This article explores what practising ethically means with specific reference to the practitioner/patient relationship in complementary medicine. What emerges is that the practitioner’s responsibilities need to be looked at alongside the patient’s self-responsibility and active participation in the therapeutic exchange.
Introduction The unique features of the holistic relationship create a variety of ethical dilemmas. The purpose of this article is to examine some important ethical principles in health care and question how these affect the therapeutic relationship. In the past, ethical discourse has been framed with reference to the doctor/patient relationship. We must therefore question what practising ethically requires with specific reference to complementary medicine. What will emerge is that any ethical framework must look not only to the practitioner’s responsibilities, but to the patient’s self-responsibility and active participation in the therapeutic exchange.
What practising ethically means Ethics is about acting morally and reaching moral decisions. It is about how people should behave, and what they ought to do. Ethical principles such as respect for autonomy, or the principle of beneficence are justified by reference to one or more overarching ethical theories. Two major groups of ethical theories are deontological theories and consequentialist theories. Deontological theories derive from the idea that there are certain fundamental rules which should be followed. This duty-based approach ties in strongly with the idea that certain groups of people, such as health professionals, incur additional duties towards others because of their position.
Consequentialist theories assess the rightness of an action by looking to the outcome that following that course of action will bring about. Utilitarianism is an example of this sort of ethical reasoning A utilitarian would weigh up potential benefits and harms involved in pursuing any proposed action and follow the course of action which maximized happiness for the greatest number of people. Customarily, a variety of theories may be invoked to justify any given ethical stand.
Key ethical principles Certain core principles stand out as being integral to good clinical practice. For the purpose of this article, we shall concentrate on four commonly identified principles, namely: beneficence, non-maleficence, respect for autonomy and justice.
1. The principle of beneficence Many practitioners see beneficence as their cardinal duty. In a health care setting, beneficence is most obviously connected with curing people and applying therapeutic skills to make sick people well. In a complementary context, benefiting patients may take on a rather different meaning. ‘Healing’, with its connotations of making whole is a wider concept than ‘curing’. A person may experience healing even if their symptoms persist. The duty of beneficence must be considered alongside its converse duty, namely the duty of non-maleficence. As well as the concept of not hurting patients deliberately, this principle should ensure that the risks involved in any given procedure are proportionate to the benefits.
The relationship between complementary therapists and their clients is based on different premises to the conventional doctor/patient relationship. Unlike the conventional model, which sees patients largely as the passive recipients of beneficent practice, here, the healing exchange is likely to be a rather different process in which the therapist facilitates the patient's own self-healing mechanisms. Within this relationship, greater reliance may be placed on self-responsibility, change coming from within the patient herself. Consent is not something that the therapist needs in order to be allowed to do something to the patient, rather, it is central to the process of healing, in which the patient is an active participant.
Because holistic practice connotes helping people to become integrated on a physical, spiritual and emotional level, a practitioner who can only deal with patients on anything other than a physical level cannot be a ‘good’ practitioner. How a practitioner responds to the patient on a personal level may be as integral to the success of the therapy as being technically proficient. In a holistic setting, helping the patient is a highly individualised process, which requires communication skills. Mostly, patient-centred treatment is about listening to patients and involving them at a profound level. For patients to be able to make decisions, they have to be given information. The concept of beneficence needs to be re-evaluated to take account of the fact that securing the patient's participation is a central part of treating them well.
Redefining competence: technical and human skills Beneficence requires practitioners to be well trained and have the requisite skills needed to help their patients. The acquisition of technical skills is, of course, important in ensuring high standards and, indeed, a technical skill base is one of the defining characteristics which sets professionals apart from other occupational groups. However, to bring about a beneficial healing effect, therapists need both technical skills and human skills. These different skills will be imparted in different ways. Whereas technical, or ‘doing’ skills, can be judged by observation and written examination, the acquisition of ‘being’ skills, that is, the attributes required of a good therapist, including empathy, compassion, humility, a strong sense of self and a high level of self-awareness, will require more creative means of teaching and assessment. The acquisition of technical skills in isolation, does not guarantee that practitioners will be good with patients.
Acquisition of technical skills Practitioners who hold themselves out to have a particular skill must have a legitimate basis for doing so. Therapists must be properly trained at a suitably accredited establishment to equip them to perform whatever therapeutic skills they are offering. To be able to act beneficently they must be able to demonstrate the competencies required of that therapy. In order to train competent practitioners, it is first necessary for each therapy to decide at a collective level what the required competencies and skills in that particular discipline are. There may be a considerable diversity of what constitutes acceptable practice within a given therapy. Once competencies have been established, therapies can work on the most appropriate way of instilling those skills.
Acquisition of human skills The ability to bring about healing is enhanced by the possession of certain personal attributes. All health practitioners need to cultivate qualities such as basic empathy, genuineness, warmth, and an ability to listen and communicate. It is debatable how far these things can be formally taught. A number of complementary courses specifically include counselling skills as part of the curriculum. To the extent that holistic practitioners work with patients on an emotional level, their training should equip them with specific counselling skills.
Limits of competence The duty of beneficence requires practitioners to know when they are out of their depth. This may be when the patient’s problems are outside the therapist’s range of expertise or when the patient’s symptoms are patently not responding to the treatment. This may require the practitioner to refer patients to practitioners who are better equipped to deal with the patient's problem. The therapist may consider referring the patient to a more experienced therapist in the same field or to a therapist working in a different therapeutic modality. This may or may not be a mainstream orthodox practitioner depending on the nature of the problem.
The ability of complementary practitioners to recognise serious medical conditions which might require acute intervention is a vexed question which raises a number of legal and ethical concerns. Although there is no body of case law to date, arguably, failure to refer a patient to an orthodox practitioner could, in an extreme case, amount to negligence. Practitioners may know very little about other therapeutic disciplines. There should be much greater awareness by all therapists of the major registering bodies in other therapies, so that patients can be pointed in the right direction.
Practising in more than one discipline Many therapists practice in more than one discipline. Cross-specialisation is ethically acceptable provided practitioners are adequately trained in each of the disciplines they are using. The random application of other therapies in which the practitioner has only a superficial knowledge is bad practice and potentially harmful to patients.
Balancing risks and harms All therapeutic encounters involve risk. Treatment decisions involve a careful balancing of risks and benefits. In ethical terms, this is about reconciling the duties of beneficence with the duties of non-maleficence, or not harming patients. Usually, in a medical context, it is permissible to cause a degree of harm to the patient if this is necessary to avert a significantly greater harm. For example, a patient might be advised to have a gangrenous foot amputated to avoid death. In a complementary setting, it is for the patient, advised by the practitioner, to assess whether the anticipated benefits of the proposed treatment justify the risks.
Practitioners must ensure that the therapies they use are as safe as possible. Practitioners are under an ethical obligation, as well as a professional one, to minimise the possibility of harm. This duty manifests itself in different ways according to the therapy. Acupuncturists should ensure their needles are of a good quality and should make sure that TENS machines are regularly maintained. The duty of beneficence also requires that practitioners themselves are in good health. The duty not to harm patients means that practitioners must be scrupulous in avoiding carrying out invasive procedures if they have any infection which could be passed on to the patient, and of course, predicates that they be in robust, psychological health.
Establishing the efficacy of therapies Another aspect of beneficence is ensuring that the therapies offered to a patient are of proven efficacy, and that the practitioner has some basis for thinking the choice of treatment will work in the particular instance. Usually, this will require some sort of empirical research. The difficulties involved in conducting research, and in particular the difficulties (although not impossibility) of conducting randomised control trials are well documented. However, the onus is on complementary practitioners to develop alternative research methodologies to establish efficacy. Practitioners have to have some basis for saying that their therapy works and charging for professional services on that basis.
2. The principle of non-maleficence The ethical imperative not to cause harm requires practitioners to refrain from any behaviour, professional or personal, which would be detrimental to the patient's health and well-being.
(a) Sexual exploitation Because many therapists are unregulated in any way, it is impossible to assess the number of incidents of sexual impropriety with any accuracy. Sexual abuse permeates all therapies, and is as much a problem within orthodox medicine. This is a problem which is not prevented by the existence of statutory regulation, although the powers to deal with an offending practitioner will be stronger where there is an effective disciplinary system in place.
The reasons sexual relations are harmful to the therapeutic relationship include breach of trust, violation of the role of the therapist, exploitation of vulnerability, misuse of power, absence of consent, impairment of the therapeutic process and bringing the profession into disrepute. Although the position is less categoric in relation to former patients, there are still strong reasons why sexual relationships are to be avoided.
Given the intimate nature of a consultation, there are certain precautions that it would be wise for any practitioner to take, such as the use of chaperones when carrying out physical examinations. Because issues to do with sexuality are still regarded as taboo, they are often omitted from training, which is extremely unhelpful. Therapists may experience sexual feelings towards clients from time to time and the issue must be expressly dealt with, particularly when training body-work therapists. At a collective level, training bodies and professional associations should be trained to respond sympathetically to patients who make allegations of sexual abuse against their members.
(b) Financial exploitation Again, it is difficult to assess the extent to which this is a problem, largely because there is very little discussion about how much therapists should charge. Arguably, the longer and more arduous the training, and the more technical the knowledge base, the more appropriate it is for the fees charged to reflect the time and money that the practitioner has invested in acquiring those skills.
A major ethical issue is prolonging therapy not for therapeutic reasons, but to continue the relationship either for financial or emotional reasons. The initial consultation should include an indication of how long the course of therapy is likely to go on. Even if a period has been set, if the therapy is not appearing to have the desired effects, or is causing the patient harm, the therapist should consider stopping treatment and consider what other therapeutic approaches might be more successful.
(c) Emotional exploitation Therapists must avoid exploiting their power over vulnerable patients. Whilst this is not to infer that all practitioners are seduced by power, or all patients are vulnerable, the power imbalance between therapist and patient opens the door to the possibility of abuse. The power to offer to heal someone is extremely persuasive when a patient is in pain, distressed and possibly confused. Patients invest a lot of faith in therapists that they can do what they claim to be able to do, which is why it is so critical that therapists do not make unrealistic claims.
Complementary therapists can emotionally exploit or abuse their patients in a number of ways, for example, by allowing a patient's dependence to develop to satisfy the therapist's own ego or shortcomings, or by prolonging therapy unnecessarily in order to satisfy his own emotional needs, such as dependency on the patient, or his own need to be needed. Therapists must be particularly aware of the additional responsibilities they incur by working with patients on an emotional level. Unless practitioners have specific counselling qualifications, there is a limit to the amount of emotional support and advice they should seek to give patients. The need to discuss these issues becomes all the more critical when the practitioner holds himself out as a holistic healer, as most complementary practitioners do.
All healers are involved in draining and sometimes traumatising work and they must be sufficiently psychologically suited to such work, with their own safety valves and access to supervision.
Harmful therapies and the principle of non-maleficence Non-maleficence requires therapists to refrain from using techniques whose harms outweigh benefits. Side-effects are an inevitable consequence of all therapies, and the benefits of any treatment have to be set against their risk of harm. Historically, orthodox medicine treats the most serious illnesses with the most aggressive therapies. Whilst complementary therapies tend to have less severe side-effects, not all therapies are safe and dangers must be minimised. Therapists must be fully cognisant of contra-indications to a particular therapy, and thorough records should be kept of any treatments given.
3. Principle of respect for autonomy The concept of autonomy is one of the strongest ethical precepts, and can be justified on the basis of numerous ethical theories. The ethical requirement of respect for autonomy is so strong that it has found legal expression through the mechanisms of the law of battery, and, in negligence, through the law relating to consent.
What does the principle of respect for autonomy require of a practitioner in practical terms? It requires listening to patients and trying to understand their perception of their symptoms, respecting their confidences, accepting their treatment wishes, including the right to resist any particular treatment (and, of course, ultimately, the right to reject the therapist himself), and providing as much information as they require to make an informed choice (a patient may not wish to receive information, which would be a legitimate exercise of their autonomy and should be respected). Likewise, the therapeutic relationship must have a facility for the patient to be able to express dissatisfactions, either of the therapist, or the way the therapy is proceeding.
The practical implication of the principle of respect for autonomy is that in law, before practitioners may carry out any therapeutic procedure, they must have the patient's consent. The amount of information that has to be disclosed by law is determined primarily by professional standards. Effectively, this means that a practitioner will not be negligent if he discloses as much information as any reasonable practitioner would give. The ethical ideal may require wider disclosure by the practitioner who should answer all questions put by patients openly and truthfully.
Information should include what the treatment entails, what risks are involved, how many sessions it should take for the therapy to work, and information about the therapist, including the therapist’s background, qualifications, training and experience. This is crucial if the patient is to have enough information to choose a therapist she feels comfortable working with.
Confidentiality Respect for patient confidentiality is another facet respecting patient autonomy. Patients have the right to direct how personal information about them should be used. Patients disclose certain personal information on the basis that it will be kept private by the practitioner and only be used for the specific purpose for which it was given, namely in the interests of the patient's health.
A particular issue is the extent to which therapists should try to keep the patient's GP or other health carers treating the patient informed about any treatment they are giving the patient. Ideally, there should be a flow of information between complementary practitioners and GPs and vice-versa. Without this flow of information, both the GP and the complementary practitioner lose out on the opportunity to follow or monitor how successful or otherwise the therapy has been. Wherever the practitioner is in doubt, he should seek the patient's explicit consent to disclosure.
Paternalism A persistent tension exists between the principle of beneficence and the principle of respect for autonomy. Historically, orthodox medical tradition has placed greater weight on the therapeutic purpose of healing, namely to help or cure wherever possible, than on respecting a patient's autonomy. The clash between these two principles arises when what the practitioner thinks as a matter of technical wisdom constitutes ‘doing good’ for the patient is at variance with what the patient wants or is prepared to accept. When practitioners override a patient's wishes purportedly in their best interests, they are acting paternalistically.
Whereas in the past, patients may have been passive recipients of health care, in today’s consumer choice culture the patient is more of a client, capable of exercising choice on the basis of relevant information, choosing between various therapies, and quite possibly, rejecting intervention altogether. Paternalistic behaviour is no longer regarded as ethically appropriate, save in the most extreme of cases, and is rarely justified in orthodox medicine. In complementary medicine it strikes at the heart of patient-empowerment and self-responsibility, and will rarely, if ever, be defensible. For there to be a truly collaborative relationship between therapist and patient, there must be full and frank disclosure which facilitates the patient making decisions on the basis of all the information available.
4. Principle of justice Access to treatment Much of the debate on justice issues is concerned with distributive justice and the question of access to health care. At present, complementary medicine is provided almost entirely within the private sector. Availability is thus limited to those who can pay. If one were to adopt a welfare rights position, it could certainly be argued that the benefits of complementary medicine, to the extent they can be established, should be freely available to all as part of a comprehensive National Health Service. Leaving access to complementary medicine to the vagaries of market forces, in contrast to state provision of allopathic medicine, with which many patients are dissatisfied, could in itself be unjust.
To date, complementary therapists have paid scant attention to wider issues relating to availability of complementary medicine. As practitioners begin to grapple with ethical precepts, they should recognise that they too have a responsibility to enter the debate as to how health services should be provided, to whom, and on what basis. These are issues which could legitimately be pursued on a collective level, through the aegis of therapeutic, or even pan-professional, organisations.
Compensation for harm The other concept of justice relates to compensation for harm. Principles of justice should ensure that people who have been harmed have access to complaints mechanisms and means of obtaining compensation, where appropriate. The likelihood of a patient securing compensation through legal means is remote. This is why it is all the more necessary that therapeutic organisations take their own members to task. Whilst it is open to individual practitioners to make amends for any harm they accept they have caused (for example, by refunding a client's fees), the centrality of this area to the question of rights demands that disciplinary and compensation matters are orchestrated at a collective level.
Collective ethics Certain ethical issues go beyond the scope of individual practice. Determining efficacy depends on co-operation of large numbers of therapists. Likewise, funding, commissioning and carrying out research is something which requires input at an organisational level. In addition, requirements of justice demand the provisions of effective complaints mechanisms and means of ensuring accountability that can only be organised at a collective level. In the absence of statutory regulation, the creation of effective disciplinary structures depends, critically, on effective forms of self -regulation. We will look briefly at some of the structures that must be in place to support and promote high standards of individual ethical conduct.
Registration of trained practitioners To monitor standards, a registration system is required to separate those who are qualified from those who are not. The more unified a therapy becomes, the more it will be able to determine acceptable standards of training within that particular therapy. This would ensure that minimum requirements for ensuring safe standards of practice apply across the therapy, and that the qualification a practitioner holds is a meaningful one. The emphasis of self-regulation should be on protecting the consumer, rather than protecting professionals, and regulatory bodies should be accessible to public requests for information. Copies of registered members should be given to the public free of charge.
Codes of Ethics Rather than the punitive codes, regulatory bodies should provide ethical advice to members which concentrates on good therapeutic practice, including the need to carry full professional indemnity insurance. In addition to producing dynamic Codes of Ethics, regulatory bodies should also exercise an educational role to the profession and regulatory bodies should give practitioners as much guidance as possible on the limits of acceptable conduct, especially in sensitive areas.
Complaints mechanisms A primary function of self-regulating bodies is to establish effective and accessible grievance procedures. Complaints systems must be tied in to a system of risk avoidance so that mistakes can be prevented in the future. This is best achieved by disciplinary bodies working in close conjunction with educational establishments. Complaints mechanisms must endeavour to respond to aggrieved clients as speedily as possible and should be as accessible to the public as possible. Specially trained office staff should be available to deal sympathetically with complaints at each stage. Ideally, regulatory bodies should take an active part in informing the public of their rights and in facilitating the bringing of complaints before the appropriate authority. Complaints procedures should also consider mechanisms for compensating aggrieved practitioners for harm they have suffered.
Disciplinary procedures Disciplinary procedures should be seen in a positive light, and not as a punitive mechanism designed to deprive practitioners of their right to practice. A professional ethos must be developed in which it is recognised that weeding out poor standards of practice is to the advantage of the profession as a whole. The main way that this can be achieved is by designing flexible sanctions with an emphasis on retraining and rehabilitation wherever possible.
Ultimately, however, disciplinary tribunals must have the right to de-register or disaffiliate someone as the ultimate sanction. Currently, the multiplicity of professional registers reduces the deterrent effect of de-registration because a practitioner can often join a different register. To the extent that a therapy is unified and there is only one professional register for that therapy, de-registration would have the desired effect of withdrawing the status of professional membership. Patients should also exercise self-responsibility by checking that the practitioner is currently registered with a professional body.
Statutory v voluntary self-regulation? A growing number of therapists currently feel that statutory regulation is the best way of protecting the public and securing the advancement of the profession. In the UK, osteopathy and chiropractic are the only statutorily regulated professions, but acupuncture, homoeopathy and herbalism are actively considering this option. It is critical to understand that the only necessary difference between a statutorily regulated profession and a well structured voluntarily regulated profession is that in the former, membership of the professional register confers a statutorily protected title, so that it is a criminal offence to use the title osteopath or chiropractor. The assumption is that deregistration, by means of erasure from the professional register, is a more effective sanction. But this need not be the case if there is only one single register per profession, and the public know that all trained professionals must belong to that voluntary self-regulating body.
Whilst there is, undeniably, high professional status associated with being a statutory profession, there are also several disadvantages. The present political climate would require complementary therapies seeking statutory regulation to justify their therapies in scientific terms. Statutory schemes are also extremely expensive to administer, costs invariably being met through membership subscriptions. It could be argued that the professional monopoly created by statutory regulation ossifies a therapy and would inhibit therapeutic innovation. Essentially, however, statutory regulation is not a guarantee that practitioners will achieve optimum standards of practice. The growing number of cases which come before the General Medical Council each year signify that statutory regulation cannot, of itself, promote the highest standards of practice. This can only be achieved through a total commitment to ethical practice, as described, promoted thoughout training and beyond.
Conclusion Every therapeutic relationship poses ethical dilemmas. The demands of patient-centred practice, together with the highly individualised and often unsupervised fashion in which many practitioners work call for a better understanding of ethical issues and should be seen as an integral and essential part of practitioners’ training. Whilst political wrangles about regulation continue at both a domestic and a European level, raising the profile of ethical practice is the most effective way of both protecting consumers and maintaining professional standards.
Julie Stone Julie Stone MA LLB is a lecturer in the Department of Biomedical Science and Ethics at the University of Birmingham Medical School, where she teaches law and ethics to medical, dental and nursing students. Having qualified as a barrister, she previously worked as a Research Associate at Hempsons Solicitors, who are specialists in medical law. She has written and lectured on all aspects of health care law and ethics for a number of years and is the Editor of IBC’s monthly journal Medical Law Monitor. Her first book Complementary Medicine and the Law was published earlier this year by Oxford University Press (see ‘Book Reviews’).