Review Article · Übersichtsarbeit
Forsch Komplementmed 2012;19:311–318
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
Alternative Medicine · Complementary medicine ·
Economics · Ethics · Evaluation · Health insurance ·
Informed consent · Research methodology
Summary
Background: The increasing demand for complementary
and alternative medicine (CAM) raises ethical questions
about specific aspects of both CAM and conventional
medicine (COM). Methods: The present article provides
a critical survey of the most important ethical aspects in
the current debate about CAM. Results: The relevant eth-
ical issues arise mainly in 4 main areas: 1) patient infor-
mation, 2) research ethics, 3) cost, and 4) education.
Most of the contributions used for our purpose are based
upon the implicit assumption that, in principle, the ethics
of CAM and COM have to be identical because of the
same underlying doctor-patient relationship. This
premise is shared by the author. Conclusions: Substan-
tial efforts on various levels will have to be made in
order to create the conditions necessary for CAM to be
ethically justified. But the ethical implications for COM
also have to be considered.
© 2012 S. Karger GmbH, Freiburg
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Fax +49 761 4 52 07 14
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Published online: December 14, 2012
Schlüsselwörter
Alternativmedizin · Komplementärmedizin ·
Ökonomie · Ethik · Evaluation · Krankenversicherung ·
Informiertes Einverständnis · Forschungsmethodologie
Zusammenfassung
Hintergrund: Die stetig zunehmende Anwendung alter-
nativer und komplementärer Behandlungsverfahren
wirft ethische Fragen hinsichtlich bestimmter Aspekte
sowohl der Komplementär- und Alternativmedizin (CAM)
als auch der Schulmedizin auf. Methoden: Der vorlie-
gende Beitrag versucht anhand der aktuellen Literatur
einen kritischen Überblick über die zur Zeit umstrittens-
ten ethischen Aspekte der gegenwärtigen Entwicklungen
im Bereich der CAM zu geben. Ergebnisse: Die ethisch
relevanten Kontroversen lassen sich vor allem folgenden
4 Bereichen zuordnen: 1) der Patientenaufklärung, 2) der
Forschungsethik, 3) dem Kostenbereich und 4) dem Bil-
dungssektor. Die meisten der hier zugrunde gelegten Ar-
beiten gehen dabei von der impliziten Annahme aus,
dass sich die Ethiken der CAM und Schulmedizin auf-
grund ihrer zugrunde liegenden handlungsnormieren-
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.
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Dr. phil. Philipp Teichfischer
Univ. of California Irvine
Fachbereich Geschichte, Ethik und Theorie der Medizin
Medizinische Fakultät der Otto-von-Guericke-Universität Magdeburg
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Leipziger Straße 44, 39120 Magdeburg, Germany
philipp.teichfischer@med.ovgu.de
Introduction
Since the last third of the 20th century, there has been a
steady increase in the use of complementary and alternative
medicine (CAM). Between 10 and 60% of all patients in the
western world use CAM, depending on the demography, the
area of illness being treated, and the methods included in
CAM [1]. Today, CAM is a broad category that encompasses
a wide range of treatment modalities from complete systems
of therapy, such as Traditional Chinese Medicine (TCM), to
individual practices, such as massage therapies or aroma ther-
apy which may be utilized as a supplement or a replacement
to conventional medicine (COM).
Today, CAM particularly plays an important role in the
treatment of chronic diseases [2, 3]. Chronic disorders often
result in patients changing their attitudes about their illnesses
and becoming especially knowledgeable about them. This
seems to be a significant reason why the use of CAM is still
rising – it apparently integrates such involved patients better
than other kinds of medicine do, while regarding their values,
beliefs, and experience [4, 5].
CAM is frequently used in tandem with COM. In addition,
the proportion of physicians who offer both CAM and COM is
permanently rising [6]. In Germany, attaining additional quali-
fications in CAM for conventional physicians is regulated by a
medical residency program. At the moment, a physician can re-
ceive qualifications in acupuncture, homeopathy, manual medi-
cine / chiropractic therapy, naturopathy, physical therapy, and
balneology [7]. Nonetheless, CAM is still mostly used outside
of the public health care system, and for that reason it can still
be considered a ‘private medicine’ [8].
In Germany, CAM services which are not part of the pub-
lic health care system must be paid for by either the patients
themselves or by private health insurance companies. In 2009,
over 9 billion EUR were spent on CAM: 5 billion EUR were
paid by patients out of pocket and 4 billion EUR by health
insurance companies [9]. This amount continues to rise, not
only in Germany but also in other countries [5, 10, 11].
Since the 1970s, a huge change has taken place in the medi-
cal culture of the western world. This change has not only led
to more patient autonomy, but to a demand for medical serv-
ices which involve the ‘whole person’ and give more promi-
nence to well-being and health than to disease and the treat-
ment of symptoms. This change also represents a very impor-
tant challenge for the current health care system and western
medicine in general. That, at least, is a big ethical challenge
[11]. As the increasing use of CAM seems to base itself upon,
among others, CAM’s offering of more value and satisfaction
for the patients, it also raises questions about the ethical obli-
gations of conventional physicians [3, 12].
In this article, an overview about some of the most contro-
versial ethical aspects of the increasing use of CAM with par-
ticular emphasis on ethical obligations of CAM providers is
given. Issues concerning the utilization of CAM in pediatric
312 Forsch Komplementmed 2012;19:311–318
and geriatric medicine go beyond the scope of this article and
thus are not included [13, 14].
An important prerequisite of this presentation is that, in
spite of some structural modifications possibly being required,
CAM is not exempted from the ‘principles of biomedical eth-
ics’ as postulated by Beauchamp and Childress [15], and ap-
plying these principles to CAM is possible although difficult.
Within this principle-based ethical framework, despite some
disagreement about such central concepts as health, knowl-
edge, and science, a basic congruence exists among CAM and
COM as both include a specific doctor-patient relationship
(doctor = broad range of professionals like physicians, nurses,
counselors, therapists etc.). This healing relationship is charac-
terized by the healer’s interest for his or her patient’s well-
being as well as by the patient’s desire to get well [16].
At appropriate points in this study’s discussion, light will
be shed on the potential ethical implications for conventional
medicine and the public health care system.
Following and modifying several approaches from recent
studies in biomedical ethics that focused on CAM and its rela-
tions to COM, relevant ethical aspects were assigned to 4 in-
terdependent topics [1, 8, 17–22]:
– informing patients
– research ethics
– the cost
– the education gap.
Informing Patients
Respect towards autonomy is one of the central ethical princi-
ples of the doctor-patient relationship. This means that pa-
tients should be considered as having free will and being capa-
ble of making the decisions relevant for therapy selection.
Most important here is the elaboration of the expected bene-
fits (principle of beneficence) and treatment-related risks
(principle of non-maleficence). Only in this way informed
consent can be possible within the framework of shared deci-
sion-making (SDM).
However, it is a fact that in Germany CAM can be lawfully
practiced by non-medical practitioners, so-called Heilprak-
tiker, which may cause patients to feel that CAM is a harmless
treatment. On a linguistic level, it is suggested to the patients
that CAM services are without side effects, whatsoever.
Terms such as ‘natural medicine’ or ‘(non-scientific) experi-
ence-based medicine’ provoke the belief that CAM is a ‘soft’
and ‘safe’ medicine [20].
It is quite hard to meet such claims given that, while ‘na-
ture’ is conceptually close to words such as ‘soft’ and ‘safety’,
‘naturalness’ does not mean ‘softness’, and a ‘(natural) experi-
ence’ cannot vouch for safety. On the contrary, studies con-
ducted to investigate the side effects of the so-called soft prac-
tices showed a relatively high rate (between 23.8 and 38.2%)
of adverse effects [23, 24].
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 Nevertheless, undesirable side effects of the mere applica-
tion of CAM methods appear to be infrequent in comparison
with those of the mere application of conventional methods
[25, 26]. Additionally, patients who get treated with CAM
therapies report less serious side effects which is one of the
most important motives for consulting a CAM practitioner
[27]. Also, the relatively low premiums for professional liabil-
ity insurance of CAM providers may result from the sus-
pected lower risk of side effects.
Similar ethical problems arise from the use of a term such
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,
the use of the term ‘complementary medicine’ alone appears
unambiguous and ethically unproblematic.
Although it may not be intended to provoke such associa-
tions, by using these terms CAM practitioners are obliged to
provide a favorable risk-benefit ratio associated with their
medical interventions. Without this evaluation, there is a risk
of serious harm in several ways: Firstly, CAM applications can
cause direct harm, especially those therapies which are inva-
sive or require drugs which, as well as other complications,
can cause toxic and allergic reactions. Secondly, they can be
indirectly harmful by being used in lieu of more effective
treatments, or in tandem with conventional therapies and thus
by interacting with them in detrimental ways [20]. There is
evidence that the application of phytopharmaceutical prod-
ucts in CAM can reduce the efficacy of COM [28]. This can
get worse if patients combine both treatments without inform-
ing their doctors.
Another question being considered here is whether CAM
procedures are ethically justified just on the basis that they
possibly do no harm. Patients that get treated both by COM
and CAM show a tendency to ascribe an improvement of their
health conditions to CAM and, vice versa, undesirable side ef-
fects to COM. As a result, the reputation of COM could be
damaged which may give rise to lower patient compliance as
well as nocebo effects in conventional therapies [20].
A further aspect concerning the information problem has
to do with COM: Is a physician, in view of the increasing use
of CAM, obliged to inform his or her patients about CAM?
Particularly given the possibility of future harm resulting from
CAM treatments or undesirable side effects when getting
treatments in both CAM and COM, one could demand well-
informed conventional physicians who principally act as confi-
dants and contact persons in medical matters. But also in re-
spect of possible health cost reduction by applying efficient
CAM methods one could demand physicians better educated
in CAM.
Thus, solving the problem of informing patients on the one
hand would require better trained and educated conventional
physicians in order to cope with the information problem, and
on the other hand more studies on the risks and benefits of
unconventional medicine. Unfortunately, such studies in
Ethical Implications of CAM
CAM are still rare when compared with COM. Therefore, the
principles of informed consent and patient participation which
are derived from patient autonomy can reverse into paternal-
ism. In view of the lack of scientific results, patients have to
rely almost blindly on the authority of those providing CAM.
Even if the authority problem may also apply for COM [29],
the question here is whether there are any good reasons for
patients to have trust in their CAM providers. It is certainly
rather risky to refer solely on the personal experience of the
provider or the patient.
Research Ethics
A few years ago, the underdeveloped level of research was
one of the most crucial problems of CAM resulting in little
favorable risk-benefit ratios of CAM methods which could
have justified their usage.
One of the reasons for this was that CAM research usually
took place outside of the scope of COM and its research infra-
structure; until recently, only a couple of high-ranking scien-
tists contributed to CAM research [11]. As a result of this lack
of expertise, CAM methodologies did remain quite weak.
Consequently, those ethical rules and guidelines for clinical
trials whose observance is monitored by ethics committees did
often become insurmountable obstacles for those applying for
CAM studies. Personal reservations and biases on the part of
committee members may also have impeded the application
procedure [8].
In the last 20 years, there has been some progress in this
field, e.g., the establishment of several peer-reviewed CAM-
related journals which are able to promote the development
of the research discourse and furthermore make it easier to
verify the credentials of individual practitioners. At the mo-
ment, the most influential journals in that area are: The Jour-
nal of Alternative and Complementary Medicine (since 1995),
BMC Complementary and Alternative Medicine (since 2001),
Alternative Therapies in Health and Medicine (since 1995),
Evidence-Based Complementary and Alternative Medicine
(since 2004), Complementary Therapies in Medicine (since
1993), Complementary Therapies in Clinical Practice (since
1995), European Journal of Integrative Medicine (since 2009),
Focus on Alternative and Complementary Therapies (since
1996), and Forschende Komplementärmedizin / Research in
Complementary Medicine (since 1994).
Besides this, internet platforms such as the EU-funded
website www.cam-cancer.org have been launched which pro-
vides tightly controlled meta-analysis and reviews on CAM
treatments in cancer therapy. In 2009, the European Informa-
tion Centre for Complementary and Alternative Medicine
(EICCAM) was founded in cooperation with the International
Society for Complementary Medicine Research (ISCMR), and
in 2010, the CAMbrella project being part of the EU’s 7th
Framework Program for Research (FP7), started [30].
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 CAM research faces particular difficulties with its method-
ologies because the evaluation of complex and holistic CAM
methods may apply different criteria than those used for re-
viewing conventional medical interventions [17, 31–33]. How-
ever, it must be emphasized that clinical research must be de-
signed and conducted with sufficiently rigorous methods to
ensure that the findings will have scientific validity [33]. The
question arises as to what the terms ‘sufficiently rigorous
methods’ and ‘scientific validity’ mean. In recent years, a shift
took place in this respect in medical anthropology, combined
with the emergence of the so-called medical pluralism. This
shift led to another perspective on the knowledge constitution
process and evaluation measures in medicine [16].
Many critics claim that the randomized clinical trial (RCT)
has to be the gold standard for measuring the potential effec-
tiveness of all medical interventions, including CAM meth-
ods. Only by RCTs the well-known logical fallacy of post hoc
ergo propter hoc can be avoided and the causal associations
can be distinguished from the confounding associations. For
those critics, the proof of effectiveness with conventional
measures like the RCT seems to be a precondition for the
emerging of CAM’s approaches into mainstream medical
practice. As a consequence of such an emerging process, the
relationship between CAM and COM may be modified at the
expense of an independent CAM [34]. A counter argument is
that the RCT was originally developed for the evaluation of
drug therapies which are focused on the causal effect of drugs
[35, 36]. At this point, one has to differentiate between the
effect of a drug and the effectiveness of a treatment. It is ar-
gued that a complex therapeutic procedure including a range
of synergistic treatment components can be useful without
the effect of any drug which might be administered during
the treatment. Furthermore, conventional therapies which
are tested with RCTs focus mostly on disease and healing;
many CAM practitioners do not claim to heal disease, but
rather to preserve health which cannot be reviewed correctly
by RCTs.
However, the various CAM methods and their applications
must be differentiated. For example, the effectiveness of
herbal medicine when used to remedy coughs and colds
should be easier to be verified by conventional standards than
the impact of spiritual healing or hypnosis, where a clinician
does not have a clear representation of what to study and how
to study it. One of the questions here is how to define the con-
dition in which to study spiritual healing. Does this definition
need to be made in terms of COM or CAM? Obviously, each
definition would involve value judgments with even further
ethical implications [16]. Recently, some efforts have been
made to define CAM/COM combined classification schemes
and specific study designs for CAM systems, such as N-of-1
trials and preference RCTs [16].
Another question is whether using CAM methods which
have no advantage over placebos and are probably based on
placebos themselves can be ethically justified. Some re-
314 Forsch Komplementmed 2012;19:311–318
searchers seem to approve the use of such placebo CAM
methods if there is no effective conventional therapy, or if
the only one available therapy comes along with serious side
effects for the patient [16, 37]. In this case, it is required that
the putative placebo effect is a true one. Possible distortions
in the interpretation of such effects may be avoided by how
the study is designed – e.g., a three-branched study could be
useful [33].
To conclude, it should be pointed out that national legisla-
tion can also impede further research on CAM. In Germany,
for example, according to the drug law (Arzneimittelgesetz
(AMG)) of 1978, new drugs belonging to the so-called tradi-
tional drugs family were allowed to be launched without any
prior evaluation in order to guarantee scientific pluralism.
Only the packaging of the drugs had to refer to the indication
and traditional experience: ‘Traditionally used for strengthen-
ing and invigoration (…) This information is based only on
tradition and long-term experience’ (AMG, §109a). However,
this is unlikely to avoid any possible complications and ethical
problems [20], nor is the principle of the so-called internal
recognition of certain drugs by the relevant experts an appro-
priate means of protecting the patient [38]. Usually, drugs
have to be tested in vitro or on animal models before being
tested on the general population. Without such evidence, the
question is how would it be justifiable to investigate tradi-
tional drugs in future [16]?
Legal proceedings concerning serious side effects regularly
give reasons for the discussion of the withdrawal of certain
drugs from the ‘traditional list’. In 2004, the European Direc-
tive on Traditional Herbal Medicinal Products (THMPD) was
issued demanding a special authorization process for phyto-
pharmaceutical products distributed in the EU, excluding those
already being marketed (for at least 30 years in a member
state and 15 years in the European Community). For the lat-
ter, a transitional period was granted ending on April 30, 2011
– after that time, all such drugs required a certain marketing
authorization procedure within which a reliable risk analysis
has to be conducted. However, drugs which are manufactured
and administered while consulting a phytotherapist are ex-
empted from that rule [39]. Of course, at this point, one has to
ask critically if the new legislation is an appropriate means to
protect the patients or if the pharmaceutical industry mainly
benefits from it. In effect, this legal provision may also result
in a shortage of the traditional drug inventory and thus in in-
creasing health care costs if patients and doctors now have to
refer to conventional drugs which are approved but more ex-
pensive. Nevertheless, in respect of a continuously changing
medical culture with new drugs, therapies, and understanding
of action mechanism, reviewing medicines that have been in
use for a long time is strongly recommended, primarily in
order to protect patients from potential harm. However, it is
doubtful whether new regulation is suitable for achieving this
goal.
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The Cost
Besides those ethical problems found in CAM research, there
is a debate about a number of socio-ethical issues concerning
cost for CAM research as well as for CAM treatment.
So far, a lobby for research on CAM comparable to that of
COM which would neither initiate nor finance research does
not exist. As one of the supposed reasons for this lack is the
missing evidence of efficacy, there inevitably exists a vicious
circle. More evidence can only be achieved by more research.
But more research funding would only be paid in the event of
more evidence. Of course, the fact that natural medicinal
products are not patentable does not stimulate the pharma-
ceutical industry to sponsor CAM research either [11]. In ad-
dition, carefully designed and performed studies on CAM are
quite expensive [8, 33]. The question must also be asked as to
whether it is ethically justifiable that the public health service
gives money for research on CAM, considering its scarce re-
sources and given that CAM methods are often incompatible
with the foundations of modern science. But a dogmatic
stance refusing CAM cannot stop it from growing. Therefore,
it seems to be better to just look and pay for further scholarly
debate and research on CAM despite the risk of future
expenses.
In view of the important role being played by CAM as a
‘big business’ [5] in today’s medical landscape, one could even
argue that the public health service is obliged to finance CAM
research for at least 2 main reasons: 1) to protect patients
from the possible harm associated with CAM treatment and
2) to ensure the required justice and equality with regard to
funding of research in COM.
Here, reference is made to the Office of Alternative Medi-
cine which was founded in 1992 by the US National Institutes
of Health (NIH) and renamed as the National Center for
Complementary and Alternative Medicine (NCCAM) in
1998. The annual budget of this organization was about 128.8
million USD in 2010 [1, 40, 41] – it held the top position
among the western industrial countries although it still seems
a relatively small amount compared with the total budget of
the NIH (about 32 billion USD) [42]. By comparison, only
0.0085% of the total research funding is spent on CAM in the
UK [43].
Another argument often used is that CAM treatments are
much cheaper than those found in COM and thus their imple-
mentation in basic health care would lead to a general cost
reduction, but this seems not to be tenable at all [44]. On the
contrary, private insurance companies that included acupunc-
ture and homeopathy in their benefits catalogue reported in-
creased costs [20]. It is caused partly by more intensive doc-
tor-patient contact and partly by higher equipment cost,
whereas drug cost were generally lower [45]. Another signifi-
cant reason for such increasing cost is that patients get treat-
ment both by CAM and COM doctors without any coopera-
tion between them.
Ethical Implications of CAM
Another problem concerning this is the reimbursement of
cost. Commonly, patients themselves or private insurance
companies have to bear the cost. Given that there are efficient
alternatives to several conventional health services, one has to
ask whether it is still justifiable that only patients who are able
to pay for them will get CAM treatments (principle of thera-
peutic freedom).
Today, not only private companies but also statutory
health insurance companies canvass prospective clients with
the offer of reimbursement of costs for CAM treatments. For
example, in cooperation with the German Central Associa-
tion for Homeopathic Physicians (Deutscher Zentralverein
homöopathischer Ärzte (DZVhÄ)), whose members must
have studied medicine at a university, the German insurance
company Techniker Krankenkasse (TK) offers reimburse-
ment of expenses for the supply of basic homeopathic care.
Before 2012, the costs of homeopathic drugs had to be paid by
the patients themselves, but now, the TK pays up to an annual
maximum amount of 100 EUR for drugs not being subject to
prescription-only, but pharmacy-only use. The same applies
to phytotherapeutic and anthroposophic medicinal products.
Since 2012, some cost for treatments in osteopathy are also
paid by the TK. However, the osteopathic practitioner con-
cerned must be a member of a professional organization of
osteopathy practitioners or have a specific education that
would allow him to become a member of such an organiza-
tion. The cost amount that the TK pays is restricted to 80% of
the total treatment costs – up to 60 EUR per treatment for 6
annual meetings at maximum. Another system used by such
companies is financed by additional insurance coverage – e.g.,
at TK’s Private Natural Remedy (‘TK-Privat Natur-Arznei’)
[46]. This trend of cost reimbursement is likely the result of
both Germany’s highly competitive health market and the
rising demand for CAM services there.
In view of the foregoing facts, the way in which the TK
project will influence cost balances will have to be assessed.
Recently conducted Swiss studies where several CAM serv-
ices were integrated into mandatory basic health care indi-
cated a cost increase [47], though not as high as the increase
that was predicted [48]. In another study from Switzerland,
the same authors report an equal or better cost effectiveness
of CAM in the setting of Swiss ambulatory care by comparing
cost of physicians applying CAM with those applying COM
only [49]. A study from The Netherlands comes to a similar
result: CAM can be cost-effective if applied by a physician
[50]. In future, more health-economic studies will have to be
conducted in order to demonstrate the potential health-eco-
nomic benefits of CAM methods [51–54].
Another issue arises from the presumed future institution-
alization process of CAM as well as its potential role in health
cost reduction. From this perspective, it would be useful to
consider a federally funded education in CAM that surpasses
a pure tax reduction for education costs. This leads to the last
issue being examined here.
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The Education Gap
On the one hand, several ethical queries can be derived from
the fact that CAM providers often do not study COM and
their methods are based upon a different understanding of
science.
The first question to be considered here is whether the lack
of education in COM of a part of CAM practitioners repre-
sents a potential risk for patients. Particularly, in the light of
potential future collaboration between conventional and al-
ternative practitioners CAM providers should have a solid un-
derstanding of medical basics [5]. Medical standards should
be among the main contents of teaching in CAM as several
classical medical techniques such as measuring pulse and
blood pressure are already standard tools of every alternative
practitioner. In addition, CAM non-medical practitioners
should be able to recognize serious and acute cases by symp-
toms in order to refer those patients to a physician. By now,
basic medical training is an important element of CAM edu-
cation in German schools like the Paracelsus School. After
years of ‘tourist examinations’ in the 1990s, examination regu-
lations were unified in almost all schools of CAM. As a result,
testing procedures in medical basics are now familiar to all al-
ternative practitioners in Germany [55].
The second question is how efficient communication can
be guaranteed between COM and CAM practitioners. This
question comes up from the convention of both types of medi-
cine often being used in tandem and from the fact that the
prejudices and certain biases on a part of the practitioners
could be used to the detriment of the patient. Preventing
harm through interaction between conventional and uncon-
ventional procedures requires an operating communication
system [3, 56]. One condition of such a system would be that
both conventional physicians and alternative practitioners
must regularly ask their patients about their potential use of
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
dialogue about CAM [3]. Another condition is that there
should be a broad and solid education of CAM practitioners
in COM and, vice versa, of conventional physicians in CAM
in order to understand their respective vocabulary, diagnostic
constructions, and treatment paradigms.
On the other hand, in view of the increasing use of CAM
as well as the growing number of doctors with additional
qualifications in CAM-associated techniques, an integration
of CAM teaching into academic curricula would be useful.
From this point, a third question can be derived: Do medical
doctors who are not or only slightly trained in CAM pose a
risk?
As previously mentioned, many patients use CAM as a
supplement to COM, often by self-treatment. Physicians non-
or only less educated in CAM may, in their role as health edu-
cators and advocates [57], lack the knowledge to give an an-
316 Forsch Komplementmed 2012;19:311–318
swer that could protect their patients from further harm.
Given the fact that some CAM methods, particularly those
containing drugs, may interact with drugs used by COM, phy-
sicians are obliged to become familiar with common forms of
CAM in order to avoid unnecessary harm [3, 12].
Additionally, a better education in CAM would also be
useful in strengthening the doctor-patient relationship [12]. A
hostile stance among medical doctors towards CAM without
being acquainted with its methodologies, could lead to a loss
of confidence and make patients believe that COM is narrow-
minded and dogmatic; patients would probably withhold men-
tioning that they are already treated by a CAM practitioner
[11, 12].
In Germany, medical doctors can acquire officially ap-
proved additional qualifications in several CAM techniques
[7]. Since winter semester 2002/2003, students are obliged to
study at least some selected CAM methods within the curricu-
lar framework of cross-cutting strand 12: rehabilitation, physi-
cal therapy, and natural medicine. Obviously, the amount of
hours CAM is taught is not sufficient to guarantee a well-
grounded education [3, 41, 58–60].
Recently, there has been an international trend towards
the further academization and professionalization of CAM
[57, 61–64]. In Germany, the pioneers held endowed chairs in
naturopathy which have existed for a number of years in, e.g.,
Essen, Munich, and Berlin. Universities such as those in Hei-
delberg and Berlin which launched several medical reform
courses were pioneers of integrating CAM into academic
teaching. This development is still pushed by and reflected in
different forums such as the Forum for University Working
Groups on Natural and Complementary Medicine (Forum
universitärer Arbeitsgruppen für Naturheilverfahren und
Komplementärmedizin) founded in 1998 or the Dialogue
Forum for Pluralism in Medicine (Dialogforum Pluralismus in
der Medizin) founded in 2000 [57, 59, 65].
Conclusions
In principle, it should be obvious that the ethical obligations
in CAM and COM are identical, given that both are derived
from the 4 bioethical principles first defined by Beauchamp
and Childress [15]. The main reason is that the conventional
as well as the alternative practitioner play the same roles as
health educators, providers, and advocates. Consequently, the
set of ethical rules of professional organizations such as the
German Association of Non-Medical Homeopathic Practi-
tioners (Fachverband Deutscher Heilpraktiker Bundesver-
band e.V. und Landesverbände) is based on medical ethics
according to the professional code of conduct that applies to
all licensed physicians [66]. The same applies for organiza-
tions in other countries like the American Chiropractic Asso-
ciation (ACA) or the American Association of Naturopathic
Physicians (AANP) [12].
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Univ. of California Irvine
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 Taking into account that the current ethical debate about
CAM is mainly concerned with safety and effectiveness,
greater efforts must be made in order to prevent damage and
to ensure that CAM applications hold an appropriate thera-
peutic value. This should also include a revision of COM’s
standards such as the use of RCT as the only proof of medici-
nal effectiveness. A conventional practitioner using both COM
and CAM would otherwise follow 2 totally different and in-
compatible ethical principles as they would take other evi-
dence criteria as a basis for CAM treatments than for conven-
tional treatments. Such a practice would not allow fulfilling the
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
apply CAM methods. Additionally, those results and experi-
ences could make self-treatment, a wide-spread occurrence in
the application of CAM, more secure [11]. The underlying
mechanisms of action could be explored, and therefore under-
standing and therapy of the disease could be improved simply
with the help of further CAM research. The objective of a so-
called integrative medicine [67] should be to choose and in-
tegrate only those CAM methods the effectiveness of which
has been proven and thus can contribute to a critical medicine
system and an improved health care system. However, as
shown in the present paper, this aim is impeded by a number
of political, economic, and structural conditions. Thus, there is
a need to consider and act on several levels in order to come
to better solutions in the future.
Disclosure Statement
The author assures that there are no conflicts of interest which would
have influenced the work carried out.

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