Future Medicine: Ethical Dilemmas, Regulatory Challenges, and Therapeutic Pathways to Health Care and Healing in Human Transformation

1. A New View of Nonmaleficence

1 A New View of Nonmaleficence Case 1A The Patient Who Chooses Yoga, Colonics, and Reiki over Surgery A fifty-two-year-old woman is referred by her naturopath to a medical doctor for evaluation of an abnormal pap smear. Cervical biopsies reveal a premalignant condition, which, if left untreated, can progress and create lesions. The physician’s recommendation is a hysterectomy, to be sure all the abnormality is removed. The patient tells her physician that she plans to pursue yoga, colonics, and Reiki for three months, rather than surgery, and then have her condition evaluated. She does, however, want the physician to continue monitoring her care. The physician is reluctant to do so and is concerned about legal and ethical implications of remaining in the therapeutic relationship.1 Case 1B The Parents Who Seek a Non-FDA-Approved Cancer Therapy A four-year old child is diagnosed with inoperable brain cancer. The child’s parents wish him to receive a controversial therapy derived from human urine, but the therapy lacks FDA approval, and the child has not been approved for any clinical trials that might offer hope for receiving other relevant, experimental treatment. The FDA therefore insists that the child undergo standard radiation and chemotherapy; the parents, however, are reluctant to subject their child to the “harsh effects of these treatments.” Further, the parents have met other parents whose children have successfully received and benefited from the controversial therapy, without experi27 encing toxicities or adverse side effects. The parents insist the decision belongs to the family, while the FDA insists it is merely following its congressional mandate to protect the public from interstate distribution of drugs not proven safe and effective. The family physician feels it is her ethical obligation to treat the child with chemotherapy and considers seeking a court order to do so. Meanwhile, the state welfare agency initiates proceedings to declare the parents guilty of abuse and neglect and unfit for custody. The physician is called as a witness in the proceedings and has mixed feelings about the testimony she plans to present.2 Preliminary Ethical Concerns about Using Complementary and Alternative Medical Therapies With the changing face of medicine and the burgeoning integration of complementary and alternative medical therapies into mainstream clinical practice, there is increasing interest in the ethical implications of providing, or not providing, such therapies, as well as in the ethical parameters and principles that might guide the choices of physicians and other health care providers in the delivery of, or referral for, such therapies. For example, is it ethical for a physician to recommend specific herbs and other dietary supplements, special nutritional regimens, Chinese longevity exercises, and other therapies that are not proven safe and efficacious to the physician’s satisfaction or are not sufficiently proven to receive general medical acceptance? Similarly, should the physician provide, or refer patients to other practitioners for, therapies such as chiropractic, acupuncture, naturopathy, massage therapy, homeopathy, nutritional care and herbal medicine, and various mindbody interventions when the physician has insufficient scientific evidence regarding the safety and efficacy of such therapies? On the flip side, when is it unethical to fail to recommend, deliver, or refer for therapies when there is some level of evidence for safety and efficacy? Likewise, what should the clinician in mainstream practice say to a patient who insists on receiving such therapies? Is there a meaningful ethical distinction between recommending therapies and approving the patient’s autonomous pursuit of such therapies (as opposed to discouraging the patient from using such treatments)? These questions become even more difficult with therapies when there are discrepan28 • Future Medicine cies between the belief systems of provider and patient. For example, should health care providers who are atheists pray with their patients—assuming scientific investigation suggests that prayer has some level of efficacy—and what kinds of conversations should providers have with patients regarding the efficacy, appropriateness, and medical understanding of prayer and other practices involving spiritual preferences? If evidence suggests that failing to pray (or provide other spiritual therapies) may diminish the therapeutic impact of the provider-patient relationship, what should the provider do? For instance, what should the physician in case 1A say to her patient about the initial choice of yoga, colonics, and Reiki for several months instead of a hysterectomy? Should the physician in case 1B accede to the parents’ wishes, terminate conventional treatment, and encourage the parents to pursue...