopathic manipulation, a full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well-being.

Qi gong ("chee-GUNG") is a component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and enhance immune function.

Reiki ("RAY-kee") is a Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.

Therapeutic Touch is derived from an ancient technique called laying-on of hands. It is based on the premise that it is the healing force of the therapist that affects the patient's recovery; healing is promoted when the body's energies are in balance; and, by passing their hands over the patient, healers can identify energy imbalances.

Traditional Chinese medicine (TCM) is the current name for an ancient system of health care from China. TCM is based on a concept of balanced qi (pronounced "chee"), or vital energy, that is believed to flow throughout the body. Qi is proposed to regulate a person's spiritual, emotional, mental, and physical balance and to be influenced by the opposing forces of yin (negative energy) and yang (positive energy). Disease is proposed to result from the flow of qi being disrupted and yin and yang becoming imbalanced. Among the components of TCM are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage.

For More Information

Sources of NCCAM Information

NCCAM Clearinghouse

Toll-free in the U.S.: 1-888-644-6226
International: 301-519-3153
TTY (for deaf and hard-of-hearing callers): 1-866-464-3615

Web site:
Address: NCCAM Clearinghouse, P.O. Box 7923, Gaithersburg, MD 20898-7923

Fax: 1-866-464-3616
Fax-on-Demand service: 1-888-644-6226

The NCCAM Clearinghouse provides information on CAM and on NCCAM. Servics include fact sheets, other publications, and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Sources of Information on Dietary Supplements

Office of Dietary Supplements, NIH
Web site:

ODS supports research and disseminates research results on dietary supplements. It produces the International Bibliographic Information on Dietary Supplements (IBIDS) database on the Web, which contains abstracts of peer-reviewed scientific literature on dietary supplements.

U.S. Food and Drug Administration (FDA)
Center for Food Safety and Applied Nutrition
Web site:
Toll-free in the U.S.: 1-888-723-3366

Information includes "Tips for the Savvy Supplement User: Making Informed Decisions and Evaluating Information" ( and updated safety information on supplements ( If you have experienced an adverse effect from a supplement, you can report it to the FDA's MedWatch program, which collects and monitors such information (1-800-FDA-1088 or

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.

NCCAM Publication No. D156
May 2002