Patient choice and complementary medicine
Authors: E Ernst
Journal: Journal of the Royal Society of Medicine (2003)

Our legal and medical systems protect patients’ rights to choose their treatments. This is ethically, morally and politically correct. At the same time, patient choice has its limits. Three examples might make this quite clear. A patient could opt to have a bone marrow transplant for no compelling reason—e.g. because of the false conviction she has a blood cancer. Another patient might ask her general practitioner for interferon treatment of her common cold. A third patient could ask for quarterly smear tests because she is afraid of cervical cancer. In all three instances, doctors are likely to advise that the intervention is not necessary, not available or not cost-effective. Consequently these patients will experience limitations to their healthcare choices, and conflicts can exist between patients’ autonomy on the one side and scientific evidence or limitation of funds on the other side. As healthcare becomes more and more expensive and evidence more and more complete, the potential for conflict increases. Consequently, the limits of patient choice are likely to narrow, and all healthcare systems have to ration resources;1 this is inevitable but it should be explicit and open.2

In complementary medicine (CM) we have been witnessing a trend that runs clearly against these developments. Here the concept of patient choice is heralded as the main basis for ‘integrated medicine’. Proponents of integrated medicine argue that patients vote with their feet in favour of CM and are generally satisfied with it. Thus, is it unfair that users of CM have to pay for CM and that the less affluent remain deprived of it?3 Inequalities in healthcare must be eliminated.4,5 The obvious solution is to integrate CM into routine care paid for through public funds. ‘Every person should have access to the treatment approach of their choice’6. On the surface, this line of argument looks compelling, particularly to proponents of CM; it could, however, create more problems than it solves.

Research into CM is in its infancy.7 Thus, few treatment modalities in this area are backed up by sound evidence. Promising data are emerging for certain therapies while others seem to have little effect beyond the placebo response. The great majority of CM interventions have not yet been sufficiently tested to allow firm conclusions about efficacy. As to the safety of these procedures, most experts intuitively feel that CM is associated with few risks, but hard data are often lacking.7

What does this mean for patient choice regarding CM? Again, three examples might clarify the complexity of issues arising. A patient with a treatable cancer prefers unproven CM approaches to standard oncology treatment. Another patient chooses reflexology because it has previously made her feel good. A third wants regular homeopathy for her work-related stress. Obviously, patients can refuse conventional treatments.1 But should patients have therapies on the National Health Service that are not supported by reasonably sound evidence? In conventional medicine, the answer would usually be no. Are arguments about evidence and affordability not applicable to CM?

Patients’ needs should be distinguished from wants.1 Needs can only extend to treatments whose value has been firmly established; wants can be satisfied outside the NHS1. I believe CM should be judged for efficacy and safety by the standards generally applied in medicine. Subsequently we should consider those modalities for routine care which pass these tests. Meanwhile, all healthcare professionals have the duty to provide sound (i.e. evidence-based) information and advice about the appropriateness of CM.8,9 I see evidence-based medicine as both an opportunity and a challenge for CM while ‘integrated medicine’ might turn out to be a threat.

Patient choice is an important concept. Unfortunately, it is sometimes limited by constraints such as evidence or affordability. Introduction of a double standard to accommodate CM would be a disservice to everyone, by rendering healthcare both more expensive and less effective.