Ethics: Ethical Issues in Complementary/Alternative Therapies

Over the past several decades, complementary therapies (also known as alternative medicine or integrated health care) have moved rapidly into mainstream health care, including nursing. According to O’Mathuna (2001), 42% of Americans in 1997 used some form of complementary/alternative therapies. A commonly heard impetus for this increased use may be the consumer who is too often disillusioned with traditional health care that fails to meet her or his standards for open-mindedness and client best interest. However, complementary/alternative therapies are not without their problems, including ethical ones. We now identify, discuss and raise questions about three ethical issues surrounding complementary/alternative therapies.

Safety

The revised provisions of the American Nurses Association’s (2001) Code of ethics for nurses with interpretive statements contain a provision that states, "The nurse promotes, advocates for, and strives to protect the health, safety [italics added], and rights of the patient" (p. 4). Safety has always been the bedrock of nursing ethics; therefore, we must ask: How safe are complementary/alternative therapies? As Synder and Lindquist (May 31, 2001) point out in topic 15 of OJIN, there are over 1800 complementary/alternative therapies. But are they safe? As an example, let us look at a common dietary supplement -- vitamins. According to the Continental Health Promotion, Inc. (Summer, 2000), vitamins are not regulated by the Food and Drug Administration as carefully as are food or pharmaceuticals. As a result, several ethical concerns surrounding safety arise:

1. Although manufacturers of dietary supplements cannot claim prevention of or cure for diseases, they can easily circumvent this language by creative wording that promises more than the dietary supplement can deliver.
2. Regarding names and advertising, there are no set standards. Therefore, legally (but not ethically) manufacturers can use clever names to make it appear they are targeting their product toward a specific group like the elderly.
3. Although the FDA requires dietary supplements to include percent of daily value, it doesn’t validate accuracy. As a result, some manufacturers of dietary supplements will add substances that have no daily value but will increase the cost. Also, some manufacturers will add large amounts of cheap nutrients but small amounts of expensive ones.
4. In the current frenzied environment of megadoses of dietary supplements, some important safety factors are often overlooked. According to the Continental Health Promotion, Inc., "Many people are unaware of the potential side effects of high doses or don’t realize that vitamins and minerals can interfere with medications and blood tests" (p. 2).

The preceding four points raise several ethical questions and concerns. In light of the tremendous increase in dietary supplements used by consumers, why has the FDA not increased its vigilance regarding higher standards for these supplements? Does the ANA have a duty to communicate with the FDA regarding higher standards? Do nurses have a duty to report false advertisements about dietary supplements to the FDA?

Regarding dietary supplements and their potential to interfere with medications and blood tests, do nurses include patients’ use of complementary/alternative supplements in every health care history? If dietary supplements are used, do nurses verify whether potential or real drug interactions can occur and inform both the physician and the patient? Health care providers appear either indifferent to their use or seemingly discard or devalue the information. Both ignorance and indifference put clients at risk for harm. Nurses must be proactive regarding the risks of dietary supplements. The American Nurses Association’s (2001) Code of ethics for nurses with interpretive statements demands it.

Scope of Practice

A critically important scope of practice issue regarding complementary/alternative therapies arises from the previously noted 1800 known therapies: Which of these therapies fall within nursing’s scope of practice? According to Buckle (1997) (as cited by Snyder and Lindquist, May 31, 2001), the Royal College of Nurses (RCN) has identified 11 beliefs related to the implementation of complementary therapies. These beliefs could be envisioned as boundaries regarding the scope of nursing practice. For example, one belief focuses on the nurse’s competence to administer the therapy in accord with the RCN’s standard of practice.

Another standard of practice that encompasses complementary/alternative therapies was addressed by Frisch (May 31, 2000) in article 4, topic 15 of OJIN. According to Frisch, the Standards of Holistic Nursing Practice were developed by the American Holistic Nurses Association (AHNA) and published in 2000 to publicly acknowledge holistic nursing as a specialty practice. In addition, the American Holistic Nurses’ Certification Corporation uses the Standards, among other documents, for certification in holistic nursing. One of the five core values of holistic nursing includes holistic ethics, and the AHNA wrote a Code of Ethics for Holistic Nursing.

Although considerable work has been done by AHNA in attempting to clarify the scope and standards for holistic nursing, ethical thoughtfulness is still required. Given that the vast majority of nurses would not state holistic nursing as their primary practice, they may be confused about the nature and roles of those nurses who identify themselves as holistic practitioners. There may be confusion over what constitutes traditional versus holistic practice (e.g., presence versus healing presence or touch versus healing touch). According to Frisch (May 31, 2001) in article 2, topic 15 of OJIN, the following questions in this direct quotation need answering:

. . . nurses may raise questions related to their legal [and ethical] scope of practice and the use of alternative/complementary modalities within professional nursing. When these techniques are taught by and practiced by individuals who are not nurses as well as by nurses, questions [arise] such as, "May a nurse practice guided imagery as an RN?" "May a nurse perform simple massage or therapeutic massage?" and "May a nurse practice therapeutic touch (TT) as a private, independent professional?"

Harm can come to both patients and nurses if scope of practice for complementary/alternative medicine is not clear. The patient could be harmed by a nurse practicing a complementary therapy on the patient for which the nurse is not prepared. The nurse could be harmed professionally by practicing outside of her scope of practice or by practicing questionable therapies. In addition, how does the nurse deal with a patient who is using dangerous complementary therapies? Or, what are the ethical consequences when nurses and doctors work at cross-purposes (e.g., either group uses complementary/alternative therapies but does not inform the other group)? These and similar questions are raised by Gaydos (May 31, 2001) in topic 15 of OJIN.

Cultural Diversity

The United States is becoming increasingly culturally diverse and this trend is expected to continue throughout the 21st century. One does not have to look far to see this reality, especially in metropolitan areas. In some cities (e.g., Miami, Los Angeles) persons in business and others must be bilingual to communicate. With the increase in cultural diversity comes a responsibility for ethical thoughtfulness on how this diversity affects health care practice (Ludwick & Silva, August 14, 2000).

As Leonard (May 31, 2001) points out in topic 15 of OJIN, nurses have a tradition of working with culturally diverse persons and communities. One aspect of that tradition relates to complementary/alternative therapies. In practice, this tradition is translated into culturally competent nursing care that includes a thorough, nonjudgmental history of clients’ use of complementary/alternative therapies. What nutritional supplements does the client take? How does the client relieve/decrease anxiety? Pain? Cognitive impairment? How does the client try to deter a disease process with use of complementary/alternative therapies?

Based on the preceding questions, what ethical questions and issues arise between the relationships of cultural diversity and complementary/alternative therapies? Probably the ethical dilemma that nurses most commonly confront regarding these therapies is a clash regarding health care values. For example, Leonard (May 31, 2001) discusses the story of an Ojibwe woman with a gangrene foot. Mainstream doctors wanted to amputate her foot after unsuccessful treatment of it for nine months. Instead of accepting this outcome, the woman and her husband returned to the reservation and went to a medicine woman who treated her foot with boiled bark. Amputation was not necessary. How would you have dealt with the boiled bark situation if you were asked to administer it?

In the preceding situation, Weston’s (2002) adage, "Don’t polarize--connect" (p. 51) applies. He says that health care professionals and clients tend to polarize their values rather than acknowledge what is right about each perspective (i.e., traditional therapies versus complementary/alternative therapies). Weston recommends identifying what each side is right about and "to integrate the values at stake" (p. 56). He proposes the following integrative strategies as ethically viable:

• When truly opposite values conflict we can at least split the difference.
• Different values may still be compatible. We can explore them with an eye to finding ways to satisfy both at the same time.
• Most disagreements are framed by deeper shared values. We can work from those shared values -- from that common ground -- toward jointly agreeable resolutions. (Weston, 2002, p. 62)

Finally, an ethical issue regarding complementary/alternative therapies that nurses must be sensitive to relates to the ethical principle of justice. Some complementary/alternative therapies cost little (e.g., massage, humor), whereas others can be costly (e.g., use of chiropractors). Thus, persons who are better off in society may have more access to and ability to pay for complementary/alternative therapies than poor persons who are too often the culturally diverse in our society. How can a just society ensure that all of its citizens receive recognized complementary/alternative therapies when they are important to a patient’s/client’s health regardless of ability to pay?

Summary

In summary, a large increase in the use of complementary/alternative therapies has occurred over the past decade. This situation has precipitated many ethical issues including those related to safety, scope of practice, and cultural diversity. Nurses must be educated about the pro and cons of complementary/alternative therapies and be prepared to discuss and help resolve ethical issues surrounding them.