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

2. Referral Strategy and the Ethics of Integration

2 Referral Strategy and the Ethics of Integration Case 2A Referral to an Acupuncturist Who Turns out to Be Negligent A physician is treating a patient for cervical cancer with chemotherapy, radiation, and other conventional therapies. The patient requests a referral to a licensed acupuncturist, as she has read an article in a popular health magazine noting that acupuncture is effective in reducing nausea and other symptoms of chemotherapy. The physician refers the patient to an acupuncturist who is covered by the same health maintenance organization that covers the physician’s services to the patient. The physician speaks to the acupuncturist once prior to making the referral and learns that the acupuncturist uses needling, together with standard herbal formulas, to relieve nausea and other side effects of chemotherapy. As it turns out, however, the acupuncturist is negligent in three ways: he or she (1) fails to follow clean needle technique; (2) uses a Chinese herb not tested by Western scientific standards for this patient or condition that has toxic side effects; and (3) uses Western herbal medicine even though the applicable state licensing statute only authorizes use of traditional oriental herbal medicine. The patient suffers an adverse reaction and sues the physician. Meanwhile, the state medical board brings charges against the physician for unprofessional conduct, alleging that the physician negligently as well as unethically referred a patient to an acupuncturist during the cancer treatment and negligently failed to supervise the acupuncturist’s use of both Chinese and Western herbal medicine. 59 Case 2B Failure to Refer to a Competent Acupuncturist The same physician is treating another patient for cervical cancer with chemotherapy, radiation, and other conventional therapies. The physician reads in medical literature that acupuncture is effective in reducing nausea and other symptoms of chemotherapy. The physician, who still is defending the earlier lawsuit , declines to refer the patient to a licensed acupuncturist, even though the acupuncturist is reimbursed by the same health maintenance organization that covers the physician’s services to the patient. The patient later reads an article on the Internet from a prestigious, peer-reviewed medical journal suggesting that acupuncture and Chinese herbal medicine would have reduced side effects of chemotherapy , including nausea and various gastrointestinal complications resulting from chronic malnutrition. The patient sues the physician for malpractice, based on failure to obtain adequate informed consent, and for intentional (reckless) infliction of emotional distress, based on physical injuries accompanying failure to disclose a therapeutic option whose effectiveness in relieving suffering was medically proven. Case 2C Referral of a Heart Patient for Yoga Therapy A cardiac patient has read on the Internet that the Ornish program, consisting of lifestyle and dietary changes, meditation , and yoga, can reverse heart disease. The patient asks the physician for an opinion regarding the risks and benefits of yoga therapy. The patient’s yoga instructor has reported that ancient yogis discovered yoga postures in meditation. The physician never has practiced yoga, does not believe in its precepts and claims, and considers the philosophy of yoga to be religious rather than descriptive—a set of beliefs adopted in faith. Further, the physician feels the yoga teacher who tries to help a cardiac patient is practicing medicine—aimed at ameliorating or curing disease—and therefore must show that yoga has the same evidence base for safety and efficacy in treatment of cardiac disease as conventional medicine. The patient’s accountant has informed the patient that she can only 60 • Future Medicine take yoga therapy as a tax deduction if prescribed by a physician. The patient insists on a referral and threatens to sue if the physician declines. The physician is particularly concerned about risks to heart patients from headstands and other inverted postures and wonders about the legal and ethical implications of writing out “yoga therapy” on a prescription or referral slip. Liability and Ethical Rules Surrounding Referrals for Complementary and Alternative Medical Therapies Cases 2A through 2C help frame the question of whether it is legal and/or ethical for a physician to refer a patient to a complementary and alternative medical provider if the physician has insufficient scientific evidence regarding, or personal belief in, the safety and efficacy of the therapies offered by the provider. Further, is it legal and/or ethical not to refer? Areas of particular relevance to this question are those within clinical practice in which professionally adopted ethical norms and standards for complementary and alternative medical therapies...