BSS Summary - University of California, San Diego



BSS Summary

Gordon Saxe

October 20, 2004

Presentation Summary

Dr. Saxe began by providing an overview of complementary and alternative medicine (CAM). He indicated that CAM treatment approaches typically arise from theoretical foundations not based in laboratory science (e.g., folk traditions). He went on to define as “alternative” those interventions that are neither taught widely in medical schools nor generally available in US hospitals. Alternative treatments replace rather than merely supplement conventional treatment. Complementary treatments, on the other hand, would refer to alternative therapies used in conjunction with, or as an adjunct to, conventional treatment.

Saxe then outlined the tenets of CAM approaches to cancer treatment, the extent and types of CAM use, funding levels for research in this area and ethical principles that apply to treating patients who elect various alternative treatment strategies. Three case studies framed the discussion. For details please see presentation slides.

Points of Discussion

▪ What are the legal and moral obligations of physicians when confronted with patients who refuse conventional treatment for disabling or life threatening conditions, e.g., biopsy and excision for an early stage melanoma?

▪ Importance of education about CAM since clearly patients increasingly use these alternatives, with or without physician knowledge.

▪ How can patient autonomy best be balanced with medical judgment about risks, benefits and harms of unproven alternatives?

▪ Patients need clear information, understanding of risks and benefits

▪ Recognition that a lot of conventional medicine, much like CAM, hasn’t passed the test of randomized, controlled trials.

▪ Medical science often operates under conditions of uncertainty, e.g., whether to radiate a tumor or treat with chemotherapy (or both), to do a more or less radical mastectomy, to wait and see with prostate cancer or elect surgery

▪ Uncertainty can make advising patients extremely difficult

▪ To what extent are physicians ethically obliged to take into account their patient’s belief system as well as their own?

▪ How ethically to advise patients?

▪ Importance of communication, of listening to the patient

▪ Obligation to convey risks and benefits in language patient can understand, to help patient identify what is important to them, e.g., expanded life span, bodily integrity, alertness, pain control

▪ Knowledge of one’s own limitation, medically and personally

▪ Willingness to make referrals

▪ Historically, what counts as “conventional” or evidence-based medicine evolves. Acupuncture increasingly accepted as legitimate treatment for nausea and certain forms of pain.

▪ Funding from NCCAM and others designed to subject CAM to normal channels of laboratory investigation. Some CAM evidence based; some not.

▪ Patient attraction to CAM therapies in part driven by the character and side effects of conventional cancer treatment: invasive, life-altering surgery; toxic regimes of chemotherapy; uncertainty of individual outcome.

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• Ethical considerations for risk/benefit analysis of CAM

• Severity of illness

• Curability with conventional treatment

• Invasiveness and side effects of conventional treatment

• Quality of evidence of safety and efficacy of desired CAM treatment

• Patient degree of understanding of risks and benefits

• Voluntary acceptance of those risks by patient (informed consent)

Adapted from Adams et al. (2002).

• Persistence of patient’s insistence on CAM.

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