Perspective: First NIH Fellow in CAM Bioethics
Jon Tilburt, M.D., M.P.H.
Jon Tilburt, M.D., M.P.H., holds the first NIH Bioethics Fellowship in Complementary and Alternative Medicine, sponsored by NCCAM and the NIH Clinical Center's Department of Clinical Bioethics. Dr. Tilburt is a graduate of Vanderbilt University School of Medicine, did his residency in internal medicine at the University of Michigan, Ann Arbor, and held a previous fellowship at the Phoebe R. Berman Bioethics Institute, Johns Hopkins University. He answered a few questions from CAM at the NIH.
What is bioethics?
Bioethics is the systematic study of moral questions (such as, what is or is not permissible to do and under what circumstances?) that arise in the context of the life sciences, health research, and medical care.
What do you hope to accomplish during your fellowship?
I hope to gain further skills in analyzing and presenting ethical arguments and in doing research related to ethical questions in CAM. In my experience with patients, I try to combine in every decision the patient's ethical values and the science. This fellowship position is an opportunity to learn more about how doctors, patients, and scientists can better combine science and ethical values in decisions related to CAM.
What are some prominent ethical issues involving CAM in clinical care?
A few examples are
- Communication issues, especially disclosure of CAM use. Patients should feel comfortable talking about CAM with their doctors, but doctors need to be better informed and comfortable talking about CAM, too.
- Integrating values with science. In their daily practice, how can doctors respect choices and desires of their patients while respecting and conveying the importance of science?
- Relationships between professionals. To what degree are conventionally trained physicians open-minded toward CAM practitioners and treating them as valued partners in patient care?
As an example of a clinical situation, I had a patient to whom I prescribed medicine for a droop in his smile (called Bell's palsy), hoping to improve his smile. He never filled the prescription because he was worried about the side effects. When he came back to me, he had decided to go to a traditional Chinese medicine practitioner to get some herbs instead. In the case of his condition, neither conventional nor CAM treatments are greatly effective; but the treatments I prescribed had no chance of working because he had judged the risks to be too great, and I was not aware of safe CAM options for his condition. If we had discussed risks and benefits in more detail, we might have been better able to address his concerns and identify a treatment whose risk/benefit profile was more tolerable for him.
A January 2005 report from the Institute of Medicine explored a full range of ethical issues in CAM and has helped us think about some of these questions. [To find out more, see www.nap.edu/catalog/11182.html.]
What are some examples of these issues in research?
Most of the following are not unique to CAM, but CAM offers a good opportunity to revisit some of the unsettled ethical questions:
- When is a therapy potentially beneficial enough to test in people?
- When are we confident a CAM therapy can be safely tested in people?
- What do we do when the way of reasoning behind a CAM treatment does not make sense to our way of scientific theory, but a long history of practice and, in some cases, a small body of research suggest that the treatment might be safe and possibly beneficial? Should we require that a CAM treatment "make sense" to us before we study it or use it?
- How can we help the research supervisors at hospitals and medical schools to fairly evaluate CAM studies?
What do you think the outlook is for integrating conventional medicine and CAM therapies in modern medical practice in the United States?
It depends. I am cautiously optimistic about a limited version of "integration."
On the one hand, it is easy to oversell some of the differences between CAM and conventional medicine. Most CAM and conventional providers are committed to do what is in the patient's best interest, even if the bodies of knowledge are different. This shared commitment may provide a common ethical ground for some integration, in both research and practice.
Also, Americans are very pragmatic. Even if they don't always agree on the theory behind something, if it seems to work (by accepted standards) they are willing to be flexible. I think this pragmatism includes large segments of CAM and conventional providers and characterizes many groups of patients.
We need to continue dialogue on what "integration" means. If it would mean wholesale acceptance and taking over of diverse health practices, I would be opposed. However, if one thinks of integrative medicine as a way to offer comprehensive whole-person medicine, which might include referrals for CAM treatments that have been proven safe and effective, I am more optimistic.
It can be difficult for many doctors in conventional medicine to find productive ways to discuss CAM therapies with their patients, and vice versa. What are some things that need to happen for this to improve?
Doctors forget things at times, not just to ask about CAM. I am hopeful that computers and electronic records will be able to help doctors by gathering information about CAM therapies and their patients' use of CAM as if these were vital signs. Then, if physicians can become more knowledgeable about CAM, patients might think it is worth discussing CAM with their doctor.
