001. "IM in CM" for an administrative ethics context:
The
activities, beliefs and claims of Integrative Medicine [IM], a recent
rebranding of the area often referred to as Complementary and Alternative
Medicine [CAM] (Morrison, 2016, p.125), particularly when housed within a
larger, mainstream academic healthcare system, pose intriguing ethical hazards
and dilemmas for the uninformed and/or credulous healthcare administrator or
executive.
[So that sets the frame of a kind of higher-than-individual-practitioner code of ethics / standards such as the American College of Healthcare Executives code, which will be later referenced. I also think the lineage of 'it all' goes: quackery became alternative became complementary and alternative became integrative. But, generally, that CAM is still...quackery, overall.]
Healthcare
has, broadly speaking, an overall goal of quality improvement within such
common stipulations as collaboration, transparency, truthfulness, integrity and
equity (NAHQ 2019). Here, such mainstream goals and stipulations will be
represented with the abbreviation CM [conventional medicine].
[So, I thought it interesting to use this very broad trend from the National Association of Healthcare Quality code of ethics as a kind of mainstream baseline. Since the essay had a work-count cap, therein with these two sentences, I can get to a preponderant, mainstream consensus as a kind of fiducial marker.]
In light of such a progressive and standard
mission, recently, the study “Complementary Medicine, Refusal of Conventional
Cancer Therapy, and Survival Among Patients with Curable Cancer”, published in
JAMA Oncology (Johnson 2018), surprising found that with greater patient use of
IM/CAM there was an associated 2-fold increased risk of death from curable
cancers when compared to populations that did not use IM/CAM due to patient
refusal of typical / conventional CM care.
[Now, I find the findings of 'CAM usage increases noncompliance shortens life' as associated with IM impeding CM to quickly make this argument serious. Something about IM undermines CM.]
Morrison's textbook Ethics in Healthcare
Administration considers IM/CAM to be “an eclectic collection of philosophies
and practices” (Morrison, 2016, p.125).
This short case study analysis will argue that IM/CAM and CM have vastly
different philosophical assumptions, standards and methodologies, philosophical
in the sense of encompassing both epistemological and ethical foundations,
which all then inform [and some may say disinform] respective activities and
claims therefore potentially explaining IM/CAM's retrograde effect upon quality
and efficacy.
[So, one could immediately cash-out if one wants to in terms of any kind of meaning to be had from the labels IM or CAM, because when composed of 'somethings so numerous', what's the point of a label at all in terms of serving as an indicator? IM and CAM might as well be replaced with the term 'any variable stuff not within CM'. In that sense, in not cashing out, which we're not doing here because obviously the essay continues, a certain amount of charity has already been granted to IM / CAM. And a certain amount of false balance. So I'll say it here though I didn't in the essay: IM / CAM is a bogus category due to its nebulousness. One might as well say whatchamacallit medicine. I also wanted to quickly bunch facts / epistemic claims, and the ethical, within the philosophical -- since both are branches of philosophy -- and the oncology outcomes. I'm also preparing the reader for a position or 'watch out for not getting told the truth' through disinform. Retrograde is important too, as a choice, because it contrasts with progressive from the paragraph that was previous. Perhaps efficacy isn't the best word, but, generally, if what someone is doing is working comparatively better or worse, generally, then quality and efficacy seem to couple well. For now.]
Since the IM footprint is quite vague, in fact Morrison
states IM is comprised of more than 200 “areas” (Morrison, 2016, p.129), this
case study will focus on one area that Morrison mentions within IM,
naturopathy. Regarding naturopathy, Morrison asserts "there is a program
for school accreditation and individual certification/ licensure for
acupuncture and naturopathy practice" (Morrison, 2016, p.129). But, is the existence of such a “program” any
guarantee of the integrity of this area of IM when that North American naturopathy
licensure exam, NPLEX, quite falsely places the science-ejected category
homeopathy within its “clinical sciences” section? (NABNE, 2019; AGDH, 2015).
[Reinforcing the vagueness of IM / CAM, I quickly hone into a component within that nebulousness. Naturopathy, of course, is my area of specialization for now about twenty years. I take great issue with the textbook's 'free pass' for naturopathy, because just because systematization is in place, there should not be an assumption that what has been systematized is even rational. And very quickly, I point out that even while systematized, naturopathy's North American exam is in fact essentially pseudoscientific. The citations are the people who govern that exam and then the Australian 2015 final nail in the coffin for homeopathy in terms of its bogosity. Again, I'm trying to get a lot done in a small amount of space.]
The
example institution for this case study, to demonstrate IM-CM hazards and
dilemmas, is
the George Washington University Center for Integrative Medicine within the
George Washington University Medical Center [GWUCIM, GWUMC]. Under an IM-CAM umbrella, their cornucopia [and
perhaps one may say nebulosity] includes:
integrative medicine
consultations, naturopathic medicine, holistic psychiatry and psychotherapy,
nutritional counseling, integrative health coaching, European mistletoe
injection therapy, mindfulness-based stress reduction, reiki, yoga, holistic
primary care, genetic profile results interpretation, intravenous therapies
(high dose vitamin c, phosphatidylcholine, Myers cocktail, glutathione),
biofeedback, Alexander technique, craniosacral osteopathic manipulation,
massage therapy, hypnotherapy, bioidentical hormone replacement therapy, body
composition testing, indoor environmental consulting by Insitu, women’s health
and holistic gynecology, naturopathic integrative oncology services, natural
product store, mind-body medicine, infrared light therapy, integrative
geriatrics (GWUCIM, 2019, Patient care services).
[It
blows my mind that so much junk is happening at such a usually
mainstream and prestigious institution. As I've said before,
naturopathic oncology are two of the scariest words out there in terms
of consumer risk. But particularly, their specification of naturopathic medicine is very helpful.]
The naturopathy page for the institution states
naturopathic methods include homeopathy,
that it is a patient-centered,
distinct primary health care profession whose members are “trained as primary
care doctors at accredited four-year naturopathic medical schools”, is based
upon the healing power of nature or vis medicatrix naturae, and that it
“combines modern scientific knowledge with traditional and natural forms of
medicine” (GWUCIM, 2019, Naturopathic
medicine).
[Now, that's where quickly the homeopathy bogosity mentioned in the NPLEX area gets real as obviously they are doing it. They are doing it under an umbrella label of GW subset medicine. Of course, how is bogosity patient-centered? Also mentioned is HPN-VMN and that is coded vitalism. Plus, we have the admission of blending. While they'd also said distinct. Again: irrationality galore.]
The two NDs listed there are Orceyre and Ledenac, with the
former a graduate of National University of Natural Medicine who uses
homeopathy and states she is medically trained, and the latter a Canadian
College of Naturopathic Medicine graduate who also states she is medically
trained and also uses homeopathy as a treatment. ND Ledenac's biography page then directs
those interested to the aforementioned naturopathy page at the institution.
[I'm not picking on the NDs personally, and I hope that is apparent. But, it is NUNM that states that naturopathy's essentials survive scientific scrutiny when they don't, and CCNM gets this all international. And though you can find at NUNM and CCNM that science-ejected vitalism stated at times explicitly, GW doesn't do such in their naturopathy overview. Again: GW subset medicine subset naturopathy subset homeopathy.]
Incidentally, Morrison's section on IM inexplicably adopts the label
“allopathic” for CM (Morrison, 2016, p.127). That term was invented by
homeopathy's founder in 1800 to describe the prescientific CM of his day and is
generally considered to be a pejorative misnomer when applied to modern CM by
fringe sectarian “areas” (Weatherall, 1996).
[Too often, perhaps in seeking some kind of symmetry, we get the -pathy categorizing of medical and once-medical as if currently true. So, homeopathy-naturopathy-osteopathy-allopathy is the temptation. But, to reiterate an old saw: modern medicine is as allopathic as modern chemistry is alchemic. Again, this is a kind of charity to fringe sectarian perspective.]
At the alma maters of the two NDs at GWUCIM, NUNM and CCNM,
one can find the naturopathy component homeopathy contained within the label
“science” (NUNM, 2019) which is similar to the ND board exam while, grossly,
homeopathy is considered outside of science (AGDH, 2015).
[Simple fact, to point out the radical epistemic deviance of naturopathy quickly.]
This is indicative of a sui generis knowledge-type self-categorizing
by naturopathy that is acutely false.
[Again, simple fact.]
Similarly, in the IM-CAM publication the Journal of Alternative and
Complementary Medicine, the ND co-authored article “Evidence-Based Medicine and
Naturopathy” states:
EBM has been touted as a
‘new paradigm’ and as a corrective for outdated, bad or unscientific practices.
Although it may be true that some medical and health practices are not
supported by a weight of evidence and that this can lead to harm, it does not
follow that doctors, scientists, or any bureaucrats should have a monopoly on
the meaning and deployment of evidence […] By imposing EBM, naturopathy is not
legitimated according to its own paradigmatic definitions, but rather, is
evaluated according to the parameters set by the scientific model resulting in
the marginalization and corruption of ‘traditional naturopathic knowledge’ […]
Naturopathy, a Western nonbiomedical ethnomedicine is based on holistic and
vitalistic principles whereas biomedicine, the prevailing ethnomedicine is
based on scientific reductionist principles. Given such extensive difference it
is inappropriate to superimpose reductionist methodologies that are
paradigmatically incongruent with the holistic practice of naturopathy
(Jagtenberg, 2006).
[Jagenberg's study, in a pro-CAM journal, has become very useful. Oddly enough, most of the study's authors are sociologists. We also get the vitalism and the antiscience deviance.]
Obviously, part of the naturopathic agenda is a
redefinition of the footprint of science to better accommodate, as opposed to
discard due to advancements, its activities, beliefs and claims.
[Again, simply pointing out the obvious in a gross manner.]
IM also desires to have
its own unique or sui generis ideas regarding ethics. This is evident in the article “Ethics and
Integrative Medicine: Moving Beyond the Biomedical Model” from the journal
Alternative Therapies in Health & Medicine.
There, we're told by David E. Guinn, lawyer and [ironically] PhD of “Moral and Political Philosophy and Philosophy of
Law”:
Those who have written
on the ethics of complementary and alternative medicine (CAM) and integrative
medicine have attempted simply to apply traditional bioethics (in the form of
principles of autonomy, beneficence, nonmaleficence, and justice) to this new
area of healthcare. In this article I argue that adopting the practices of CAM
requires a new ethical understanding that incorporates the values implicit in
those practices (Guinn, 2001).
[I find Guinn's credentials impressive, so therein I find Guinn's position here quick embarrassing. Like what is going to be the replacement for: benefit the patient, don't harm the patient, don't lie to the patient and the patient will decide when properly informed, and fairness. Really. That is nucking futs. This somehow akin to flat-Eartherism but instead its for ethical values that-ain't-a-changing.]
So, amazingly, and perhaps bizarrely, not only
does IM argue for its own peculiar definition of science, but also its own
peculiar though undefined definition of ethics.
These positions, in my opinion, are narrow, obscure, unjustifiable,
regressive, and often hidden. It is the
opposite of CM's goals and stipulations, which previously were listed as
universal, and geared toward improvement, collaboration, transparency,
truthfulness, integrity and equity.
[I like the list. And the contrast. One necessity of the paper was to employ an ethical framework, and therein broad universalities.]
Specifically, in terms of those opposite IM characteristics so cleverly unmentioned, the GWUCIM
has the page “About Integrative Medicine”, containing a link to their naturopathy page.
[Yes, a little snark.]
That page does not
contain the root scien- nor the root ethic- and mildly states “within our
Center, integrative, complementary, or alternative medicine and modalities are
distinct from Western, conventional, or allopathic medicine” (GWUMC, 2019, Integrative medicine).
[Yes, they state this deviance and anti-preponderance is not CM, yet of course this is belied by their NDs stating they are medically trained and not being distinct about what naturopathy specifically is.]
A site search of GW through google.com via
>site:gwcim.com ethic< does not produce a code of conduct or ethical code
for their IM area. To reiterate that
reality: a major academic medical institution that contains a collection of
areas marketed as Integrative Medicine that do not adhere to the standard
boundaries that typify science, medicine and healthcare ethics does not alert
the public to its peculiar positions in a simple, understandable, and
straightforward manner. Instead,
actually, GWUCIM states:
Integrative
Medicine is defined as the practice of healing in a medical environment where
the emphasis is on the integrative use of complementary alternative modalities
along with conventional treatments to promote one’s natural ability to heal,
thus achieving wellness (GWUCIM, 2019, Integrative
medicine consultations).
[It blows my mind that at the time of writing this, no ethical code there. And no disclosure in a meaningful way. And that claim of "medical" umbrella. Cake and eat it too.]
The claim or context is posed
as “medical”, as if what occurs in IM happens within mainstream medical
boundaries, conduct codes, and epistemological and ethical context. Their NDs also stated “medical.” Yet, for
instance, if one refers back to the naturopathy schools which graduated the
naturopaths at GW, and to the previous Jagtenberg quote, “natural ability to
heal” or vis medicatrix naturae is actually IM's pedestrian verbiage or coding for
the historically science-ejected concept of vitalism (Bechtel, 1998). Vis medicatrix naturae, which is a commitment
to the doctrine of an invisible vital or life force running the body that is
not in evidence and is also science-discarded, is historically categorized as
sectarian (Popular Science, 1890).
[That PopSci is one of my favorite references.]
Regarding
what “medical” thinks of naturopathy, from a state that has licensed
naturopathy since 1920, Connecticut (Naturopathic Diaries, 2018), the medical
associations have opined. Contrary to
IM's apparently nonexistent guardrails, Connecticut's Fairfield County Medical
Association states “all members must subscribe to the Principles of Medical
Ethics of the American Medical Association and must not hold themselves out as
practitioners of sectarian medicine” (FCMA, 2019). And specifically, regarding IM’s naturopathy,
the Connecticut State Medical Society has testimony publicly available that
states:
our
naturopathic colleagues openly spurn both evidence-based and science-based
knowledge and therapeutics [...] we remain concerned that patients will be
confused and misled by providers who are neither true believers in naturopathy
nor committed practitioners of the science-based medicine that has been the
foundation of medical practice for doctors of medicine (MD) and doctors of
osteopathy (DO) ever since Flexner set down his guidelines more than 110 years
ago (CSMS, 2018).
[So, in my State of residence, quite a contradiction exists. State sponsored and licensed grifting. And a small shout-out to BH's web site through that reference.]
Usually, an ethical dilemma is quite downstream from foundational
assumptions, mannerisms, and perspectives.
In that sense, the playing field is established, along with a set of
rules. This then allows for productive
discourse. The IM in CM situation
instead demonstrates two mutually exclusive worldviews that do not have such
commonalities which could then allow for fair deliberation of an ethical or
factual issue to occur. The Connecticut
county and state medical associations’ pronouncements obviously illustrate IM
via naturopathy to be incompatible with the CM hallmarks of quality improvement,
collaboration, transparency, truthfulness, integrity and equity. Yet, one is
trading off the status of another, namely IM is not holding itself to the
rigors, methods and foundations of CM in its activities, beliefs and claims yet
IM positions itself within a CM wrapping of
“medical” for its benefit. Some
may remark that this is akin to a bait-and-switch and is a retrograde overall
effect in terms of progress along many healthcare fronts.
[Sure, sure. ]
IM, apparently, as found through its literature and omissions, seeks
to keep the public, patients and inevitably healthcare administrators or
executives uninformed and/or regards them as credulous. Therein, fundamentally,
informed consent, within the ethical principle of autonomy, is quite trampled
upon. How does the public benefit from false positions claimed to be true, such
as science-based non-science? How does
the public benefit when a diagnostic and therapeutic area does not occur within
what is commonly expected ethically and factually speaking yet is housed [or
camouflaged] within such assumptions? IM
within a mainstream academic setting, as illustrated by naturopathy within GWU,
is largely both a hazard and a danger ethically and epistemically speaking.
[Sure, sure.]
It would be an act of great credulity to make typical assumptions
about IM in terms of quality, integrity, transparency, truthfulness, and
equity. Contrary to IM's epistemic and
ethical deviance or sui generis footprint, allied healthcare codes of
ethics at every level quite explicitly occur within mainstream contexts and are
not ahistorical. Until IM states its
explicit and bizarre epistemic and ethical deviance up front, and then justifies
the utility of that context, I do not believe the business of IM should occur
within mainstream allied healthcare.
[Sure, sure.]
The Code of Ethics of the American College of Healthcare
Executives states “healthcare executives […must] provide prospective patients
and others with adequate and accurate information, enabling them to make
enlightened decisions regarding services” (ACHE, 2017). In terms of just how
'down the rabbit hole IM within CM truly is', as paraphrased from the physicist
Wolfgang Pauli, “this isn't right. This isn't even wrong” (Prochnow,
1966). IM in CM will not be right, will
not be assessable, until it agrees to the same playing field and rules as all
other areas of modern healthcare.
[So, an attempt to do a lot in a small space.]
References
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