CAM and the registered medical practitioner

1. CAM and the registered medical practitioner Dr Alma Rae Consultant Psychiatrist Master of Bioethics and Health Law candidate

2. What is CAM? • “Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being.” • This definition is used by the Cochrane Collaboration.

3. Disclosures • I make a living from conventional medical practice, aka “biomedicine” • I have also from time to time made use of a wide range of CAM and readily acknowledge that much of it is harmless and some of it effective. • I do not believe that the Western analysis of human existence answers all questions, or that our current understanding of human health is remotely complete.

4. Statute Law • Health and Disability Commissioner Act 1994 • Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996 clause 2 • aka THE CODE • Health Practitioners Competence Assurance Act 2003 • Medicines Act 1981 • Accident Compensation Act 2001

5. Introduction • This is going to be a Master’s dissertation and is in an early stage. • The basic idea is that there may be a problem with the current freedom of doctors to use bits of CAM in their practice. • The plan is to examine the law in this area, ask whether there are any problems with it, and if so, suggest what changes may be useful.

6. Common Law • Extensive – includes decisions by: • Health and Disability Commissioner • Medical Practitioners’ Disciplinary Tribunal • Courts at home and abroad • However, very little precedent on doctors who also use CAM

7. Practising guidelines • Medical Practice in New Zealand - A Guide to Doctors Entering Practice (Medical Council of New Zealand 1995) • Ian St George, “The doctor who uses complementary and alternative medicine” in Cole’s Medical Practice in New Zealand (2011 ed, Medical Council of New Zealand) • Statement on complementary and alternative medicine, Medical Council of New Zealand, March 2011 • Codes of Ethics

8. Hypothetical case 1 • Middle-aged woman becomes ill and visits her doctor. • Appropriate investigations are done and a diagnosis of metastatic cancer is made, for which several conventional treatments are available. • Woman does not want these lest the side effects prevent her finishing her PhD • Doctor puts on his other hat and proposes Ayurvedic tablets aimed at “boosting her fire element”.

9. Hypothetical case 2 • Doctor sells her these (at cost). • She goes away and takes them for a month but is no better; comes back as instructed. • Doctor then suggests that for $11,000 he can arrange for a group of Ayurvedic practitioners in India to conduct a ceremony to cleanse the patient’s karma. • Patient departs hurriedly, never to be seen again.

10. Possible Problems 1 The Code • Right 4(1) “Every consumer has the right to have services provided with reasonable care and skill.” • Bolam“The test is the standard of the ordinary skilled man exercising and professing to have that special skill.” • Bolitho “If … the professional opinion is not capable of withstanding logical analysis, the judge is entitled to hold that the body of opinion is not reasonable or responsible.”

11. Problems 2 • An Ayurvedic practitioner would not be expected to meet the same standards as a doctor, but: • The MPDT has found against a GP for inappropriately emphasising the alternative side of his practice, and: • Joanna Manning has written: “want of proper care and skill by a CAM practitioner can be established either by expert evidence … or by proof that the prevailing standard of skill and care in that art is itself deficient.”

12. Problems 3Qualifications in CAM • “Oriental Medicine includes an effective method of diagnosis which can indicate potential patterns that may, over a period of time, develop into a disease state. The early intervention in these patterns is seen to be a method of prevention on which Oriental Medical philosophy is based. This system is quite different to allopathic medicine, as different in characteristic as Western culture is to Eastern culture.” (HDC 2004)

13. Problems 4Meaning of the Medical Degree • Patient thought she could be confident the doctor would not be “a goofball” (HDC decision 2001) • People attending a doctor do not expect, and ought not to receive, “treatment programmes that are inappropriate, unproven and unjustified and are not supported by a substantial body of medical opinion.” (A Guide to Doctors Entering Practice)

14. Problems 5Right 4(2) • “Every consumer has the right to have services provided that comply with legal, professional, ethical and other relevant standards.” • Doctors using CAM must: “ensure that the treatment is efficacious, safe and cost effective” and “not misrepresent information or opinion. Patients must be made aware of the likely effectiveness of a given therapy according to recognised peer-reviewed medical publications, notwithstanding your individual beliefs.” (MCNZ)

15. Problems 6A contradiction? • “No person may be found guilty of a disciplinary offence under this Part merely because that person has adopted and practised any theory of medicine or healing if, in doing so, the person has acted honestly and in good faith.” [HPCA s100(4)]

16. Problems 7Rights 4(3) and 4(4) • “Every consumer has the right to have services provided in a manner consistent with his or her needs.” • “Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.”

17. Problems 8Harm • Evidence-based treatment for life-threatening disease was delayed by use of an entirely unproven alternative (not one clinical study of Vedic remedies has ever been done). • Ayurvedic medicines contain heavy metals (JAMA 2004) and can be toxic e.g. series of eight cases of lead poisoning in Auckland (NZMJ 2006) • “Mrs A had a right to have the appropriate medication prescribed for her condition.” [HDC 2001]

18. Possible Improvements • Overhauling the Medicines Act so that it includes all “alternative” remedies containing actual active ingredients. • Dropping s100(4) from the HPCA Act • Requiring doctors who use CAM to be properly qualified according to practitioners of the modalities they use. • Taxpayer funding of good clinical trials of CAM modalities.

19. In an ideal world… • “To me, there’s only two kinds of medicine: medicine that works and medicine that doesn’t. If it works, it’s not alternative; if it doesn’t work, it isn’t medicine.” [Professor Joe Schwarz, McGill]

20. Thank you Comments welcomed