I recently ran across an editorial on the subject of the legal and ethical issues associated with conventional doctors referring patients for alternative medical therapies. It does a nice job of highlighting an issue which I think gets too little attention. If a therapy is unproven, implausible, or has been clearly shown not to work, can one ethically refer a patient for that therapy?

CAM practitioners are always suggesting that conventional doctors skeptical of their practices “leave it to the experts.” We are expected to declare ourselves incapable of giving reasoned judgments or recommendations and simply allow believers in a particular CAM therapy to be the only source of information for clients about that therapy. This is the fox guarding the henhouse in its purest form. My recent series of articles about veterinary homeopathy illustrates this claiming of expertise and the right alternative medicine practitioners claim to be the only voice patients get to hear on the topic of their methods.

One problem I’ve pointed out with this approach is that the label of “expert” is generally self-applied in CAM. There are no “CAM specialties” in medicine recognized as legitimate by anyone other than CAM practitioners. Astrologers and psychics may declare themselves to be experts in their fields, but it would be ridiculous to suggest that the rest of us should defer to their judgment about whether astrology and psychic phenomena are legitimate. The same is true for CAM practices.

Another question that arises for the conventional doctor considering referral for CAM therapy is what the patient (or in the veterinary field, the client) wants. Does it matter if my client wants homeopathy? Does that make it legitimate to refer them to a homeopathy even if it is clear homeopathy is nothing but a placebo? Is the right therapy for your patient always whatever therapy the patient (or owner) wants? These are some of the issues addressed in this commentary.

Timothy Caulfield, Ubaka Ogbogu, Gerald Robertson. Commentary: the law, unproven CAM and the referral challenge. Focus on Alternative and Complementary Therapies Volume 18(1) March 2013 1–7

The authors begin by pointing out that conventional medicine has certain well-defined and widely accepted standards of evidence, based on the methods of science, that a doctor is expected to understand and rely on in judging all therapies. They then show, as I have previously, that CAM practitioners and advocates often have a different set of standards:

compared to conventional physicians, ‘[p]roviders of CAM may conceive of “evidence” in broader terms – including their own clinical experience – and place less emphasis on population-based empirical data’. While there has been a push to gain more evidence on the efficacy of various CAM therapies and approaches, a significant portion of the most popular therapies remain unproven or, alternatively, there is disagreement about the nature, quality and value of the relevant data.

The fact is that very little within CAM can be considered evidence-based, and most of the practices exist in that vaguely defined group of practices precisely for this reason. CAM practitioners are only interested in scientific evidence when it supports their claims, but they have no fundamental philosophical problem ignoring such evidence when it does not. CAM is almost never judged by the same standards as conventional medicine. Therefore, conventional doctors have to decide whether to adhere to the standards they use for their conventional practices, or to accept a separate-but-equal set of standards for CAM.

Can physicians, who are bound by the (increasingly) evidence-based ethos of their profession, refer patients to CAM practitioners known to provide a range of unproven treatments? Could such a referral be construed by the patient as an endorsement of all the services offered by the CAM practitioner?

The authors answer these questions for physicians the same way I would answer them for veterinarians:

We conclude that physicians have a legal and ethical obligation to adhere to a consistent evidence and science-based approach to referral decisions regardless of the type or nature of the therapy in question.

Many vets I know who are don’t accept the claims for most CAM methods as legitimate nevertheless feel uncomfortable telling clients this. They often simply claim not to know anything about these methods and refer the client to a vet who practices CAM. I cannot see how this could be seen by clients as anything other than an endorsement of the practices they are being referred for. In my opinion, it is a complete abdication of ethical responsibility to the client and the patient, to refer for a therapy you believe to be ineffective or even possibly unsafe.

So why do conventional doctors who are skeptical about CAM claims refer for CAM services? The main reason for physicians to do so is likely the same reason vets do so, a misguided belief that clients want these services and that doctors are bound to give clients what they want, whether or not this is what is in the best interests of the patient.

I’ve written previously about the perceived demand for CAM services. While there is no question many people will express some interest in these therapies when asked, and while self-administration of over-the-counter dietary supplements and herbal products is quite widespread, studies consistently show that only a tiny minority of Americans regularly use most CAM services such as acupuncture and homeopathy, and even the most popular, chiropractic, is only rarely used for anything other than its one reasonable indication, back pain. So the notion that there is widespread aggressive demand for these services is simply inaccurate. People are always interested in something that might help them or their pets, but they are also very interested in their doctors’ help in deciding what is and what is not a safe and useful therapy.

And even when people actively request CAM therapies for themselves or their pets, this does not relieve a conventional doctor of the obligation to recommend only appropriate therapies based on scientific standards of evaluation.

The law is clear that ‘[i]f a patient requests treatment which the doctor considers to be inappropriate and potentially harmful, the doctor’s overriding duty to act in the patient’s best interests dictates that the treatment be withheld’…use a CAM therapy that does not meet requisite evidentiary standards for therapeutic use would conflict with the physician’s overriding legal and ethical duty to act in the patient’s best interests.

The authors of this editorial explore briefly the legal implications of CAM referral. While the details of this discussion relate primarily to laws for physicians in Canada, the ethical and legal principles are broadly similar in human and veterinary medicine and in Canada and the U.S. There is case law that demonstrates physicians are responsible for the harm done by therapies they recommend if they ought to have reason to believe these therapies are inappropriate for their patients. In one example,

a family physician was held to have been negligent in referring a patient to a chiropractor for treatment of his neck injury. The Court held that the physician ought to have known that chiropractic treatment was contraindicated in the circumstances. In addition, it was no defence for the physician to claim that the chiropractor was negligent. In the words of the Court, the physician ‘generated the risk of injury by referring [the patient] for inappropriate treatment. It is no answer that the treatment was administered negligently.’

Conventional doctors are legally, as well as ethically, responsible for knowing that unproven or inappropriate treatments have risks, and this responsibility does not disappear if a patient is injured because a CAM practitioner they were referred to does something inappropriate once the patient is in their hands.

This is especially important since CAM therapies, and a disdain for conventional treatment, tend to cluster together. Even if chiropractic therapy might be appropriate, for example, for a patient’s back pain, the physician has some responsibility if they send a patient to a chiropractor knowing they may be subjected to colonic irrigation, untested herbal remedies, and other unsafe practices or that the patient may be discouraged from using conventional healthcare methods, such as vaccinations or pharmaceutical medications.

I often tell clients, when they appear skeptical of something I recommend, that they are paying for my advice and I am obligated to give it, though they are not obligated to follow it. This is a somewhat casual and humorous way of expressing a very powerful and serious ethical duty. I owe my patients, and their owners, the most accurate, informed, and honest advice I can provide. It is not ethical for me to simply plead ignorance of therapies I don’t practice and pass the patient on to someone who claims expertise in those practices. It is my duty to, at a minimum, be familiar with the balance of the evidence regarding most therapies available to my clients and whether they are proven or unproven, safe and effective or useless and harmful. This holds for alternative therapies just as it does for conventional practices.

And it is not ethical for me to simply give clients what they ask for even when I know, or ought to know, that they are misinformed about the safety and effectiveness of what they request. CAM providers often complain, quite legitimately, about the misuse of pharmaceuticals. Giving clients an antibiotic for an infection I know is almost certainly viral and not bacterial is not acceptable practice. And referring clients for homeopathy, Chinese Medicine, or other practices that are either clearly not effective or of unknown safety and efficacy is just as inexcusable, even if the clients asks me to do so.

People certainly have a right to choose the therapies they wish, even if they don’t really understand the evidence concerning them. But this freedom does not relieve me of my obligation to understand this evidence and to refuse to provide or recommend therapies that are not in my patients’ best interest. This obligation is perhaps even greater for veterinarians than for physicians since our patients cannot speak for themselves or make their own healthcare choices. We, therefore, must advocate for what we believe to be best for our patients even in those uncomfortable situations in which this runs contrary to what our clients may want.