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Tilburt JC, Miller FG. Responding to medical pluralism in practice: a principled ethical approach.
J Am Board Fam Med. 2007 Sep-Oct;20(5):489-94. PMID: 17823467

An important contribution to the growing literature on clinical applications of complementary and alternative medicine, from a bioethical perspective. The authors incorporate the key concept of medical pluralism into their analysis.

From the abstract:

The popularity of complementary and alternative medicine (CAM) raises a range of ethical issues for practicing clinicians. Principles of biomedical ethics define obligations of health care professionals, but applying principles in particular cases at the interface of CAM and biomedicine may be particularly challenging. “Recognition of medical pluralism” can help clinicians’ ethical deliberations related to CAM. Here we outline a 3-point practical approach to applying basic principles of biomedical ethics in light of medical pluralism: (1) inquiring about CAM use and the scientific evidence related to CAM, (2) acknowledging the health beliefs and practices of patients, and (3) accommodating diverse healing practices. Construed as such, recognition of medical pluralism encourages pragmatic willingness to examine the personal and cultural meaning associated with CAM use, the biases and assumptions of biomedicine, as well as the risk-benefit ratio of CAM practices. In this way, recognition of medical pluralism can help clinicians enhance patient care in a manner consistent with basic ethical principles.

In a case study, Tilburt and Miller include the following trenchant observation on the placebo effect:

In modern biomedicine, therapeutic benefit is determined formally using methods of evidence-based medicine to ascertain efficacy. Typically, the standard for efficacy is superiority to a placebo control in a double-blind, randomized trial. Treatments that are no better than placebo are considered therapeutically worthless. However, recognition of medical pluralism would allow for stretching the biomedical interpretation of efficacy to include objective treatment improvements from placebo interventions themselves without violating the spirit of evidence-based medicine. Patients may derive benefit from treatments that work by virtue of a placebo effect, as evidenced by clinically meaningful superiority to a (no treatment) control group in randomized trials. If such superiority is demonstrated for either CAM or conventional therapies, prescribing such a therapy could be warranted provided that full disclosure is offered to the patient, there are no significant safety concerns, and no other treatment options are available. Such an expanded understanding of treatment benefit may support an ethically justified referral for a broader range of CAM treatments.

For new posts about free-access, peer-reviewed articles reviewing complementary medicine theory, practice and policy, visit my new blog CAMWATCH.

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