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Review Article · Übersichtsarbeit

Forsch Komplementmed 2012;19:311–318 Published online: December 14, 2012

DOI: 10.1159/000346001

Ethical Implications of the Increasing Use of

Complementary and Alternative Medicine
Philipp Teichfischer
Fachbereich Geschichte, Ethik und Theorie der Medizin, Medizinische Fakultät der Otto-von-Guericke-Universität Magdeburg, Germany

Keywords Schlüsselwörter
Alternative Medicine · Complementary medicine · Alternativmedizin · Komplementärmedizin ·
Economics · Ethics · Evaluation · Health insurance · Ökonomie · Ethik · Evaluation · Krankenversicherung ·
Informed consent · Research methodology Informiertes Einverständnis · Forschungsmethodologie

Summary Zusammenfassung
Background: The increasing demand for complementary Hintergrund: Die stetig zunehmende Anwendung alter-
and alternative medicine (CAM) raises ethical questions nativer und komplementärer Behandlungsverfahren
about specific aspects of both CAM and conventional wirft ethische Fragen hinsichtlich bestimmter Aspekte
medicine (COM). Methods: The present article provides sowohl der Komplementär- und Alternativmedizin (CAM)
a critical survey of the most important ethical aspects in als auch der Schulmedizin auf. Methoden: Der vorlie-
the current debate about CAM. Results: The relevant eth- gende Beitrag versucht anhand der aktuellen Literatur
ical issues arise mainly in 4 main areas: 1) patient infor- einen kritischen Überblick über die zur Zeit umstrittens-
mation, 2) research ethics, 3) cost, and 4) education. ten ethischen Aspekte der gegenwärtigen Entwicklungen
Most of the contributions used for our purpose are based im Bereich der CAM zu geben. Ergebnisse: Die ethisch
upon the implicit assumption that, in principle, the ethics relevanten Kontroversen lassen sich vor allem folgenden
of CAM and COM have to be identical because of the 4 Bereichen zuordnen: 1) der Patientenaufklärung, 2) der
same underlying doctor-patient relationship. This Forschungsethik, 3) dem Kostenbereich und 4) dem Bil-
premise is shared by the author. Conclusions: Substan- dungssektor. Die meisten der hier zugrunde gelegten Ar-
tial efforts on various levels will have to be made in beiten gehen dabei von der impliziten Annahme aus,
order to create the conditions necessary for CAM to be dass sich die Ethiken der CAM und Schulmedizin auf-
ethically justified. But the ethical implications for COM grund ihrer zugrunde liegenden handlungsnormieren-
also have to be considered. den Arzt-Patienten-Beziehung prinzipiell nicht voneinan-
der unterscheiden sollten. Dieser Prämisse schließt sich
der Autor bei seiner Darstellung grundsätzlich an.
Schlussfolgerungen: Um zu einer ethisch gerechtfertig-
ten Praxis in der CAM zu gelangen, bedarf es einer Dis-
kussion und Lösung der aufgezeigten Schwierigkeiten.
Das schließt auch die ethische Reflexion und Erweite-
rung von Handlungsfeldern der Schulmedizin mit ein. - 5/5/2018 10:25:18 PM

© 2012 S. Karger GmbH, Freiburg Dr. phil. Philipp Teichfischer

Univ. of California Irvine

1661-4119/12/0196-0311$38.00/0 Fachbereich Geschichte, Ethik und Theorie der Medizin

Fax +49 761 4 52 07 14 Medizinische Fakultät der Otto-von-Guericke-Universität Magdeburg
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Introduction and geriatric medicine go beyond the scope of this article and
thus are not included [13, 14].
Since the last third of the 20th century, there has been a An important prerequisite of this presentation is that, in
steady increase in the use of complementary and alternative spite of some structural modifications possibly being required,
medicine (CAM). Between 10 and 60% of all patients in the CAM is not exempted from the ‘principles of biomedical eth-
western world use CAM, depending on the demography, the ics’ as postulated by Beauchamp and Childress [15], and ap-
area of illness being treated, and the methods included in plying these principles to CAM is possible although difficult.
CAM [1]. Today, CAM is a broad category that encompasses Within this principle-based ethical framework, despite some
a wide range of treatment modalities from complete systems disagreement about such central concepts as health, knowl-
of therapy, such as Traditional Chinese Medicine (TCM), to edge, and science, a basic congruence exists among CAM and
individual practices, such as massage therapies or aroma ther- COM as both include a specific doctor-patient relationship
apy which may be utilized as a supplement or a replacement (doctor = broad range of professionals like physicians, nurses,
to conventional medicine (COM). counselors, therapists etc.). This healing relationship is charac-
Today, CAM particularly plays an important role in the terized by the healer’s interest for his or her patient’s well-
treatment of chronic diseases [2, 3]. Chronic disorders often being as well as by the patient’s desire to get well [16].
result in patients changing their attitudes about their illnesses At appropriate points in this study’s discussion, light will
and becoming especially knowledgeable about them. This be shed on the potential ethical implications for conventional
seems to be a significant reason why the use of CAM is still medicine and the public health care system.
rising – it apparently integrates such involved patients better Following and modifying several approaches from recent
than other kinds of medicine do, while regarding their values, studies in biomedical ethics that focused on CAM and its rela-
beliefs, and experience [4, 5]. tions to COM, relevant ethical aspects were assigned to 4 in-
CAM is frequently used in tandem with COM. In addition, terdependent topics [1, 8, 17–22]:
the proportion of physicians who offer both CAM and COM is – informing patients
permanently rising [6]. In Germany, attaining additional quali- – research ethics
fications in CAM for conventional physicians is regulated by a – the cost
medical residency program. At the moment, a physician can re- – the education gap.
ceive qualifications in acupuncture, homeopathy, manual medi-
cine / chiropractic therapy, naturopathy, physical therapy, and
balneology [7]. Nonetheless, CAM is still mostly used outside Informing Patients
of the public health care system, and for that reason it can still
be considered a ‘private medicine’ [8]. Respect towards autonomy is one of the central ethical princi-
In Germany, CAM services which are not part of the pub- ples of the doctor-patient relationship. This means that pa-
lic health care system must be paid for by either the patients tients should be considered as having free will and being capa-
themselves or by private health insurance companies. In 2009, ble of making the decisions relevant for therapy selection.
over 9 billion EUR were spent on CAM: 5 billion EUR were Most important here is the elaboration of the expected bene-
paid by patients out of pocket and 4 billion EUR by health fits (principle of beneficence) and treatment-related risks
insurance companies [9]. This amount continues to rise, not (principle of non-maleficence). Only in this way informed
only in Germany but also in other countries [5, 10, 11]. consent can be possible within the framework of shared deci-
Since the 1970s, a huge change has taken place in the medi- sion-making (SDM).
cal culture of the western world. This change has not only led However, it is a fact that in Germany CAM can be lawfully
to more patient autonomy, but to a demand for medical serv- practiced by non-medical practitioners, so-called Heilprak-
ices which involve the ‘whole person’ and give more promi- tiker, which may cause patients to feel that CAM is a harmless
nence to well-being and health than to disease and the treat- treatment. On a linguistic level, it is suggested to the patients
ment of symptoms. This change also represents a very impor- that CAM services are without side effects, whatsoever.
tant challenge for the current health care system and western Terms such as ‘natural medicine’ or ‘(non-scientific) experi-
medicine in general. That, at least, is a big ethical challenge ence-based medicine’ provoke the belief that CAM is a ‘soft’
[11]. As the increasing use of CAM seems to base itself upon, and ‘safe’ medicine [20].
among others, CAM’s offering of more value and satisfaction It is quite hard to meet such claims given that, while ‘na-
for the patients, it also raises questions about the ethical obli- ture’ is conceptually close to words such as ‘soft’ and ‘safety’,
gations of conventional physicians [3, 12]. ‘naturalness’ does not mean ‘softness’, and a ‘(natural) experi-
In this article, an overview about some of the most contro- ence’ cannot vouch for safety. On the contrary, studies con-
versial ethical aspects of the increasing use of CAM with par- ducted to investigate the side effects of the so-called soft prac-
ticular emphasis on ethical obligations of CAM providers is tices showed a relatively high rate (between 23.8 and 38.2%)
given. Issues concerning the utilization of CAM in pediatric of adverse effects [23, 24]. - 5/5/2018 10:25:18 PM

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Nevertheless, undesirable side effects of the mere applica- CAM are still rare when compared with COM. Therefore, the
tion of CAM methods appear to be infrequent in comparison principles of informed consent and patient participation which
with those of the mere application of conventional methods are derived from patient autonomy can reverse into paternal-
[25, 26]. Additionally, patients who get treated with CAM ism. In view of the lack of scientific results, patients have to
therapies report less serious side effects which is one of the rely almost blindly on the authority of those providing CAM.
most important motives for consulting a CAM practitioner Even if the authority problem may also apply for COM [29],
[27]. Also, the relatively low premiums for professional liabil- the question here is whether there are any good reasons for
ity insurance of CAM providers may result from the sus- patients to have trust in their CAM providers. It is certainly
pected lower risk of side effects. rather risky to refer solely on the personal experience of the
Similar ethical problems arise from the use of a term such provider or the patient.
as ‘alternative medicine’, as it also carries unrealizable norma-
tive claims that such ‘natural’ medical practices could elimi-
nate the need for conventional medical treatment. However, Research Ethics
the use of the term ‘complementary medicine’ alone appears
unambiguous and ethically unproblematic. A few years ago, the underdeveloped level of research was
Although it may not be intended to provoke such associa- one of the most crucial problems of CAM resulting in little
tions, by using these terms CAM practitioners are obliged to favorable risk-benefit ratios of CAM methods which could
provide a favorable risk-benefit ratio associated with their have justified their usage.
medical interventions. Without this evaluation, there is a risk One of the reasons for this was that CAM research usually
of serious harm in several ways: Firstly, CAM applications can took place outside of the scope of COM and its research infra-
cause direct harm, especially those therapies which are inva- structure; until recently, only a couple of high-ranking scien-
sive or require drugs which, as well as other complications, tists contributed to CAM research [11]. As a result of this lack
can cause toxic and allergic reactions. Secondly, they can be of expertise, CAM methodologies did remain quite weak.
indirectly harmful by being used in lieu of more effective Consequently, those ethical rules and guidelines for clinical
treatments, or in tandem with conventional therapies and thus trials whose observance is monitored by ethics committees did
by interacting with them in detrimental ways [20]. There is often become insurmountable obstacles for those applying for
evidence that the application of phytopharmaceutical prod- CAM studies. Personal reservations and biases on the part of
ucts in CAM can reduce the efficacy of COM [28]. This can committee members may also have impeded the application
get worse if patients combine both treatments without inform- procedure [8].
ing their doctors. In the last 20 years, there has been some progress in this
Another question being considered here is whether CAM field, e.g., the establishment of several peer-reviewed CAM-
procedures are ethically justified just on the basis that they related journals which are able to promote the development
possibly do no harm. Patients that get treated both by COM of the research discourse and furthermore make it easier to
and CAM show a tendency to ascribe an improvement of their verify the credentials of individual practitioners. At the mo-
health conditions to CAM and, vice versa, undesirable side ef- ment, the most influential journals in that area are: The Jour-
fects to COM. As a result, the reputation of COM could be nal of Alternative and Complementary Medicine (since 1995),
damaged which may give rise to lower patient compliance as BMC Complementary and Alternative Medicine (since 2001),
well as nocebo effects in conventional therapies [20]. Alternative Therapies in Health and Medicine (since 1995),
A further aspect concerning the information problem has Evidence-Based Complementary and Alternative Medicine
to do with COM: Is a physician, in view of the increasing use (since 2004), Complementary Therapies in Medicine (since
of CAM, obliged to inform his or her patients about CAM? 1993), Complementary Therapies in Clinical Practice (since
Particularly given the possibility of future harm resulting from 1995), European Journal of Integrative Medicine (since 2009),
CAM treatments or undesirable side effects when getting Focus on Alternative and Complementary Therapies (since
treatments in both CAM and COM, one could demand well- 1996), and Forschende Komplementärmedizin / Research in
informed conventional physicians who principally act as confi- Complementary Medicine (since 1994).
dants and contact persons in medical matters. But also in re- Besides this, internet platforms such as the EU-funded
spect of possible health cost reduction by applying efficient website have been launched which pro-
CAM methods one could demand physicians better educated vides tightly controlled meta-analysis and reviews on CAM
in CAM. treatments in cancer therapy. In 2009, the European Informa-
Thus, solving the problem of informing patients on the one tion Centre for Complementary and Alternative Medicine
hand would require better trained and educated conventional (EICCAM) was founded in cooperation with the International
physicians in order to cope with the information problem, and Society for Complementary Medicine Research (ISCMR), and
on the other hand more studies on the risks and benefits of in 2010, the CAMbrella project being part of the EU’s 7th
unconventional medicine. Unfortunately, such studies in Framework Program for Research (FP7), started [30]. - 5/5/2018 10:25:18 PM

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CAM research faces particular difficulties with its method- searchers seem to approve the use of such placebo CAM
ologies because the evaluation of complex and holistic CAM methods if there is no effective conventional therapy, or if
methods may apply different criteria than those used for re- the only one available therapy comes along with serious side
viewing conventional medical interventions [17, 31–33]. How- effects for the patient [16, 37]. In this case, it is required that
ever, it must be emphasized that clinical research must be de- the putative placebo effect is a true one. Possible distortions
signed and conducted with sufficiently rigorous methods to in the interpretation of such effects may be avoided by how
ensure that the findings will have scientific validity [33]. The the study is designed – e.g., a three-branched study could be
question arises as to what the terms ‘sufficiently rigorous useful [33].
methods’ and ‘scientific validity’ mean. In recent years, a shift To conclude, it should be pointed out that national legisla-
took place in this respect in medical anthropology, combined tion can also impede further research on CAM. In Germany,
with the emergence of the so-called medical pluralism. This for example, according to the drug law (Arzneimittelgesetz
shift led to another perspective on the knowledge constitution (AMG)) of 1978, new drugs belonging to the so-called tradi-
process and evaluation measures in medicine [16]. tional drugs family were allowed to be launched without any
Many critics claim that the randomized clinical trial (RCT) prior evaluation in order to guarantee scientific pluralism.
has to be the gold standard for measuring the potential effec- Only the packaging of the drugs had to refer to the indication
tiveness of all medical interventions, including CAM meth- and traditional experience: ‘Traditionally used for strengthen-
ods. Only by RCTs the well-known logical fallacy of post hoc ing and invigoration (…) This information is based only on
ergo propter hoc can be avoided and the causal associations tradition and long-term experience’ (AMG, §109a). However,
can be distinguished from the confounding associations. For this is unlikely to avoid any possible complications and ethical
those critics, the proof of effectiveness with conventional problems [20], nor is the principle of the so-called internal
measures like the RCT seems to be a precondition for the recognition of certain drugs by the relevant experts an appro-
emerging of CAM’s approaches into mainstream medical priate means of protecting the patient [38]. Usually, drugs
practice. As a consequence of such an emerging process, the have to be tested in vitro or on animal models before being
relationship between CAM and COM may be modified at the tested on the general population. Without such evidence, the
expense of an independent CAM [34]. A counter argument is question is how would it be justifiable to investigate tradi-
that the RCT was originally developed for the evaluation of tional drugs in future [16]?
drug therapies which are focused on the causal effect of drugs Legal proceedings concerning serious side effects regularly
[35, 36]. At this point, one has to differentiate between the give reasons for the discussion of the withdrawal of certain
effect of a drug and the effectiveness of a treatment. It is ar- drugs from the ‘traditional list’. In 2004, the European Direc-
gued that a complex therapeutic procedure including a range tive on Traditional Herbal Medicinal Products (THMPD) was
of synergistic treatment components can be useful without issued demanding a special authorization process for phyto-
the effect of any drug which might be administered during pharmaceutical products distributed in the EU, excluding those
the treatment. Furthermore, conventional therapies which already being marketed (for at least 30 years in a member
are tested with RCTs focus mostly on disease and healing; state and 15 years in the European Community). For the lat-
many CAM practitioners do not claim to heal disease, but ter, a transitional period was granted ending on April 30, 2011
rather to preserve health which cannot be reviewed correctly – after that time, all such drugs required a certain marketing
by RCTs. authorization procedure within which a reliable risk analysis
However, the various CAM methods and their applications has to be conducted. However, drugs which are manufactured
must be differentiated. For example, the effectiveness of and administered while consulting a phytotherapist are ex-
herbal medicine when used to remedy coughs and colds empted from that rule [39]. Of course, at this point, one has to
should be easier to be verified by conventional standards than ask critically if the new legislation is an appropriate means to
the impact of spiritual healing or hypnosis, where a clinician protect the patients or if the pharmaceutical industry mainly
does not have a clear representation of what to study and how benefits from it. In effect, this legal provision may also result
to study it. One of the questions here is how to define the con- in a shortage of the traditional drug inventory and thus in in-
dition in which to study spiritual healing. Does this definition creasing health care costs if patients and doctors now have to
need to be made in terms of COM or CAM? Obviously, each refer to conventional drugs which are approved but more ex-
definition would involve value judgments with even further pensive. Nevertheless, in respect of a continuously changing
ethical implications [16]. Recently, some efforts have been medical culture with new drugs, therapies, and understanding
made to define CAM/COM combined classification schemes of action mechanism, reviewing medicines that have been in
and specific study designs for CAM systems, such as N-of-1 use for a long time is strongly recommended, primarily in
trials and preference RCTs [16]. order to protect patients from potential harm. However, it is
Another question is whether using CAM methods which doubtful whether new regulation is suitable for achieving this
have no advantage over placebos and are probably based on goal.
placebos themselves can be ethically justified. Some re- - 5/5/2018 10:25:18 PM

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The Cost Another problem concerning this is the reimbursement of
cost. Commonly, patients themselves or private insurance
Besides those ethical problems found in CAM research, there companies have to bear the cost. Given that there are efficient
is a debate about a number of socio-ethical issues concerning alternatives to several conventional health services, one has to
cost for CAM research as well as for CAM treatment. ask whether it is still justifiable that only patients who are able
So far, a lobby for research on CAM comparable to that of to pay for them will get CAM treatments (principle of thera-
COM which would neither initiate nor finance research does peutic freedom).
not exist. As one of the supposed reasons for this lack is the Today, not only private companies but also statutory
missing evidence of efficacy, there inevitably exists a vicious health insurance companies canvass prospective clients with
circle. More evidence can only be achieved by more research. the offer of reimbursement of costs for CAM treatments. For
But more research funding would only be paid in the event of example, in cooperation with the German Central Associa-
more evidence. Of course, the fact that natural medicinal tion for Homeopathic Physicians (Deutscher Zentralverein
products are not patentable does not stimulate the pharma- homöopathischer Ärzte (DZVhÄ)), whose members must
ceutical industry to sponsor CAM research either [11]. In ad- have studied medicine at a university, the German insurance
dition, carefully designed and performed studies on CAM are company Techniker Krankenkasse (TK) offers reimburse-
quite expensive [8, 33]. The question must also be asked as to ment of expenses for the supply of basic homeopathic care.
whether it is ethically justifiable that the public health service Before 2012, the costs of homeopathic drugs had to be paid by
gives money for research on CAM, considering its scarce re- the patients themselves, but now, the TK pays up to an annual
sources and given that CAM methods are often incompatible maximum amount of 100 EUR for drugs not being subject to
with the foundations of modern science. But a dogmatic prescription-only, but pharmacy-only use. The same applies
stance refusing CAM cannot stop it from growing. Therefore, to phytotherapeutic and anthroposophic medicinal products.
it seems to be better to just look and pay for further scholarly Since 2012, some cost for treatments in osteopathy are also
debate and research on CAM despite the risk of future paid by the TK. However, the osteopathic practitioner con-
expenses. cerned must be a member of a professional organization of
In view of the important role being played by CAM as a osteopathy practitioners or have a specific education that
‘big business’ [5] in today’s medical landscape, one could even would allow him to become a member of such an organiza-
argue that the public health service is obliged to finance CAM tion. The cost amount that the TK pays is restricted to 80% of
research for at least 2 main reasons: 1) to protect patients the total treatment costs – up to 60 EUR per treatment for 6
from the possible harm associated with CAM treatment and annual meetings at maximum. Another system used by such
2) to ensure the required justice and equality with regard to companies is financed by additional insurance coverage – e.g.,
funding of research in COM. at TK’s Private Natural Remedy (‘TK-Privat Natur-Arznei’)
Here, reference is made to the Office of Alternative Medi- [46]. This trend of cost reimbursement is likely the result of
cine which was founded in 1992 by the US National Institutes both Germany’s highly competitive health market and the
of Health (NIH) and renamed as the National Center for rising demand for CAM services there.
Complementary and Alternative Medicine (NCCAM) in In view of the foregoing facts, the way in which the TK
1998. The annual budget of this organization was about 128.8 project will influence cost balances will have to be assessed.
million USD in 2010 [1, 40, 41] – it held the top position Recently conducted Swiss studies where several CAM serv-
among the western industrial countries although it still seems ices were integrated into mandatory basic health care indi-
a relatively small amount compared with the total budget of cated a cost increase [47], though not as high as the increase
the NIH (about 32 billion USD) [42]. By comparison, only that was predicted [48]. In another study from Switzerland,
0.0085% of the total research funding is spent on CAM in the the same authors report an equal or better cost effectiveness
UK [43]. of CAM in the setting of Swiss ambulatory care by comparing
Another argument often used is that CAM treatments are cost of physicians applying CAM with those applying COM
much cheaper than those found in COM and thus their imple- only [49]. A study from The Netherlands comes to a similar
mentation in basic health care would lead to a general cost result: CAM can be cost-effective if applied by a physician
reduction, but this seems not to be tenable at all [44]. On the [50]. In future, more health-economic studies will have to be
contrary, private insurance companies that included acupunc- conducted in order to demonstrate the potential health-eco-
ture and homeopathy in their benefits catalogue reported in- nomic benefits of CAM methods [51–54].
creased costs [20]. It is caused partly by more intensive doc- Another issue arises from the presumed future institution-
tor-patient contact and partly by higher equipment cost, alization process of CAM as well as its potential role in health
whereas drug cost were generally lower [45]. Another signifi- cost reduction. From this perspective, it would be useful to
cant reason for such increasing cost is that patients get treat- consider a federally funded education in CAM that surpasses
ment both by CAM and COM doctors without any coopera- a pure tax reduction for education costs. This leads to the last
tion between them. issue being examined here. - 5/5/2018 10:25:18 PM

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The Education Gap swer that could protect their patients from further harm.
Given the fact that some CAM methods, particularly those
On the one hand, several ethical queries can be derived from containing drugs, may interact with drugs used by COM, phy-
the fact that CAM providers often do not study COM and sicians are obliged to become familiar with common forms of
their methods are based upon a different understanding of CAM in order to avoid unnecessary harm [3, 12].
science. Additionally, a better education in CAM would also be
The first question to be considered here is whether the lack useful in strengthening the doctor-patient relationship [12]. A
of education in COM of a part of CAM practitioners repre- hostile stance among medical doctors towards CAM without
sents a potential risk for patients. Particularly, in the light of being acquainted with its methodologies, could lead to a loss
potential future collaboration between conventional and al- of confidence and make patients believe that COM is narrow-
ternative practitioners CAM providers should have a solid un- minded and dogmatic; patients would probably withhold men-
derstanding of medical basics [5]. Medical standards should tioning that they are already treated by a CAM practitioner
be among the main contents of teaching in CAM as several [11, 12].
classical medical techniques such as measuring pulse and In Germany, medical doctors can acquire officially ap-
blood pressure are already standard tools of every alternative proved additional qualifications in several CAM techniques
practitioner. In addition, CAM non-medical practitioners [7]. Since winter semester 2002/2003, students are obliged to
should be able to recognize serious and acute cases by symp- study at least some selected CAM methods within the curricu-
toms in order to refer those patients to a physician. By now, lar framework of cross-cutting strand 12: rehabilitation, physi-
basic medical training is an important element of CAM edu- cal therapy, and natural medicine. Obviously, the amount of
cation in German schools like the Paracelsus School. After hours CAM is taught is not sufficient to guarantee a well-
years of ‘tourist examinations’ in the 1990s, examination regu- grounded education [3, 41, 58–60].
lations were unified in almost all schools of CAM. As a result, Recently, there has been an international trend towards
testing procedures in medical basics are now familiar to all al- the further academization and professionalization of CAM
ternative practitioners in Germany [55]. [57, 61–64]. In Germany, the pioneers held endowed chairs in
The second question is how efficient communication can naturopathy which have existed for a number of years in, e.g.,
be guaranteed between COM and CAM practitioners. This Essen, Munich, and Berlin. Universities such as those in Hei-
question comes up from the convention of both types of medi- delberg and Berlin which launched several medical reform
cine often being used in tandem and from the fact that the courses were pioneers of integrating CAM into academic
prejudices and certain biases on a part of the practitioners teaching. This development is still pushed by and reflected in
could be used to the detriment of the patient. Preventing different forums such as the Forum for University Working
harm through interaction between conventional and uncon- Groups on Natural and Complementary Medicine (Forum
ventional procedures requires an operating communication universitärer Arbeitsgruppen für Naturheilverfahren und
system [3, 56]. One condition of such a system would be that Komplementärmedizin) founded in 1998 or the Dialogue
both conventional physicians and alternative practitioners Forum for Pluralism in Medicine (Dialogforum Pluralismus in
must regularly ask their patients about their potential use of der Medizin) founded in 2000 [57, 59, 65].
both CAM and COM in tandem, while giving them the belief
that this information is very important for the success of their
therapy [12] and creating a welcoming environment to open a Conclusions
dialogue about CAM [3]. Another condition is that there
should be a broad and solid education of CAM practitioners In principle, it should be obvious that the ethical obligations
in COM and, vice versa, of conventional physicians in CAM in CAM and COM are identical, given that both are derived
in order to understand their respective vocabulary, diagnostic from the 4 bioethical principles first defined by Beauchamp
constructions, and treatment paradigms. and Childress [15]. The main reason is that the conventional
On the other hand, in view of the increasing use of CAM as well as the alternative practitioner play the same roles as
as well as the growing number of doctors with additional health educators, providers, and advocates. Consequently, the
qualifications in CAM-associated techniques, an integration set of ethical rules of professional organizations such as the
of CAM teaching into academic curricula would be useful. German Association of Non-Medical Homeopathic Practi-
From this point, a third question can be derived: Do medical tioners (Fachverband Deutscher Heilpraktiker Bundesver-
doctors who are not or only slightly trained in CAM pose a band e.V. und Landesverbände) is based on medical ethics
risk? according to the professional code of conduct that applies to
As previously mentioned, many patients use CAM as a all licensed physicians [66]. The same applies for organiza-
supplement to COM, often by self-treatment. Physicians non- tions in other countries like the American Chiropractic Asso-
or only less educated in CAM may, in their role as health edu- ciation (ACA) or the American Association of Naturopathic
cators and advocates [57], lack the knowledge to give an an- Physicians (AANP) [12]. - 5/5/2018 10:25:18 PM

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Taking into account that the current ethical debate about mechanisms of action could be explored, and therefore under-
CAM is mainly concerned with safety and effectiveness, standing and therapy of the disease could be improved simply
greater efforts must be made in order to prevent damage and with the help of further CAM research. The objective of a so-
to ensure that CAM applications hold an appropriate thera- called integrative medicine [67] should be to choose and in-
peutic value. This should also include a revision of COM’s tegrate only those CAM methods the effectiveness of which
standards such as the use of RCT as the only proof of medici- has been proven and thus can contribute to a critical medicine
nal effectiveness. A conventional practitioner using both COM system and an improved health care system. However, as
and CAM would otherwise follow 2 totally different and in- shown in the present paper, this aim is impeded by a number
compatible ethical principles as they would take other evi- of political, economic, and structural conditions. Thus, there is
dence criteria as a basis for CAM treatments than for conven- a need to consider and act on several levels in order to come
tional treatments. Such a practice would not allow fulfilling the to better solutions in the future.
doctor’s role as an integer instance for trust and confidence.
Only valid research results and a doctor’s own experience
can support his or her decision about how and whether to Disclosure Statement
apply CAM methods. Additionally, those results and experi-
ences could make self-treatment, a wide-spread occurrence in The author assures that there are no conflicts of interest which would
have influenced the work carried out.
the application of CAM, more secure [11]. The underlying

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