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Issues in complementary and alternative medicine

Introduction

The stresses of modern living take their toll in terms of our health. This unit is formed from three extracts. The first extract is called ‘Understanding why people use complementary and alternative medicine'. This part discusses: the meaning of health, its origins in terms of components and beliefs. Also models of health care delivery are discussed together with concepts and beliefs about complementary and alternative medicine. Extract two 'Critical issues in the therapeutic relationship' examines: users’ experiences, changing notions of the relationship and issues surrounding the therapeutic relationship. The last extract 'Ethics in complementary and alternative medicine' is about: ethics in health care relationships and ethical behaviour. Ethical practice and accountability are also discussed in terms of professional bodies and individual practitioners’. This extract ends with the key ethical issues which are important for complementary and alternative medicine practitioners.

This unit is from our archive and is an adapted extract from Perspectives on complementary and alternative medicine (K221) which is no longer taught by The Open University. If you want to study formally with us, you may wish to explore other courses we offer in this subject area.

Learning outcomes

By the end of this free course you should be able to:

  • understand the diversity of values associated with the use and provision of complementary and alternative medicines (CAM) and explore some of the legal and ethical issues associated with CAM use;

  • reflect upon and critically evaluate personal and lived experiences of health in relation to CAM;

  • relate ethics and values to your own personal situation and to that of others within a given case study or scenario;

  • analyse some of the theoretical and professional rationales relating to allopathic and complementary health modalities.

1. Extract 1 Understanding health and healing

1.1 Introduction

Since the Second World War, health has come to signify much more than an absence of physical disease for many people in western societies. Interest in health now includes concerns about food, the strength of social networks and the quality of the environment. The stresses of modern living are recognised as a serious health issue. Personal choices are positively or negatively charged, depending on whether they are ‘good for you’ or ‘bad for you’. Most newspapers and magazines publish numerous health-related stories, and television programmes and health journals explain how to lead, or even buy, healthier lifestyles. By giving consumers unprecedented access to health information, the internet has further fuelled people's fascination with health.

This extract explores people's beliefs about health and illness, focusing on the meanings they ascribe to their health and wellbeing and how these influence their health behaviours. You will consider whether the individual experience of illness contrasts with the disease model underpinning the biomedical approach, and whether this leads some people to seek health advice and treatment from a wider range of sources. The issues of plurality and the multiplicity of ways of both understanding health and responding to it are examined with reference to existing models of health.

You will probe the extent to which the philosophies underpinning various approaches to health provide suitable frameworks for accommodating beliefs about health and healing. As there is relatively little information available about attitudes to using complementary and alternative medicine (CAM), this extract looks more broadly at health beliefs in general.

Aims of Extract 1

  • To understand the different meanings of ‘health’ and ‘healing’.

  • To debate the relationship between professional and lay concepts in health practice.

  • To describe an understanding of relevant models of health, including the biomedical, biopsychosocial, salutogenic and alternative or holistic models.

1.2 What is health?

What do the words ‘health’ and ‘healthy’ mean or imply? Superficially this seems a fairly straightforward question: for example, you may recognise that a house plant does not look too healthy. Does this mean it is diseased or is going to die, or that it requires some attention?

When applied to humans the term ‘healthy’ is often associated with a variety of other, more elaborate concepts. For example, it may mean that a person looks ‘well’, as a result of being fit (doing regular exercise), or feeling content with life (being emotionally robust). Older people with mobility difficulties may have different perspectives of ‘healthy’, compared with an athlete or a young person struggling to make ends meet. Health is a subjective determination – in other words, your own definition of health depends on your cultural background, personal aspirations, physical and mental condition, and situation in life. As life is a course and not static, these aspects fluctuate and the meaning of ‘health’ is constantly reassessed and re-formed.

Activity 1: Defining health

Timing: 0 hours 30 minutes

In 1946 the World Health Organization (WHO) proposed the following definition of health:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

(WHO, 1948)

Consider this definition of health and then answer the following questions.

  1. Do you think this is a useful definition?

  2. Does this definition provide a useful framework for how you think about your own health?

  3. In what ways does the WHO definition tally with and/or contrast with your beliefs about your own health?

Discussion

You might disagree with the WHO's definition and view health as being the absence of disease; or you may believe health includes emotional and spiritual wellbeing, social functioning, satisfaction, and work/life balance. According to the WHO definition, very few people would describe themselves as completely healthy. It represents an ideal state, and you might not expect to achieve this level of optimum functioning all the time. You probably recognise that most people experience fluctuating levels of health and do not necessarily seek professional help for every episode of illness. You may have considered whether you view health as your responsibility and whether you attempt to self-manage health issues. Certainly, the WHO definition of health seems to envisage an aspirational level of health that goes beyond what the National Health Service (NHS) provides treatment for.

Despite the practical and resource implications of the WHO definition, its vision of health is still valuable, capturing a broader understanding that many people experience about their own health: namely, health is a holistic notion that goes far beyond reductionist explanations of disease. However, this definition has limitations, particularly in relation to measuring health outcomes (Bowling, 1991). To date, health indicators have been primarily mortality and morbidity rates, rates of health service uptake, and subjective indicators, which might include self-reported or collected data about behaviour (such as consulting CAM practitioners, or lifestyle indicators such as smoking). Collecting such data is fraught with difficulties, as health may be seen at one end of the spectrum and death at the other (Bowling, 1991). It is important to note that there is no universal agreement about the meaning of the terms ‘health’, ‘illness’ and ‘disease’ and that these terms are contested (see Helman, 2001). For the purposes of this extract, illness is the subjective state – the behavioural response to which may be noticed by other people – whereas disease is the pathological condition identified by biomedical strategies (the ‘clinical gaze’) or technology such as blood tests.

1.2.2 Reviewing the research: how people understand ‘health’

Being a contested concept, ‘health’ is constantly being redefined and re-evaluated. Lay people do not necessarily accept biomedical definitions of health and illness uncritically. Instead they have a complex web of beliefs, constructs and understandings about health and illness. These inform people's health behaviour, including decisions about whether to self-manage, seek help within local or lay networks, or consult a health professional.

Some lay people regard health as the absence of disease. Indeed, in a large study in the UK, Cox et al. (1987) investigated lay views of health and ill health. This health and lifestyle study found that 30 per cent of respondents defined health as ‘not ill’ or ‘disease-free’, which could imply different meanings of ill health or disease. One rather crude explanation could be that only certain diseases, which individual lay people cannot manage without professional help, are classified as ‘illnesses’. Most people treat their own ill health, whether it is with lay remedies or over-the-counter (OTC) medicines, with or without the advice of a pharmacist, friend or relative.

So how do people build up their knowledge about health and the nature of healing? Stacey (1988) explains that, for much of the 20th century, the main concern when investigating lay concepts was to ascertain how much lay people understood and took heed of ‘what biomedicine taught about appropriate health behaviour’ (p. 142). Stacey and other medical sociologists have noted that lay concepts are important because they provide information on what:

people think about and explain to themselves in their own way – ways which they may share with others – the misfortunes which happen to them, the ailments which afflict their bodies and the disorders which enter their lives. Their ideas are taken as logical and valid in their own right, although they may not be consonant with biomedical science or any other organized healing system. Ordinary people, in other words, develop explanatory theories to account for their material, social and bodily circumstances. These they apply to themselves as individuals, but in developing them they draw on all sorts of knowledge and wisdom, some of it derived from their own experience, some of it handed on by word of mouth, other parts of it derived from highly trained practitioners. These lay explanations go beyond common sense in that explanations beyond the immediately obvious are included …

(Stacey, 1988, p. 142)

People's explanations of health are diverse and can be contradictory, as demonstrated by examples taken from four studies of different populations. Firstly, Herzlich's research (1973) on lay beliefs in middle-class French people identified three distinct ways of conceptualising health:

  1. health as something to be had – a reserve of strength, a potential to resist illness, which is determined by temperament or constitution

  2. health as a state of doing – the full realisation of a person's reserve of strength, characterised by equilibrium, wellbeing, happiness, feeling strong, getting on well with other people

  3. health as a state of being – the absence of illness.

Secondly, Williams’ study (1983) of the health histories of older men and women in Aberdeen identified four similar categories of beliefs about health:

  1. health as the absence of illness and disease

  2. health as stamina – the ability to keep going

  3. health as inner strength – a reserve of fitness

  4. health as the capacity to cope with illness or endure chronic pain.

Thirdly, Blaxter's survey of health and lifestyles (1983) revealed a multiplicity of meanings of health and distinct differences according to age, gender and class. Her research identified six main definitions of health:

  1. health as not being ill

  2. health as a functional capacity

  3. health as physical fitness

  4. health as leading a healthy lifestyle

  5. health as a psychological concept

  6. health as a reserve.

Lastly, Calnan's research (1987) identified broadly similar categories to the others, but also indicated the need to look systematically at differences between the social classes. He proposed four different concepts of health:

  1. health as never being ill

  2. health as being able to get through the day – to carry out routines

  3. health as being fit – being active, taking exercise

  4. health as being able to cope with stresses and crises in life.

In Calnan's study, working-class women were more likely to quote the first two concepts, while the latter two concepts were referred to more frequently by middle-class women. This was true only when the women were asked to talk in general terms about health; the class difference was less apparent when the respondents talked about their own health. To summarise, these four studies show that people work with multiple meanings of health, rather than a single, unitary concept.

Further research shows that people commonly relate ill health to life events such as the death of a close relative, marriage, divorce or job change and do not simply accept or interpret their ill health as being due to objectively verifiable pathogens or disease processes. In a historical study, Herzlich and Pierret (1986) demonstrate that lay people always take a variety of causal factors into account when conceptualising health and ill health, including air, climate and seasons, and poor working conditions. People may switch between professional and lay belief systems to make sense of their personal experience of illness.

1.3 Components and origins of health beliefs

Health beliefs, like other personal beliefs, are learned. Knowledge about health and illness is built up from childhood onwards, from diverse sources including family, social networks, community and religion, and through ‘official’ government health messages. Individual health beliefs, while rarely ‘scientific’ in themselves, none the less are grounded in experience, modified over time in the light of that experience, and rational in the light of people's wider belief systems and world views. There can be a dissonance between people's ‘lay’ beliefs about health, including the appropriate ways of maintaining health, and professional understandings of health and disease. There may be contradictions within the same individual, or health practitioners may ‘dispense’ advice contrary to their own personal health-related behaviour: for example, encouraging people to stop smoking or drinking alcohol excessively.

Individual accounts of health are sometimes dismissed as naïve and irrational, despite their ability to provide meaning for that person's experience of illness. However, beliefs about health give meaning to personal experiences of illness and how they fit in with unique life stories and world views. These beliefs are so strong that people often cling to them, even when faced with rational scientific explanations to the contrary.

So, people use a variety of constructs, both professional and lay, to make sense of their illnesses. These constructs are socially and culturally determined. In a study of the health beliefs and folk models of diabetes in British Bangladeshi people, Greenhalgh et al. (1998) found that informants wanted to understand and explain the onset and experience of illness. However, this tended to lead not to a systematic search for professional or scientific explanations but, rather, to a reflection on personal experience and the experiences of friends and relatives. Lay sources of information were frequently cited as a major influence on behaviour. While all the Bangladeshi respondents held strong religious (Muslim) views, and often gave explanations in terms of ‘God's will’, such views were usually held in parallel with accepting individual responsibility and understanding the potential for change. The authors of the study note that the people they interviewed may simultaneously hold both ‘traditional’ constructs (deeply rooted values and perceptions drawn from their culture of origin) and ‘recent’ ones (drawn from the host culture and less enduring in the long term).

Thus, people live with, and draw on, multiple realities and paradigms for understanding health. This phenomenon is apparent in all cultures, even seemingly homogeneous ones. Helman (2001) states that modern urbanised societies, whether western or non-western, exhibit ‘health care pluralism’. Although different therapeutic modes coexist, they are often based on entirely different premises and may even originate in different cultures, such as western medicine in China or Chinese acupuncture in the modern western world (Helman, 2001).

1.4 Influences on health and illness behaviour

Activity 2: Experiencing health and illness

Timing: 0 hours 30 minutes

Drawing on your own experiences of health and illness, answer the following questions.

  1. When do you decide you might be ill and need advice?

  2. Who do you turn to for health information, advice or treatment?

  3. When?

  4. Why?

Discussion

Different people react in different ways to illness. One person who did this activity said, first, she consults someone close to her – a family member or a friend – wondering whether she should be concerned about the problem. She might also look on the internet – initially she would be concerned about the diagnosis. If this concern persisted, she would consult a doctor; however, if she thought she knew what the problem was, she might do any of the following: treat it herself; go to a pharmacist or doctor; go to another ‘conventional’ therapist (for example, dentist, chiropodist, optician); or go to an ‘alternative’ therapist (such as a chiropractor or an osteopath).

Health behaviour is influenced by many factors. Helman (2001) discusses the variety of people in different societies who each offer users their own way of advising on, explaining, diagnosing and treating ill health. As a result, people may decide to rest or take a home remedy; ask advice from a friend, relative or neighbour; consult a local priest, folk healer or wise person; or consult a doctor if one is available. People seek different forms of help and advice depending on the stage and progression of their condition. They may be more likely to seek professional help after other channels of advice and treatment, including self-management, have proved ineffective.

People choose one form of healing rather than another for a variety of reasons, including beliefs, expectations, geographical access, affordability, or congruence with wider cultural beliefs. Research shows that whom people talk to about their health influences what they do and the course of action they take to resolve health problems (Wellman, 2000). The influence of other people varies according to the strength of the tie (whether the advice is given by an intimate friend or merely an acquaintance) and the basis of the relationship (whether it is kinship, friendship or professional). These sources of advice and influence are often described as ‘health networks’. Granovetter (1973) argues that weak ties (those between socially dissimilar people, rather than members of the same social circle) transmit a greater range of information, including information about potential alternatives, although strong ties may be more persuasive (Wellman and Wellman, 1992). In making health decisions, people also access and draw on health information from a variety of sources, including self-help groups, health magazines and websites (for example, NHS Direct).

Various models of health and illness behaviour have been devised to answer the question: ‘How do individuals come to recognise, understand and cope with health problems?’ Four models of health and illness behaviour dominate the literature (Pescosolido, 2000): the Socio-Behavioural Model, the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behaviour. The key features of these models are described in Box 1.

Box 1: Models of health and illness behaviour

The Socio-Behavioural Model (SBM)

The SBM details three basic categories: need, predisposing characteristics and enabling factors. Need for care must be established, which depends on the nature of the illness and its severity (for example, the ‘hurt’, ‘worry’, ‘bother’ or ‘pain’ that it causes). The SBM considers how people perceive this need and how symptoms are experienced. Predisposing characteristics include gender, ethnicity, education and beliefs: that is, the social and cultural factors which shape an individual's tendency to seek care. Enabling characteristics recognise that individuals need to act on a desire to receive care, and include the means and knowledge to get treatment (having a source of care, travel time and financial ability, as well as the geographical availability of doctors, clinics, etc.).

The Health Belief Model (HBM)

Whereas the SBM focuses on the influence of the system and issues of access, the HBM examines the meaning of ‘predisposing’ characteristics and analyses how an individual's specific health beliefs (for example, about the severity of symptoms) and their preferences (for example, the perceived benefits of treatment), as well as their experiences (with health care problems and with providers and their knowledge), affect decisions to seek care and adopt health behaviours.

The Theory of Reasoned Action (TRA)

The TRA concerns expectancy: individuals rate how current and alternative actions can reduce their health problems. Like the HBM, this theory focuses on motivations, the individual's assessment of risk, and the desire to avoid negative outcomes. Individuals evaluate whether or not to engage in healthy (for example, taking exercise) or risky (for example, smoking) behaviours and whether to seek preventive as well as curative medical services.

The Theory of Planned Behaviour (TPB)

The TPB evolved from the TRA, but differs by recognising that individuals do not necessarily have control over their behaviour. The amount of behavioural control – or self-efficacy – that individuals perceive they have is an important element in this model. Also, ‘cues’ or ‘habits’ become an important part of the decisions individuals make to engage in health and illness behaviours.

(Source: adapted from Pescosolido, 2000, pp. 176–7)

Although the four models are practical, Pescosolido (2000) notes some weaknesses: for example, what she calls the ‘tyranny of use/no use’ created by the strict either/or conceptualisation of choices inherent in these empirical models. She argues that the traditional models do not capture the richness of ethnographic research, which provides deeper understandings of procedures and users. She also notes that focusing on ‘illness’ overlooks the fact that people may define physical and mental health in terms of moral failure, supernatural punishment, the ‘ups and downs’ of life, etc., for which seeking medical care is only one of several possible responses. Pescosolido argues that this unnatural separation of illness behaviour from social life is reflected in the reliance of traditional models on rational choice as the underlying mechanism at work. By calling these models ‘decision-making’ or ‘help-seeking’ models, the values of rationality and individuality are overemphasised, which are precisely the same values that led to the professional dominance of allopathic medicine.

Having looked at some of the influences on health and illness behaviour, it is clear that users' knowledge of and beliefs about different forms of health care shape their choices about which practitioners to consult in different circumstances. The next section focuses on some models of health care delivery.

1.5 Models of health care delivery

In the quest to understand health and illness behaviour, social and medical researchers have developed various models to explain the different forms of health care delivery. These models emerged because, in the mid-20th century, social researchers began to question not only the position of professions in western countries but also the relationship between professionals and users. Early explorations of the patient's role in health care suggested that it was fairly prescribed (Parsons, 1951), as was that of the physician (Freidson, 1970). However, by the 1980s there was greater awareness of the diversity of ways of receiving healing and health care, particularly in indigenous cultures. Currer and Stacey explain this in their ground-breaking overview of health concepts:

Any thorough-going critique of health care planning and administration requires the imaginative consideration of modes of healing based upon conceptualisations alternative to the contemporary dominant mode.

(Currer and Stacey, 1986, p. 1)

They also note that even within western cultures there are considerable variations across the population in the ways in which the dominant health care model is conceptualised:

Members also have access to, and possibly accept concepts derived from, other cosmologies or other modes of healing, and also from earlier formulations of biomedicine itself.

(Currer and Stacey, 1986, p. 1)

The medical anthropologist Arthur Kleinman (1980) notes that all healing systems orient around explanatory models of health and illness. He describes cultural explanatory models as cognitive orientations that determine how disease is named, defined and understood. He identifies the following six universal themes which underpin people's explanatory models.

  1. Aetiology: the cause of the illness.

  2. Time and mode of onset of symptoms: the significance of what was happening when the symptoms began.

  3. Pathology: what the illness is and what is going wrong with the person who is ill.

  4. Course of the illness: how long the illness might last and how it might develop.

  5. Consequences of the illness: the possible effects of the illness on the person's life.

  6. Treatment: what could be done to alleviate or cure the illness.

Four theoretical models are discussed in this section: the biomedical model, the biopsychosocial model, the salutogenic model and alternative or holistic models. Each is a conceptual model which provides a theoretical framework for how health is practised at both an individual practitioner and an institutional level. Eisenberg (1977) explains that models are ways of constructing reality, of imposing meaning on the chaos of the ‘phenomenal world’. Each model understands health, illness, the body, and the respective roles of users and healers in different ways. Note that the models described here are theoretical constructs (that is, they do not operate in a rigid way), and are not a blueprint for practice. In addition, few practitioners derive their ideas about health and illness solely from the models under discussion.

1.6 Models of health care delivery: the biomedical model

Figure 1
Sally and Richard Greenhill ©
Sally and Richard Greenhill
Figure 1: A consultant on a ward round talking to colleagues and leaving the patient isolated

Activity 3: The biomedical model

Timing: 0 hours 30 minutes

Read the following description of the biomedical model. Then list what you would consider are (a) the positive and (b) the negative implications of it for lay users.

Biomedicine (which is also known as allopathy, conventional medicine or modern western scientific medicine) is relatively new, unlike some ancient healing systems which have been practised for several thousand years. In the UK biomedicine dominates contemporary and official understandings of health and forms the basis of the NHS and other western health care systems. While the biomedical model is considered the epitome of scientific, objective, reproducible medicine, the actual delivery of health care may be somewhat different in practice. The following statements about biomedicine thus represent an idealised, necessarily artificial version of this model.

  • Health is predominantly viewed as the ‘absence of disease’ and as ‘functional fitness’.

  • Health services are geared mainly towards treating sick and disabled people.

  • A high value is put on the provision of specialist medical services, in mainly institutional settings, typically hospitals or clinics.

  • Doctors and other qualified experts diagnose illness and disease and sanction and supervise the withdrawal of service users from productive labour.

  • The main function of health services is remedial or curative – to get people back to productive labour.

  • Disease and sickness are explained within a biological framework that emphasises the physical nature of disease: that is, it is biologically reductionist.

  • Biomedicine works from a pathogenic (origins of disease) focus, emphasising risk factors and establishing abnormality (and normality).

  • A high value is put on using scientific methods of research and on scientific knowledge.

  • Qualitative evidence (given by lay people or produced through academic research) generally has a lower status as knowledge than quantitative evidence.

(Source: adapted from Jones, 1994)

Discussion

(a) Biomedicine has advantages as well as disadvantages for the consumer. For example:

  • Biomedicine provides diagnostic categories and ways of dealing with pathologies that may help in the treatment or prevention of life-threatening illnesses.

  • Biomedicine provides an easily identifiable structure which users can navigate to get their health needs addressed.

  • Biomedicine provides effective treatment for many serious illnesses – for example, bypass surgery for heart conditions – which in the past may have resulted in death or long-term disability.

Biomedicine produces experts who are highly specialised.

(b) However:

  • Some medical interventions can have serious side effects.

  • The user's view of why they are ill is not prioritised by biomedical practitioners.

  • The use of technology may yield a diagnosis of disease which does not tally with how the user feels.

  • Specialisation may imply a narrow focus and might lead to the practitioner neglecting interactional processes.

Biomedicine is potentially the most polarised of all health care models. In its idealised form, biomedicine considers ‘professional knowledge’ to be expert, rational and scientific. Lay beliefs, by contrast, are perceived as ill informed, non-rational, unscientific and superstitious, and are thus devalued. According to this theory, lay people have beliefs and doctors have knowledge (Bury, 1997). In the biomedical model, symptoms are prioritised to the extent that they conform to diagnostic models. The doctor's job is to diagnose relevant symptoms.

In biomedicine the focus is on objective, measurable phenomena, and technology can be used to achieve diagnoses. Advances in medical technology led to a greater ability to localise disease processes within the body, so that sites of pathology could be pinpointed with greater accuracy (Helman, 2001). Although this is of great benefit to users and clinicians, the process ‘has also contributed to a narrowing of medical vision – to the reductionism, mind-body dualism and objectification of body so characteristic today of the disease perspective’ (Helman, 2001, p. 65). Normality is established by referring to statistically derived ranges, which do not take account of the individual (for example, a person may always have had ‘abnormally low’ blood pressure).

Biomedical practitioners are criticised for being more interested in symptoms than in people: for example, a stereotypical hospital ward round in the past might have involved the consultant being directed to ‘the duodenal ulcer in bed seven’. Greenhalgh and Hurwitz describe the problem as follows.

At its most arid, modern medicine lacks a metric for existential qualities such as the inner hurt, despair, hope, grief, and moral pain that frequently accompany, and often indeed constitute, the illnesses from which people suffer.

(Greenhalgh and Hurwitz, 1999, p. 50)

In the biomedical model attention focuses on physical symptoms, and the emotional side of a service user's health state is secondary, except in psychiatric services. Effective doctor–patient (‘patient’ being the correct term in biomedicine) communication is relevant in that the patient needs to understand what is expected of them, so they can comply with instructions, such as adhering to a regimen, taking medication, and so on. There is no standardised model for health provider–user interactions. These vary considerably depending on the familiarity between the parties and the nature of the consultation: for example, an encounter with a familiar general practitioner is different from a single encounter with a radiographer.

Critics of the biomedical model usually cite the depersonalised, objectifying nature of biomedical practice, such as focusing on the disease rather than the individual. Fuelled by technology, biomedicine promotes a reductionist interest in the body in which, as Helman (2001) puts it, ‘specialists learn more and more about less and less’. The risks of conventional medicine also cause concern.

If the biomedical model characterises the theoretical underpinnings of scientific medicine, the biopsychosocial model has replaced it as the model that best characterises contemporary western health care delivery.

1.7 Models of health care delivery: the biopsychosocial model

Activity 4: The biopsychosocial model

Timing: 0 hours 30 minutes

Read the following description of the biopsychosocial model and make notes on the positive and negative implications for lay users.

While disease dominates biomedical thinking, the biopsychosocial model incorporates social, psychological and emotional factors in diagnosis and treatment. It recognises that illness cannot be studied or treated in isolation from the social and cultural environment. Whereas the biomedical model prioritises professional knowledge, the biopsychosocial model expects health carers and doctors to acknowledge and take into account users' circumstances. This change in focus is reflected in research priorities, in that government departments increasingly respect qualitative research (previously dismissed by the medical research community as ‘soft’). (See, for example, ESRC, 2003.)

Medicine practised within a biopsychosocial framework acknowledges the links between socioeconomic deprivation and adverse health. It also considers issues such as improving access to health services and reducing health inequalities as a legitimate and appropriate function of health service provision (Engels, 1980).

Discussion

The biopsychosocial model recognises the connection between health and the experience of illness and the physical and social environment. Heart disease and obesity are linked epidemiologically to ethnicity and poverty, and therefore cannot be explained simply in terms of individual self-responsibility and willpower. Rather, definitions of health within a biopsychosocial model consider the way in which people negotiate their way through environmental, social and informational influences (Fulder, 1998). Health is a process concerned with norms of functioning and wellbeing, which are determined by society and professionals, and vary from time to time and group to group. In this sense, health is relative rather than absolute: a process rather than a fixed, defined condition. Fulder describes this process as ‘one of dynamic balance where the capacity of the organism to self-repair, self-support, and renewal is not overwhelmed by the interactions with the world within and outside the organism’ (1998, p. 152). Within this model, ‘the organism’ means the community as well as the individual.

The dominance of the biopsychosocial model in western health care is exemplified by the inclusion in medical training of subjects such as medical sociology, medical anthropology and community medicine. None the less, this model is still grounded in scientific method, thus building on the major elements of biomedicine.

The implications of the biopsychosocial model for users and therapeutic relationships include the accommodation of emotional and spiritual aspects of health. Consultations with health professionals who use this model should acknowledge the wider environment, users' social support networks, family support and stress levels. In theory, the biopsychosocial model can generate hypotheses about individual illness which tally with people's broader understandings about why they are ill, in the context of their whole life story. This moves away from professionals deciding what is wrong to a more balanced therapeutic relationship in which users are encouraged to be active partners in health decisions. There may also be scope for more ‘caring’ therapeutic relationships: some people will value the opportunity to talk about their emotions and broader concerns and may find this therapeutic in itself.

1.8 Models of health care delivery: the salutogenic model

Whereas pathogenesis (the way disease processes develop) underpins the biomedical model, the concept of positive health, or salutogenesis, focuses on how and why people stay well. Salutogenesis can be seen either as a model in its own right or as an example of the biopsychosocial approach (Antonovsky, 1979, 1987). Antonovsky's salutogenic model was designed to advance understanding of the relationship between stressors, coping and health, with the aim of explaining how some individuals remain healthy despite stressors in their everyday life.

Unlike previous health research on stress, which looked at different kinds of stressors and the conditions most likely to lead to stress, Antonovsky's model highlights the inadequacy of pathogenic explanatory factors and concentrates on the adaptive coping mechanisms underscoring the movement to the healthy end of the ‘ease–dis-ease’ spectrum. Antonovsky proposed that generalised resistance resources (wealth, ego strength, cultural stability, social support) can promote a sense of coherence, which is central to people's ability to cope with stress. Antonovsky defines the sense of coherence as:

a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.

(Antonovsky, 1987, p. 19)

Antonovsky describes the substantive structure of the sense of coherence as comprising three components: comprehensibility, manageability and meaningfulness. These develop as people's experiences are influenced by consistency, balancing underload–overload and shaping outcomes respectively. Unlike concepts such as locus of control, self-efficacy and problem-oriented coping, the sense of coherence model is intended to be a construct that is universally meaningful and cuts across divisions of gender, social class, religion and culture.

A salutogenic model rejects the current tendency to hold individuals responsible for the fate of their health. It recognises that optimal functioning requires social stability, rewarding occupations and freedom from anxiety, stress and persecution. The salutogenic model stresses health as a balance: ‘an ecological process, within and without the individual’ (Fulder, 1998, p. 153). Thus, it has much in common with alternative models of health, which are discussed in the next section.

1.9 Models of health care delivery: alternative or holistic models

Many CAM modalities have grown from a wide range of concepts of the body and health and healing that differ from the models discussed so far. As Fulder notes:

The body, in Chinese medicine, is energetic. In yoga and healing, the body is spiritual. In modern (conventional) medicine, the body is physicochemical. In homeopathy, it is phenomenological. In naturopathy it is vital, etc. All of these conceptions do not necessarily overlap with each other.

(Fulder, 2002, p. 395)

These examples demonstrate some of the diversity of concepts within and between CAMs and suggest that finding a model to encompass this diversity is difficult.

CAM embraces nearly 200 different forms of healing modalities. This suggests a considerable diversity of theories, philosophies and therapies (Furnham and Vincent, 2000). Fulder identifies the following common beliefs underpinning CAM.

  • Self-healing is paramount

  • Working with, not against, symptoms

  • Individuality

  • Integration of human facets

  • No fixed beginning or ending but a continuum of wellness/illness

  • Conformity to universal principles, whereby remedies are used in conformity to patterns of relations between all living creatures and their environment.

(Fulder, 1998, pp. 148–50)

However, Fulder also points out that not all CAM therapists use all of these concepts. Even if they underpin traditional forms of treatment, there may be reasons why practitioners do not practise them, including: people present symptomatically; therapy has made concessions to secure political advantage – for example, osteopathy has become progressively less distinct from allopathic medicine (Johnson and Kurtz, 2002); or practitioners hold different health beliefs from others in their particular therapeutic group.

CAM has replaced much of what was previously considered ‘folk medicine’. Folk medicine provides mechanisms for coping with ill health as part of the wider context of dealing with misfortune and anxiety. In doing so, it overlaps significantly with cultural and religious beliefs held by the society in which it operates. Arguably, these phenomena are now incorporated into, and form part of, CAM's attraction.

[C]ontributing to the recent reconsideration of alternative medicine is a societal acknowledgement of cultural, religious, and ethnic diversity. This dissolving of a single modernist medical narrative has formed an increased awareness of medical pluralism. The old cultural war of a dominant culture versus heretical rebellion in politics and religion as well as medicine has begun to transform into a recognition of postmodern multiple narratives. Also, alternative medicine may provide a vehicle for establishment medicine to become more consumer-savvy and to ‘placate’ public dissatisfaction with such perceived mainstream health care problems as the impersonality of medical technology or the absence of robust patient–physician relationships. In addition, emerging economic and legal forces undoubtedly play a huge role in the recent rapprochement. Perhaps because it is beleaguered from battles on other fronts, orthodox medicine has simply abandoned its crusade against alternative medicine.

(Kaptchuk and Eisenberg, 2001, p. 193)

By rejecting the either/or thinking characterising the biomedical model in favour of multiple realities or ‘ways of knowing’, CAM allows for a wide variety of belief systems and cosmologies. These approaches may offer a congruent way of meeting the full range of health needs of people whose cultural beliefs about health are overlooked in the biomedical approach.

Traditional health care systems represent philosophical approaches to managing health and disease that differ substantially from those of Western biomedicine. The question of what is common to these traditional systems has been largely overlooked, but spirituality is an integral part of each. As this trait is often directly related to the dominant religion or philosophical system of the originating culture, it is taken for granted within the context of health care. For example, the ancient Chinese health care system was influenced by several spiritual schools, in particular Taoism. Ayurveda, a traditional medical system of India, reflects the traditional Hindu world view. Similarly, Tibetan physicians practice Buddhist meditation as an integral part of their medical training.

(Eskinazi, 1998, p. 1621)

CAM therapies originating from a different culture do not have the same potency, value and efficacy when practised in a culture dominated by biomedicine. Joan Engebretson points out:

As these techniques have been taken out of the cultural context of their historical and geographical or ethnic setting, the techniques are often used without a full understanding of cultural or philosophical underpinnings, beliefs and values.

(Engebretson, 2002, p. 178)

CAM is not homogeneous. Not all practitioners subscribe to every underlying principle. Some therapies claim to be more holistic than others (just as many general practitioners try to practise holistically). Watts (1992) maintains that, while virtually all orthodox medicine is underpinned by the same theoretical foundations, complementary medicine is the product of either many philosophies or none. A bewildering variety of sometimes contradictory ideas coexist, ‘their various exponents apparently untroubled by what, to the outsider, seems hopelessly chaotic’ (Watts, 1992, p. 106). There is also a dearth of research on the views and beliefs held by CAM practitioners. Individual practitioners may have personal views and philosophies that are at odds with mainstream thought in their particular therapy. The wide variation in practitioners’ health beliefs is described in the next section.

1.10 Concepts of healing: philosophies underpinning CAM practice

Activity 5: Health beliefs in CAM

Timing: 1 hour 0 minutes

Read the following accounts by individual CAM practitioners of four different modalities. These are personal perspectives, which may vary from other people's in their disciplines. As you read the accounts note:

  1. the positive and negative implications for lay users

  2. different approaches to healing among the four CAM modalities.

Osteopathy

Currently osteopathy has no agreed definition. It is a hands-on approach to various health problems which manifest themselves through the neuro-musculo-skeletal system (the moving parts of the body and the associated nerves and blood vessels). This approach embraces a holistic system of diagnosis and treatment involving palpation and manual intervention, complemented by health education. It recognises the primacy of the therapeutic relationship and is based on the philosophy and principles first enunciated by Andrew Taylor Still in 1874:

  • Displaced joints may obstruct the free flow of blood – ‘the rule of the artery is absolute’.

  • All diseases are mere effects, the cause being partial or complete failure of the nerves to conduct the fluids of life properly.

  • The body tends to be self-regulating and self-healing.

  • All body structures and processes are interdependent.

Therefore, rational treatment is based on the above principles and directs proceedings rather than attempting to effect change directly. Still's therapeutic maxim was to ‘find it, fix it and leave it alone’ (that is, to diagnose the disorder, treat it, and leave the rest to the spontaneous forces of nature), in recognition of his understanding of the body as an internally organising system.

Figure 2
Science Photo Library ©
Science Photo Library
Figure 2: Osteopathy has a unique approach to the body, striving to repair the problem and then leaving the body to heal itself
Acupuncture

Acupuncture is part of a comprehensive system of health care called ‘oriental medicine’. This has a clinical history of at least 2000 years to the present day. Indeed, it is all based on the concept of qi, or ‘vital energy’, a concept that every living organism has energy running through and around it, which enables physical movement, emotional balance and spiritual connection, provided it is in balance and can flow smoothly. This model is based on natural laws and has connections with Taoism. These laws are: the eight principles of yin/yang, deficiency/excess, cold/hot and interior/exterior; the five elements (earth, air, fire, water and wood) and their associations; the causes of disease – internal or external, miscellaneous and secondary; and a different diagnostic language to identify the energetics of each individual patient. Many patients do not want treatment for one complaint, but rather for an apparently disconnected set of complaints or because they do not feel well. Acupuncturists can make connections of the mind, body and spirit for patients and enable them to start making sense of their perceived and experienced ‘dis-ease’. Practitioners use a research method of investigation based on looking, asking, feeling and listening (sizhen), leading to diagnosis (bazheng, or eight rules), then testing the hypothesis in treatment (ben and biao, or root and branch) and evaluation. In its simplest terms, acupuncture stimulates the body's own healing response and helps restore its natural tendency to balance and harmony by inserting, and manipulating in a variety of ways, fine needles into specific points along the channels of energy (meridians). Centuries of observation, analysis and empirical use have resulted in an extensively catalogued location and function of all the points. There are believed to be low-level electrical resistances at these points, but how acupuncture works is still not known. Western thought insists on the search for an explanation in scientific terms; eastern thought does not.

Herbalism

Western medical herbalists are trained in orthodox medical science and use the same technical language as the orthodox medical professions. Although they may use the same labels in terms of pathology, their aim is to support normal physiology and help the ways in which the body heals itself, rather than to treat a named disease. Sometimes users are encouraged to see symptoms such as tiredness or fever as being part of their healing rather than just an aspect of their problem. Herbal medication is seen as having three modes of action:

  1. a biochemical pharmacological action

  2. a micronutritional effect (plant remedies contain a range of trace nutrients that are often missing from a modern diet)

  3. an energetic action.

For any particular required pharmacological action there are several possible herbal remedies. The herbalist has a subjective appreciation of the character of each of them and tries to match the correct remedy to the client's needs.

Reiki

The philosophy of reiki is that everything in the Universe is made of energy, which vibrates at different rates and frequencies on a continuum from the dense, slow vibrations of physical matter to the fast vibrations of spiritual energy, consciousness or light. The human body is made of energy which is dense enough to become physical matter, so it can be seen and touched, but people also have a field of spiritual energy called an aura, which surrounds and interpenetrates the physical body. Life-force energy (qi or chi) flows within the physical body through energy centres called chakras and energy pathways called meridians, as well as flowing around the body in the aura. Reiki is a spiritual energy vibrating at a very high rate, which helps to break through blockages, flowing through all the affected parts of the aura, charging them with positive energy and raising the vibratory level of the whole energy field. It clears and balances the chakras and straightens the energy pathways, allowing the life force to flow in a healthy and natural way around the whole body. This strengthens and accelerates the body's natural ability to heal itself, and opens the mind, emotions and spirit to an acceptance and understanding of the factors that led to ‘dis-ease’ in both the physical and the energy bodies.

Discussion

For some practitioners, CAM is more than simply about treating disease: an accusation levelled at the biomedical model in its purest form. Individualised user-centred treatment is central to their philosophies. CAM therapists explore and treat underlying causes, not merely control symptoms. CAM therapies sometimes use phenomena that are outside the biomedical understanding of health and disease. For many practitioners, building strong therapeutic relationships is crucial. This includes practitioners’ attempts to bridge their own philosophy or cosmology to that of the user, so as to provide an account of illness that resonates for that user. CAM promulgates the view that users promote their own healing, and that the therapist is a conduit for healing energy. While the philosophy of holistic health concerns the user's mind, body and spirit, the treatment is individually targeted.

This extract introduced four (of many) models of health. Although they were presented as discrete entities, in practice there is considerable blurring of the boundaries between them. Many features of alternative health models are now being incorporated into mainstream medicine and vice versa. For example, a study comparing osteopathic practitioners and doctors in the UK notes that the holistic approach is less confined to osteopathic physicians, especially in speciality hospital care, and is, perhaps, even becoming a trend in the approach to care used in allopathic medicine (Johnson and Kurtz, 2002). As CAM and orthodox medicine continue to integrate, there will probably be further overlap and evolution of health models, reflecting the plurality of ways of knowing about health and dealing with illness.

1.11 Researching health beliefs and CAM users' expectations

People's beliefs about health and illness play an important role in determining whether and when they seek medical care and the extent to which they follow advice and treatment regimes. Beliefs can influence the outcome of treatments (Zola, 1973; Stainton-Rogers, 1991). Therefore, it is important to explore whether users of CAM have different beliefs about and different expectations of health care than non-users.

Adrian Furnham and his colleagues conducted several psychological studies designed to examine the extent to which certain beliefs and attitudes influence the use of CAM, and whether beliefs change as a result of using it. These studies use the Health Belief Model (HBM) as a starting point, which, as you may recall from Box 1, suggests that health beliefs can be correlated with behaviour and can differentiate between those who do and those who do not exhibit various health behaviours. Furnham and other researchers have examined whether users of CAM perceive themselves to be more susceptible to disease, whether they have stronger beliefs about self-control, and whether they have different attitudes about the perceived efficacy of biomedical treatment.

The findings vary according to which therapy is studied but they have revealed some statistically significant results. For example, users of homoeopathy were more critical and sceptical of biomedicine (Furnham and Smith, 1988; Furnham and Bragrath, 1992) and were more conscious of their health generally, lending some support for Giddens’ description of the more reflexive and sceptical consumer (Giddens, 1991). A further study by Furnham and Forey (1994) revealed that users of homoeopathy were also more likely to believe that their health could be improved, had more self and ecologically aware lifestyles, were concerned about ensuring a holistic approach to health care, and were generally more knowledgeable about their bodies than users of conventional health care. Furnham and Smith (1988) and Conroy et al. (2000) also showed that users of CAM did not consider themselves to be more susceptible to disease than non-users and were no more anxious about their health.

A study of people who use acupuncture revealed lower levels of confidence in general practitioners than non-users and a reduced faith in biomedical drugs (Furnham et al., 1995). These levels of dissatisfaction were not present among users of homoeopathy, although a study in the USA found that they were more displeased than people who used chiropractors (Yu et al., 1994). A comparison of users of osteopathy, homoeopathy and acupuncture showed that homoeopathy users valued their involvement in the healing process, while acupuncture users were most concerned about the side effects of biomedical drugs (Vincent and Furnham, 1997). Furthermore, Sirious and Gick (2002) showed differences between long-term and new users of CAM in terms of their values and beliefs, although in both groups health-aware behaviour and dissatisfaction with conventional medicine were the best predictors of use. More importantly, there appear to be as many subtle differences between users of CAM as there are between users and non-users. CAM users should not be considered a homogeneous group with similar beliefs, attitudes and expectations. Nevertheless, this work helps to locate some differences in attitudes and beliefs and suggests reasons for the popularity of CAM. However, and perhaps most interestingly, these studies did not ask the users about their reasons for consulting a CAM practitioner.

Sharma (1992) showed that most CAM users are pragmatic and eclectic. They are interested in whether the therapy might work for them, rather than the theory behind the practice, although Sharma notes that they appreciate explanations which make sense of previously unaccountable experiences or symptoms. She concludes from her research that lay convictions about the causes of health and illness may be relatively unstructured and that patients will try any treatment that seems to work or has worked for people they know. This might account for users expressing satisfaction with a variety of CAM therapies based on mutually exclusive models. Sharma also suggests that a therapy could be said to ‘work’ in that the practitioner's discourse provides meanings and interpretations that are more satisfactory to the user than orthodox explanations. One attraction for users is that CAM practitioners can give an explanation of health and illness that is more congruent with their own account:

Complementary practitioners may have explanations that make sense to patients – such as describing illness as a result of environmental factors or as a physical expression of emotional patterns. Conventional medicine may have problems with such explanations if they have no scientific justification, but sociological research shows that patients consider them beneficial when they reinforce their own beliefs and expectations.

(Zollman and Vickers, 1999, pp. 1487–8)

Watts asked what users wanted and found that:

Many people get more out of being told that their inner being is out of balance than they do out of knowing that their haemoglobin level is low. The latter may mean little to them; but even sceptics will recognize the former as a kind of metaphorical description of the feelings that may have driven them to seek help in the first place.

(Watts, 1992, p. 105)

How far will users go along with the therapist if the treatment is strange and unusual and not what they were expecting? Sharma's study suggests that CAM users do not necessarily seek out practitioners who share similar beliefs about health and healing to their own. Users can often be persuaded to try out new ideas:

I suspect that sick people who find the treatments offered altogether too bizarre or counter to their own notions of what will make them better drop out before the treatment has gone too far. Others can be cajoled into accepting unfamiliar, time-consuming or even painful regimes because the therapist is prepared to explain the treatment and provide moral support, for which the orthodox doctor has little time and sometimes no inclination.

(Sharma, 1992, p. 168)

Sharma suggests that, even if some users start out using CAM believing they are no different from non-users, their exposure to therapists’ ideas may affect their health beliefs over time. Sharma speculates that this is more so when the use of one non-orthodox type of medicine leads users to experiment with other forms of CAM, thus increasing their exposure to alternative beliefs:

There is no reason to suppose that therapist and patient always share beliefs about health and illness, but equally there is no reason to suppose that the one may not influence the other as they interact.

(Sharma, 1992, p. 88)

Sharma's study of CAM practitioners researched the extent to which they explicitly and consciously offer alternative explanations of health and illness, and whether the encounter between practitioner and user is used as an opportunity to socialise users into new ways of interpreting what happens to their bodies – an issue that is returned to in Extract 2. Sharma asks whether practitioners treat their special knowledge as a source of dominance: a resource they are not prepared to share. She wonders whether there is an element of control in practitioners trying to bring round users to their way of thinking (Sharma, 1992, p. 168). One homoeopath said it was not so much about getting users to comply with the advice of medical authority (the doctor or practitioner), but rather it was more about getting users to a stage where they take responsibility for their own health (Sharma, 1992).

The practitioners in Sharma's study rejected the notion of professional mystique: that is, that they would give away too much power if they explained too much about the therapy and how it works. None the less, practitioners were not always keen to give detailed explanations of what they did and why. Sharma (1992) also found that practitioners had ways of accounting for therapeutic failures that made sense within their own theories of healing: ‘the patient was clinging to his/her illness, s/he was not the kind of patient who could easily accept homoeopathy, the patient did not give the treatment long enough to work.’

Clearly, researching people's beliefs and expectations about CAM, and their motivation for using it, reveals a variety of findings. While some people are attracted to a specific philosophy or set of beliefs, others seem content to pursue a therapy if they believe it will work for them. Researchers acknowledge the methodological difficulties of trying to analyse individuals’ health choices and behaviours retrospectively.

1.12 Conclusion to Extract 1

The biomedical model that dominated health professional–user interactions for the past 100 years or so marginalised and appeared to devalue certain aspects of the individual and personal experience of illness. However, health care provision is now more user-centred in the prevailing biopsychosocial model. Despite the diversity of health beliefs, the edifice of modern medicine is built on a dominant scientific perspective, which promotes a certain world view at the expense of other cosmologies. CAM offers a diverse array of other philosophical approaches to health and healing. This extract showed that the enterprise of health and healing is far broader than the world view encompassed by biomedicine. Cultures and societies produce profoundly different beliefs about health. Where the mainstream health care provision is insensitive towards lay understandings of health and illness, people seek out healing practices that are more congruent with their experiences, belief systems and culture. Whereas in the past this always involved folk and traditional healing, increasingly it includes the use of CAM.

Key points

  • The ways in which people understand health and illness vary considerably, lay understanding often conflicting with professional understanding of disease.

  • People may hold multiple and conflicting beliefs about health.

  • Individuals' health beliefs are not constant and fixed, but reflect their life experiences and acquisition of knowledge from a variety of sources.

  • People's health beliefs influence their health behaviours, including the decision about when and whom to consult for health advice.

  • Models of health provide understanding on the basis of different cosmologies. These models are not fixed but overlap and continuously evolve.

  • The biomedical model has gradually given way to a broader biopsychosocial understanding of health. This is reflected in both medical training and clinical practice.

  • CAM can provide ways of understanding the body that accord with and give meaning to people's lay understanding.

  • Despite a greater professed interest in the balance between people and their environment, CAM treatments may promote an individualistic analysis of health.

  • There is no single CAM philosophy. CAM therapists work in a variety of ways, some being more holistic than others, some working with philosophies that can be accommodated within a biomedical understanding of the body (e.g. osteopathy) and others that cannot (e.g. acupuncture).

  • Users of CAM are not necessarily drawn to therapists because of their particular philosophy.

1.13 Extract 1 References

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2. Extract 2 Critical issues in the therapeutic relationship

2.1 Introduction

This extract examines the main areas of criticism of the therapeutic relationship in complementary and alternative medicine (CAM). Both social scientists and media commentators have extensively critiqued what some people call a ‘therapy culture’. Many critics have questioned the dependency that some users develop in their use of CAM and voice concerns about the ways in which the therapeutic relationship can be abused. In challenging some of the assertions made on behalf of CAM practitioners, you will be able to reflect once more on your own experiences and expectations of therapeutic relationships, and consider the strength of these arguments.

The extract begins by introducing a range of users' experiences of the therapeutic encounter in CAM. It illustrates how these experiences can be very diverse, with both positive and negative effects for users.

Then there is a more critical analysis of CAM therapeutic relationships by looking at how therapeutic relationships have changed, and re-evaluating possible therapeutic responsibilities held by users and practitioners of CAM. The work of Rosalind Coward (1990) is used to illustrate the views of a growing group of social commentators who believe social factors that contribute to ill health are often rejected by CAM in favour of emphasising the individual's responsibility for their own health and illness.

The next section explores how CAM practitioners, as well as doctors, may try to impose on the user an understanding of illness that robs them of their own views, making them feel disempowered. Even though CAM can occasionally give the user helpful ways of reconceptualising their body and their illness, both ‘reductionism’ and ‘holism’ can reduce them to a mere pawn in the practitioner's paradigm, minimising rather than facilitating the user's sense of control.

Next the controversial debate is raised about whether the success of the CAM therapeutic relationship is a powerful form of placebo. Critics using biomedical approaches to health often argue that the placebo effect is both the reason for CAM working and its weak point. They say that healing in CAM is often a result of the powerful effects of the therapeutic encounter and users' and practitioners' belief that the therapy will work.

The next section discusses what happens when the therapeutic encounter fails. It looks at four ways in which therapeutic relationships can be said to fail: clinically, interactionally, through a mismatch of expectations or as a breach of boundaries. This section also considers how far users can challenge practitioners when they believe the therapeutic relationship has been unsuccessful.

Finally, this extract briefly examines some factors that may alter the nature of therapeutic relationships in CAM in the future, including a greater integration of CAM into orthodox care, a growing litigation culture, and future advances in science.

Aims of Extract 2

  • To explain how therapeutic relationships have changed in recent decades.

  • To discuss and debate reasons for the diversity of patients' experiences within the CAM therapeutic relationship.

  • To identify how the philosophy and principles of CAM therapeutic relationships have been critiqued by social scientists.

2.2 Users' experiences of the therapeutic relationship

CAM users may seek a very different type of therapeutic relationship from those they experience with orthodox practitioners. Some people may want to spend more time with a CAM practitioner than they do with their GP, to have more say in determining the frequency of access to practitioners, to have more control over what happens in the consultation room, and to have more choice about the treatments they are given.

In any therapeutic encounter, people want to be treated with respect, to be listened to, and to have a sense of importance in relation to knowing about their own health. This seems to apply whatever the therapy, setting or level of formality.

Many people can have good and bad therapeutic relationships within the same CAM modality; that is, they may have had a range of experiences within, say, osteopathy or shiatsu. This suggests that some practitioners are better than others at developing healing therapeutic relationships. It could also suggest that some therapeutic styles suit some users more than others and that these users are attracted to particular styles. For example, some users may want the practitioner to take control of the interaction, asking direct questions and seeking answers. Other users might prefer to talk at length about their health problems as they understand them while the practitioner listens.

Patterns of interaction change within the therapeutic encounter according to the stage of illness being treated, which means that relationships between user and practitioner can be fluid. Some users choose a therapy almost at random, without having a clear idea, or realistic expectations, of what it can offer them. Lack of communication about what the therapy is and does leads to dissatisfaction and the person is unlikely to return for further treatment. The same applies when a person feels they have been cheated, either because the practitioner did not seem sufficiently skilled, or because the treatment had no obvious effect.

A practitioner and a client may simply not get on with one another. People who pay for therapy are likely to shop around until they find a practitioner with whom they can have a rapport. A decision not to pursue therapy with a practitioner does not necessarily indicate that the therapeutic relationship has failed, nor does it necessarily cast aspersions on the practitioner.

2.3 Changing notions of the therapeutic relationship and responsibility

The shift in practitioner-patient relationships in the last 30 years was described earlier in this book. In addition, Budd and Sharma note that in industrialised societies the nature of the majority of illnesses presented to doctors has changed from acute to chronic and, along with this, the nature of the healing relationship has also changed (1994, p. 11). For many long-term conditions, orthodox treatment can provide only short-term gains. Instead, the key issue is the management of symptoms. In many cases, a person takes on the role of being an expert in that they direct and know the best ways of dealing with episodes of ill health. This type of person is what the government terms ‘the expert patient’ (DoH, 1999, 2001). At the same time, everyone is presented in health policy ideology as a new consumer of health care services under the NHS, whether they are chronically ill or not. People have rights about their own health and obligations to look after it, while state-provided health services claim to be more patient-centred.

Changes in the therapeutic relationship can be seen in the way in which the training of doctors, nurses and the professions allied to medicine now pays more attention to social and psychological aspects of care. The shift from paternalism to shared decision making is perhaps most apparent in primary care services and is witnessed by the growing interest in narrative-based medicine, which puts the patient's story centre stage (see, for example, Greenhalgh and Hurwitz, 1998). Despite the rhetoric of patient-centredness, change is slow because of entrenched attitudes about the appropriate roles of practitioners and patients. For patients to gain greater power and control, professionals have to relinquish their power and control. Real change requires a complete restructuring of health services and health roles. However, in theory, if not fully in practice, there is a definite shift towards sharing therapeutic responsibility (for a discussion of this, see Coulter, 1999). This includes giving people the information they need to make decisions and be an active partner in the therapeutic alliance. To what extent this idea of partnerships of responsibility is a reality depends on both the individuals (users and practitioners) and the settings, situations and health matters involved.

2.3.1 Patients and therapeutic responsibility

Activity 6: Therapeutic responsibility
Timing: 0 hours 15 minutes

Based on your own experience, and using the evidence you have read about and heard, answer the following questions.

  • Do you believe there has been a significant shift towards shared decision making during therapeutic encounters with CAM practitioners?

  • What impact do you think more equal relationships might have on shared therapeutic responsibility?

Discussion

Whereas, in the past, responsibility for successful outcomes was exclusively the practitioner's, people are now encouraged to accept a far greater level of self-responsibility in the therapeutic relationship. How far this extends to taking some responsibility for therapeutic outcomes should also be considered.

In CAM, outcomes and expectations may not be just about a narrow definition of health. Patients may seek happiness or wellbeing, a new understanding of their health or their lives, education about a particular topic, a feeling of pleasure and relaxation, or even the fulfilment of a sense of curiosity (Budd and Sharma, 1994, p. 2). The aims of CAM therapy are not, therefore, limited to a cure or the management of symptoms. Given this diversity, the question is whether the models of therapeutic responsibility used in other settings, such as orthodox health care, are useful or appropriate for discussing CAM. Stone and Matthews (1996) argue that, even though CAM relationships stress the centrality of patient self-responsibility, courts and professional bodies still place the entirety of the burden of therapeutic responsibility on the practitioner:

[T]he law is not prepared to impose duties of self-responsibility on patients. Patients are not held personally responsible in a legal system which is shaped more by the Hippocratic medical tradition than one which sees the legitimacy of health professionals as deriving solely from the patient's rights and the patient's consent to be treated. … there is little room for contributory negligence in a medical negligence action. Is there anything wrong with the status quo? The answer in relation to cases concerning allopathic medical practitioners is probably not. The technical expertise base of most of modern medicine is such that it probably is justifiable to regard the practitioner as the expert, and the patient as the grateful, and often passive, recipient of health care who expects not to be harmed by unreasonable errors, and expects to find legal redress should such errors occur.

(Stone and Matthews, 1996, p. 213)

In orthodox medicine, where doctors assume a high degree of professional expertise and successful therapeutic outcomes are attributed to a range of interventions, doctors should arguably be held accountable when things go wrong, because the person on the receiving end of that professional expertise cannot contribute much to professional wisdom, and so depends entirely on responsible professional judgement being used. The more power that a single party holds, the fairer it seems to place all the liability on that one party because, in essence, the disempowered party cannot significantly influence the outcome of the therapeutic exchange. Stone and Matthews (1996) argue that, as health care becomes more patient-centred, this way of thinking about therapeutic responsibility will become increasingly outmoded. This model is not appropriate for a therapeutic relationship which depends for its success on the client's active participation. They cite psychotherapy as an example of how existing legal and professional models of accountability may be ill-suited to analyse patient-centred encounters. In psychotherapy, they argue, the therapist gives the client space to realise their potential. If the client fails to do so, no one would expect this to be expressed through the law: for example, ‘I'm suing you because you promised to make me happy.’ Where the efficacy of a therapy depends on both the patient and the practitioner exercising self-responsibility, the practitioner should not be held accountable if the patient fails to fulfil their part of the deal.

Stone and Matthews go on to argue that, unless and until the law shifts towards a contractual model founded on mutual responsibility, the notion of patient self-responsibility will amount to little more than lip service. Patient-centred rhetoric is one matter, but backing up patient-centredness with the force of law denotes a significant shift in how practitioner-patient relationships are conceptualised:

Suggesting this model has profound political implications. If we are to expect patients in this context to make responsible choices and to take steps to promote their own health, then this relies on the patient having access to a far greater amount of information than the law currently requires.

(Stone and Matthews, 1996, pp. 292–3)

2.3.2 Responsibility for the causes of ill health

Doyal and Pennell (1979) write from the perspective of political economy and argue that there is a continual state of conflict hidden within health experiences and health care relationships. Society produces ill health through an unrelenting drive towards profit and a failure to put the health and wellbeing of individuals first. Work and everyday social life are bound up with taking risks. Many workers experience stress and some occupations involve the risk of physical injury. Social class groupings, affluence or poverty, gender, age and ethnicity can all impact on the likelihood or not of an individual becoming ill. Some occupations are associated with diseases, such as miners and industrial workers (white finger), hairdressers (eczema) and typists (carpal tunnel syndrome). From the perspective of political economy, the development of more ‘caring’, and allegedly equal, therapeutic relationships in orthodox health care settings is little more than an attempt to gloss over the inequalities that lead to ill health in the first place. For all the talk about patients’ rights, and the shared responsibility between doctor and patient, it is the patient who carries the risk and burden of industrial and work-related stress, illness and disease. Orthodox medicine has arguably done little to address these underlying causes of illness. While a small proportion of doctors will take on an advocacy role for their patients, the politics of ill health remain outside the surgery door.

Should CAM therapists be expected to be more overtly political? Poverty, social deprivation and overwork are key stressors for people in modern society. Much CAM business involves helping individuals whose health has been adversely affected by these types of problem. Critics of CAM, such as journalist and social commentator Rosalind Coward (1990), argue that CAM practitioners do not really deal with the social causes and aspects of ill health. Thus, while a hypnotherapist is happy to help a client learn to deal with stress at work (and charge the going rate for this service), hypnotherapists are not marching to Parliament en masse to complain about poor workplaces, heavy workload, bullying and interpersonal aggression, which can lead to people seeking help for stress-related problems. In other words, CAM does not attribute much importance to the political context of illness. Instead it compounds the view that the individual is responsible for dealing with their damaged health.

It can be argued that CAM practitioners perpetuate an unhealthy obsession with perfect health. Because practitioners offer to treat people's minds, bodies and spirits, the quest for perfect health may, for some, become a relentless preoccupation. When treatment is extended beyond illness to wellbeing, people may feel they could always do more to enhance their health. This might reflect a more general concern with control over their life which people in western industrialised societies are encouraged to feel they should have.

2.3.3 CAM and the ‘tyranny of health’

Some commentators criticise the very idea of the ‘therapy culture’. The issue for them is not how to get people more involved with their health and the therapeutic relationship, but the unhealthy attitude many people have towards seeking perfect health in the first place. How healthy is it for people to constantly turn to professionals or therapists for advice on health care and lifestyle? Should people believe that being in the best of health is the main concern in their lives? The cultural acceptance of purveyors of the various kinds of health knowledge can be interpreted as suggesting a growing dependency on ‘experts’ to deal with everyday, normal problems of living. Health may become an unending quest for feeling good, balance and a sense of being understood. As everyone's life involves some degree of conflict, problems, sad and upsetting events, and adaptation to difficult circumstances, when will the quest ever end? Rather than health being a fluid experience of the body and mind, Michael Fitzpatrick (2000) argues that it is now sought and valued above all else. He coined the term ‘tyranny of health’ to describe the moral imperative that everyone faces to take good health seriously and seek it at all costs.

There are consequences of living in a world focused on ‘good health’. Lee-Treweek (2003) uses the term ‘tyranny of healing’ in developing Fitzpatrick's original concept to indicate how many people who have chronic health problems are pressurised never to give up seeking their former health. Friends, family and colleagues who want to support a person with a chronic illness often encourage them to keep trying new CAM, herbal and vitamin products, etc. Also some CAM modalities and practitioners are more than happy to advertise being able to help with a multitude of symptoms and ills. In the marketplace of claims about health products and CAM, it can be hard to accept that healing may not occur; and other people may even interpret such acceptance as the chronically ill person ‘giving up’. However, in some circumstances, chasing the dream of total healing is psychologically and emotionally distressing, economically unviable and ‘unhealthy’ in itself.

2.4 Ownership, control and ideas about the body

This section focuses on the extent to which a person becomes invisible when a practitioner rigidly adheres to a specific view of health and disease, and fails to accept that others (specifically the person they are treating) may have different ideas about illness or, indeed, about their body. The imposition of a fixed view of illness and disease can be extremely disempowering for people seeking help.

Activity 7: Conflict over treatments

Timing: 0 hours 25 minutes

Think about times when you visited orthodox health care practitioners and CAM therapists or were a hospital inpatient. Make notes on situations when you thought the treatment you received was not what you wanted, or you were ‘out of control’, or your personal views and wishes were ignored.

Discussion

At some time in their lives most people experience unease at receiving medical treatment or advice they are not very happy with. It can feel as though you have disappeared behind your symptoms, especially if what you say is not taken seriously or you are left out of discussions about your own body. Also, it can be hard to insist on what you want when the ‘professionals’ seem to have a fixed view about what is the appropriate form of treatment. Examples of this include being prescribed drugs you are not happy with; being forced to submit to examinations or procedures that you do not want; and being treated in a way that makes you feel your body and your symptoms, rather than you as a person, are of much more interest to the practitioner.

2.4.1 Reductionism and ‘ownership’ of the body

Social scientists interested in changing relationships between workers and users of health care often draw attention to what is termed the loss of ownership or loss of governance of the body. These terms mean that a person's body is treated in some health situations as more important than the person themselves. It is almost as if they are purely a case, an example of a type of disease, or a set of symptoms. Traditionally, such criticisms were levelled against biomedical approaches to the body, and medical historians sought to demonstrate that power over the body is central to the development of medical authority. The work of the sociologist and historian David Armstrong is important to debates in this area (Armstrong, 1987, 1993). He argues that modern medicine developed its power in society through its knowledge of the body and through mapping physiology, anatomy and the biology of disease processes. As the inside of the body was investigated, medicine could claim knowledge about how it worked, giving medicine a monopoly over these new understandings. The science of the body and of disease became the preserve of the medical establishment. The study and treatment of the ill and diseased body moved into medically dominated settings such as hospitals and clinics (Foucault, 1973).

One effect of this focus on the diseased body and the medical ‘case’ was that the individual person could easily become hidden behind a disease label or a set of medical notes. The focus on parts of the body, rather than the whole person, is called reductionism. A reductionist attitude towards healing and treatment means the patient becomes little more than an object of medical treatment and a battleground on which to fight disease. How patients feel about their treatment and the role of the patient's mind and emotions while in health care settings become side issues to the imperative of treating the body.

Reductionist medicine is a direct product of Cartesian ideas about the body, specifically, the long-held view that the mind is separate from the body. The philosopher René Descartes (1596–1650) argued that minds and bodies are made of totally different substances: minds are spiritual matter and bodies are material matter. Within conventional scientific thinking, there was no way to link the activities of the mind with the functions of the body. As Mitchell and Cormack explain:

As translated into biomedical practice, there has been a focus on the physical aspects of illness, with diseases being understood as biological phenomena in which signs and symptoms are manifestations of underlying pathology. Social and psychological aspects of illness may have been recognized and viewed as significant in themselves, but there has been no philosophical or theoretical framework for links between the psychosocial and the physical.

(Mitchell and Cormack, 1998, pp. 63–4)

In theoretical terms, concerns about the limitations of the reductionist biomedical model gave rise to the emergence of the biopsychosocial model of health and illness, proposed by Engels (1980). This model, which now underpins conventional training and practice, recognises that behaviours, thoughts and feelings influence a person's physical state. Engels argues that psychological and social factors influence biological functioning and also play a role in health and illness. However, even the biopsychosocial model fails to provide a scientific basis for exploring treatments or approaches to considering the patient as a whole. The discovery in the 1980s of a rich supply of nerves linking the brain with the immune system led to a new branch of science: psychoneuroimmunology or PNI (Evans, 2003). Finally, a theoretical basis was established to support a relationship between the brain and the immune system, which some CAM practitioners cite in support of their philosophy that the mind can influence events in the body. The science of PNI is in its infancy, but developments in this area will be highly influential in the shift away from biomedical approaches in which personal meaning and bodily processes are viewed as distinct and separate.

2.4.2 Holism and ideas about the body

Reductionist medical approaches have been criticised for providing a fixed, mechanistic view of the body, which fails to capture the patient's experience. The power associated with biomedical diagnoses and expertise means that patients’ explanations for their illnesses are often overlooked or dismissed. Does holism, which seeks to treat the mind, body and spirit, fare any better in giving patients a sense of control or ownership of what their illness means? This question is often reframed in terms of patient-centredness:

All healthcare practitioners, conventional or complementary, aim to tailor their interventions to the needs of individual patients. However, conventional practitioners generally direct treatment at the underlying disease processes, whereas many complementary practitioners base treatment more on the way patients experience and manifest their disease, including their psychology and response to illness. Treatment is ‘individualised’ in both cases, but patients’ personalities and emotions may be more influential in the latter approach.

(Zollman and Vickers, 1999, pp. 1486–7)

However, claiming that a treatment is holistic and user-centred may not make the user feel more in control, as the following hypothetical example shows.

Control and CAM treatment

A 30-year-old man visits a chiropractor, having had numerous experiences of care in the NHS, some of them upsetting and, he feels, humiliating. The first visit to the chiropractor includes an hour-long, extensive initial interview and he leaves feeling very satisfied and that, at last, someone is listening. However, on subsequent visits the appointment is much shorter (15 minutes), he undresses, receives a back treatment and leaves. This happens on several occasions and, although there is improvement, he believes the chiropractor is now more interested in treating his back and not in treating him as a person. He leaves and goes to another chiropractor who seems to spend time each session assessing how he is doing overall health-wise.

None the less, CAM does offer various ideas or explanatory models about what the body is and how it becomes ill, some of them opposing traditional biomedical notions of anatomy and physiology:

Teresa … had sought acupuncture treatment … to help with back pain which was thought to be associated with secondary cancer in her liver … she expected to have needles inserted in her back … where she had experienced pain, [but] she also had needles inserted on her calves and feet, areas considered unrelated to back pain in Western anatomy and physiology … her acupuncturist … explained that these were points on a liver meridian.

(Busby, 1996, p. 141)

Teresa's practitioner offered a view of the body according to traditional Chinese acupuncture (TCA) that she had not encountered before. In particular, the idea of energies moving around the body through meridian lines provided a different form of treatment and, doubtless, a different way of thinking about her illness. Busby (1996) goes on to discuss the way in which the notion of the body as ‘energy’ fits with some of Teresa's ideas about her own body. That is, some of the concepts of TCA were congruent with how Teresa experienced her body and thought about illness. Other therapies that explain health states by relating to energies in transit around the body include shiatsu, reiki healing, vortex healing and all healing systems that use the notion of chakras (energy centres positioned at various points on the body). With energy-based therapies, some people gain much from seeing themselves through the framework provided by the practitioner – that is, as having an energy imbalance which led to illness – rather than through the frameworks provided by GPs or orthodox medical specialists.

Other CAM therapies also provide different frameworks for understanding and thinking about bodies and disease or illness, which include the following.

  • Mechanical view of pain and dysfunction in the body – for instance, some osteopathic and chiropractic approaches.

  • Illness or disease as the product of imbalance in their systems – homoeopathy and many traditional healing systems, such as ayurvedic medicine.

  • Illness or disease as the product of stress, negative thinking or no longer useful subconscious processes – hypnotherapy and guided imagery therapies.

  • Emotions and shocks are held in the body and require healing – some osteopathic approaches, homoeopathy, massage and probably all the energy-healing modalities.

This list of different ways of conceptualising the body and illness or disease is not exhaustive, but it demonstrates the way in which CAM appears to offer a variety of ways for individuals to think about health, the body, the mind and the causes of disease. Patients can be empowered through having a sense of congruence and control in CAM therapy that they perhaps do not have in orthodox forms of medical care.

Activity 8: Who benefits from different views of the body?
Timing: 0 hours 15 minutes

Note down some reasons why health care users might gain from a different view of their bodies. Are there any ways in which a different view of their body may be damaging or distressing for a user?

Discussion

Some users' health problems may not ‘fit’ orthodox care services, or their conditions may not be treated easily by orthodox means. Complementary therapy may be a chance to develop a therapeutic relationship with someone who does not even use the illness categories of orthodox care and is prepared to help with difficult symptoms when orthodoxy has perhaps ‘given up’. For instance, people diagnosed with the rheumatic illness fibromyalgia, which can lead to debilitating muscle pain in various parts of the body, often find that orthodox services have little to offer them and that some orthodox practitioners even doubt the authenticity of their symptoms. CAM may therefore give a sense of practitioner acceptance and support after what is a journey through orthodox care that is sometimes confusing, harmful or less than supportive.

So far in this extract the discussion has been about how CAM approaches to the body offer alternatives to the traditional biomedical approaches that have been criticised for making people feel out of control. From a positive perspective, new ways of seeing the body can enable users to choose those most congruent to their own personal ideas. A holistic view of the body and more equal relationships between practitioner and user could lead to a more empowering experience for the user.

However, is this experience of empowerment and congruence a feature of all CAM therapeutic relationships? Arguably, users can feel as out of control in a CAM encounter as in a conventional encounter. Numerous critics of CAM point to the way in which some CAM modalities leave little room for users' own views and can create their own sense of ‘loss of ownership’ of the body. Individuals have varying experiences of the CAM therapeutic relationship and what some people experience as empowering can for others be overbearing, bizarre or at odds with their own views of the world.

The issue of congruence and blame is very important. Some therapies are founded on the idea that different parts of the body relate to how the person feels inside. For example, the New Age ‘guru’ Louise Hay sees the body and its ailments as reflecting more general problems in a person's life and thinking (Hay, 1984). She believes the nature of illness yields clues about the person's problems. For instance, illness involving the eyes may indicate that the patient does not like what they see in their own life. Likewise, skin problems may indicate difficulties with anxiety, fear or being threatened. These views of illness or bodily malfunctions are open to a wide range of interpretations by individuals who are exposed to them. Some people use these pronouncements metaphorically, to help them see their condition in a new light and take active steps to ‘heal their life’. However, for others such an approach is at odds with how they feel and Hay's theory may seem intimidating or threatening. Some may also consider this approach to be ‘victim blaming’ in that it somehow suggests that people exhibit illness precisely because of their approach to themselves and their lives. The individualisation of illness that is helpful to some people may also demonstrate a gap between CAM practitioners’ views on health or illness and how the person receiving ‘therapy’ or advice feels.

Figure 3
Courtesy of Hay House, Inc. ©
Courtesy of Hay House, Inc.
Figure 3: Louise Hay has had an enormous influence on a variety of CAM practitioners

2.4.3 How CAM therapists impose their views on users

As most people do not have a wide knowledge of complementary perspectives and philosophies, the therapeutic relationship can break down because of a mismatch between what the practitioner offers and what the user of the service wants. The practitioner's ideas about health, illness, mind and body may be at odds with the user's, which can lead the user to find another therapist who offers therapy that is more congruent with their beliefs.

The scholar Ursula Sharma argues that users of CAM most probably match themselves with practitioners who offer approaches that they can connect with and find palatable (Sharma, 1994). Conversely, when faced with a therapist or therapy that does not fit with their views on health, users will tend to fail to return. Sharma (1994, p. 20) notes that one area in which users of CAM may find that their views clash with particular therapists is the issue of personal change. For instance, users who attend for relief of symptoms may view the idea of changing their lifestyles or sense of self as intrusive or inappropriate.

Therefore, a CAM practitioner who promotes strict exclusion diets as being essential to healing may put off someone with a mechanistic view of their body who wants it ‘fixed’ with as little change to their lifestyle as possible. Similarly, practitioners who offer or promote New Age, spiritual or religious aspects to treatment may also find that some patients will leave the therapeutic relationship. However, others may be attracted by such approaches and actively seek practitioners who integrate ideas that fit with their own world views. The apparent need for congruence between practitioners and users makes it even more important for therapists to discuss their therapeutic orientation with users before starting a therapeutic relationship, so that users can make an informed choice about whether to invest their time, money and hope in such an approach.

2.5 The therapeutic relationship as a placebo

Mitchell and Cormack propose that the relationship aspect of a therapeutic encounter can be as important as the technical dimensions of healing (Mitchell and Cormack, 1998). CAM practitioners argue that the therapeutic relationship itself may be an important tool in healing. Critics of CAM turn this argument on its head, suggesting that CAM is, in fact, no more than a powerful form of placebo. What they generally mean is that it is not the specific treatments used that evoke a healing response; rather, it is the combination of non-specific effects of the CAM therapeutic relationship which create a belief in the user that they are being healed. In other words, it is not the acupuncturist's needles, or the homoeopath's remedies, or the osteopath's manipulations that benefit the user, but the ritual, supportive relationship and powerful belief in the effectiveness of the therapy that makes users feel better. Obviously, CAM practitioners regard this assertion as contentious, and a denigration of their technical skills, which often have been learned over many years. Peters (2001, p. xi) notes that practitioners might find it demeaning having to accept that recovery might depend on responses they trigger. For many practitioners, calling CAM ‘mere placebo’ is a way of dismissing it as trickery or an elaborate sort of con. To call CAM a placebo is to infer that, if it heals users at all, the healing is all in the user's mind, and not a result of the treatment.

Placebo generally means an inert substance, given in place of an active drug or treatment. Over the centuries, physicians realised that some people felt better for taking a placebo, even if it was nothing more than water or sugar. The placebo effect refers to the phenomenon that, in certain conditions, including pain and depression, approximately 30 per cent of people will get better, even when they have been given a dummy pill or procedure. The placebo effect is not the same as spontaneous remission or the natural waxing and waning of symptoms over the course of a disease.

To understand why this is such a contentious debate, remember that orthodox medicine (not to mention pharmaceutical companies) has much invested in the idea of ‘magic bullets’, or specific interventions to cure specific diseases. Much clinical research is dedicated to proving that drug X works for condition Y. Drug trials are carefully designed to prove whether the drug (or procedure, or device) can demonstrate a desired specific effect beyond any possible placebo effect. In order to prove this, potential biases and variables are taken out of the equation as far as possible, so that the only aspect being tested is the intervention with the specific effect. This form of scientific method led to the development of the double-blind, randomised controlled trial (or RCT).

RCTs represent the scientific gold standard for assessing the effectiveness of any new treatment. They eliminate the very factors that exert a powerful effect in the CAM therapeutic relationship: the practitioner's time and interest in the user; the formation of a close, empathetic relationship; the giving of hope; and the practitioner's enthusiasm for the therapy. This represents a clash of systems and values. Some scientific scholars argue that the only definitive way to prove that a CAM therapy works is to subject it to the same scientific processes as conventional medicine (that is, the RCT), whereas other scholars (and many CAM therapists) argue that it is pointless to consider the specific effects of their therapy in isolation, since it is a combination of the specific and non-specific effects, acting together, that creates the power of the healing effect. They also argue that it is unfair and unrealistic to be expected to test their therapies in a way that fails to capture the holistic nature of the interaction.

This argument is not simply about research methodology. As with so many other dimensions of CAM, it has political overtones. The future integration of CAM requires more evidence of its efficacy and cost-effectiveness. Sustained consumer enthusiasm for CAM similarly depends increasingly on evidence to support its claims. Many practitioners appreciate that developing a stronger evidence base is essential to maintaining their increasing credibility and professionalisation, and they accept that research must be done. Compromises will have to be sought, which may include innovative research design for testing specific and non-specific effects (for example, the use of pragmatic RCTs, which test the intervention as a whole, as it is delivered in practice) and sufficient research funding in CAM, so that any placebo effect can be rigorously and scientifically tested (for example, by comparing an active CAM treatment with a placebo and no treatment whatsoever).

Regarding the claim that orthodox medicine is becoming more patient-centred, doctors may also want to explore how the non-specific effects of treatment might make patients feel better. Whether or not specific effects are caused by evoking a placebo response, or through chemical processes in the body (as PNI might suggest), anything that improves a patient's subjective experience of suffering is worth investigating.

Placebo might work through psychoneuroimmunology (Armstrong, 1993); that is, the complex interrelationship between the mind or psychology, the brain, the immune system and general health. A psychoneuroimmunological approach tries to take all these facets of a person into account in understanding a symptom, an illness or a disease. Thinking about and treating the whole person could evoke a stronger placebo effect. As Evans (2003) notes, rather than dismissing CAM practitioners as frauds or quacks, if their healing abilities are ‘just’ about placebo then orthodoxy could learn a great deal from them.

Without further research, the question of whether CAM is a placebo will continue to generate controversy and polarise CAM practitioners and scientists.

2.6 The failure of CAM therapeutic relationships

Although therapeutic relationships have the capacity to heal, they can also harm. In reality, the outcome of most therapeutic encounters and relationships lies somewhere on a continuum between good and harm. Few therapeutic relationships are a complete success but, judging by the number of complaints, even fewer are a complete disaster. Studies of therapeutic encounters invariably show high levels of patient satisfaction (see, for example, Sharma, 1992; Kelner et al., 2000). None the less, it is important to consider the ways in which the therapeutic relationship can be unsuccessful or even counter-therapeutic. This can be considered in the following areas.

  • Clinical failure: the therapy either does not help the user or makes them worse. This may be seen as a failure of the practitioner's ethical duty of beneficence and non-maleficence.

  • Failure in interaction or communication: sometimes users fail to ‘connect’ with the practitioner, either personally or with the philosophy or ideas involved with their particular CAM. Sometimes a practitioner's style of interaction and questioning is not acceptable to the user. This can also be seen as a failure both of the practitioner's ethical duty of beneficence and non-maleficence and of the practitioner's duty to respect the person's autonomy.

  • Mismatch of expectations: the user might have different ideas about how soon to expect results from the form of treatment they seek, or what kind of results to expect.

  • Breach of boundaries: failure by the user, the practitioner or both to manage appropriate boundaries in the therapeutic encounter (for example, the patient or practitioner makes suggestive or judgemental comments, or the practitioner performs an examination that seems unnecessary). This can be seen as a failure of the practitioner's ethical duty of non-maleficence, in that they are actively harming the patient.

Of course, separating relationship failures in this way may be rather artificial. In practice, a therapeutic relationship flounders for several different reasons. As discussed earlier, the components of the therapeutic relationship operate synergistically. Thus, a clinical failure may result from failed communication or an inability to form a supportive, empathetic relationship with a user. A breach of boundaries may be detrimental to healing, even when the practitioner has been technically proficient. The most likely outcome of failure in communication or interaction is that the user will not return to that practitioner. Failed encounters of this sort are detrimental in that they may inhibit the patient from seeking further treatment that may be of benefit. Also, remember that users who pay for their CAM treatment may simply not have the resources to shop around indefinitely. However, it is failures of the final type that cause most concern, since they have the greatest capacity to harm patients directly. Although, stereotypically, people tend to associate breach of boundaries with practitioners acting in a sexually inappropriate way, the scope of failures is considerably broader.

2.7 The failure of CAM therapeutic relationships: breach of boundaries

In this section, failures caused by breach of boundaries are discussed under the following headings:

  • ‘wounded healers’

  • creating dependency to satisfy practitioners’ emotional and financial needs

  • sexual abuse and exploitation.

To reiterate a point made earlier, breaches of the therapeutic relationship cover a spectrum. Some breaches invariably thwart a successful therapeutic outcome (for example, when a therapist is physically aggressive and intimidating towards a patient). Other breaches may inhibit a maximally effective therapeutic outcome, but do not necessarily destroy the entire foundation of the relationship (for example, a therapist who tells the user more about their personal circumstances than the user cares to know). The most unacceptable sorts of breach tend to be expressly prohibited within practitioners’ codes of conduct. Professional bodies in CAM prohibit sexual relationships between practitioners and users or former users, or direct financial relationships, such as borrowing or lending money. (For example, see the codes of ethics for osteopaths and chiropractors: General Chiropractic Council, 2004; General Osteopathic Council, 2004.) Other breaches are more subtle and less well documented. While the focus here is on CAM relationships, it is important to remember that breaches of boundary occur in all health and caring professions (POPAN, 2000).

2.8 The failure of CAM therapeutic relationships: wounded healers

Sometimes, practitioners allow their personal life and personal issues to become central to the therapeutic relationship. In a range of therapies, the practitioner is assumed to bring not only their skills but also their experiences to the therapeutic relationship. This has led to the concept of the ‘wounded healer’ (Nouwen, 1977): that is, a practitioner who, in experiencing physical, psychological or emotional pain, develops a greater understanding and empathy with other people's pain. The debates about whether practitioners can draw positively on their own negative past experience and their ways of getting over negative life events in their work are in the literature on pastoral care, counselling and psychoanalysis. The Catholic spiritual writer Henri Nouwen first developed the idea of the wounded healer and argued the need for all ‘people workers’ to recognise how their own experiences of abuse and pain can contribute towards a greater awareness of the needs of other people (Nouwen, 1977). The CAM movement took up this term, and in many therapies the idea of understanding one's own pain and personal coping mechanisms is central to being a practitioner.

Although there is no reason why personal experience may not provide a useful reservoir of insight into some users' experiences for a reflective practitioner, it can lead to therapeutic failure if practitioners cannot manage their own feelings adequately. If not properly understood, the notion of the ‘wounded healer’ could appear to excuse or support some of the following unhelpful assumptions.

  1. ‘Wounded healers’ are the most able practitioners to help users (having experienced pain themselves).

  2. Inevitably there are ongoing issues with pain or personal distress.

  3. It is appropriate to divulge this to users who have attended for treatment in an attempt to cope with their own pain and symptoms.

The concept also seems to imply that healers who are not ‘wounded’ are less able to be good, competent and caring practitioners. Clearly this is false. A practitioner need not have experienced the same pain as the user to be able to empathise. It would be like saying that only people who have experienced house fires can comfort others whose houses have burned down, or that only people who have explored their own capacity for deviance should become forensic psychotherapists. Many experiences can give an insight into another person's wish for healing or change. Also, people's ability to learn and use skills such as rapport, empathy and listening means that practitioners do not necessarily have to experience a difficult life to understand another person's difficult life.

The main problem with the wounded healer concept is that it can be used as an excuse for practitioners not to establish and maintain clear boundaries between themselves and the users. In the extreme case, the practitioner may feel it is all right to emotionally ‘open up’ to clients or users about their life experiences at inappropriate times or in inappropriate ways. For instance, a shiatsu practitioner who spends much of the initial interview before treatment regaling their clients with details of their failed marriage is unlikely to add to the client's sense of wellbeing or to inspire the sort of confidence in the practitioner that forges a good therapeutic relationship. Indeed, the relationship may change so that the client almost becomes the practitioner's counsellor or supporter. The alternative course of action is for the client to leave either immediately or at the end of the treatment and not return. Either way, it is difficult to see the interaction between such practitioners and their clients as being particularly therapeutic. Using the therapeutic relationship to fulfil the practitioner's own psychological or emotional needs can be seen as a form of abuse.

2.9 The failure of CAM therapeutic relationships: creating dependency to satisfy practitioners' emotional and financial needs

Although a failed therapeutic relationship is often assumed to involve a patient not returning, the case of a patient who attends repeatedly can also be highly problematic. This phenomenon can be seen as a breach of boundaries in that an inappropriately extended therapeutic relationship changes from being a healing encounter into a dependency relationship or friendship. Unlike the timescale contracts that may be negotiated in counselling and psychotherapy, there are no fixed timescales for most CAM therapies. Some CAM users will continue to attend as and when they feel like it, especially when the CAM therapies have a strong leisure or relaxation component, such as massage or aromatherapy. In the more ‘medicalised’ therapies, practitioners usually indicate to users the timescale in which they hope to see some improvement. Negotiating an appropriate timeframe helps patients to feel in control, and gives a realistic period in which to judge whether the treatment is beneficial.

Figure 4
The Wellcome Trust ©
The Wellcome Trust
Figure 4

Other CAM therapies are based on the notion of minimum intervention. For example, in osteopathy the general aim of the treatment is that patients are not long term. Once a lack of improvement or a levelling off is observed then the practitioner is expected to help the patient end the treatment. Of course, some patients will return for ‘top-up’ sessions, or when a condition flares up. However, research by the British School of Osteopathy suggests that returning patients are quite common (Pringle and Tyreman, 1993).

Practitioners are often at a loss to know where to send patients who report they are not getting better. In some cases, practitioners think these patients have no one else to turn to and that they have an ongoing duty to relieve the patients’ distress, even though they cannot offer a cure. This raises interesting issues about what therapy is really for, and how attendance may be affected by lack of support or care for particular patient groups in orthodox services. Continually returning patients are the subject of a considerable literature in orthodox health care and they are often called ‘heart sink’ patients (for example, Pietroni and Chase, 1993; O'Rourke, 2000). The ‘returnee’ may be CAM's equivalent.

2.10 The failure of CAM therapeutic relationships: sexual abuse and exploitation

Another issue that can cause a therapeutic relationship to break down is the failure to maintain appropriate personal or professional boundaries, to the extent that it constitutes serious abuse. A broad spectrum of activities can be called abuse. The term ‘abuse’ originates from the Latin meaning ‘a departure from the purpose (use)’ (Rutter, 1990, p. 41). Given this meaning, clearly some of the boundary issues mentioned above are on the fringes of the category of abuse within CAM. Much of the literature on abuse in one-to-one healing encounters is from counselling and psychotherapy and focuses on the issue of sexual abuse and exploitation within the therapeutic relationship (for example, Pope and Vetter, 1991; Jehu, 1994).

Perhaps the most easily identifiable abuse within CAM relationships is where a practitioner makes sexual moves towards a user or engages in a sexual relationship. Such behaviour constitutes a gross breach of trust. Such boundary violations are invariably counter-therapeutic, whatever the practitioner and the user may feel about it. As with all boundary violations, sexual exploitation is no more likely in CAM therapeutic relationships than in other healing encounters. However, factors which might increase the likelihood of abuse in CAM include working from home, or in other informal settings (including the user's home), lack of knowledge about what the therapy is supposed to involve, and lack of formal regulation (Stone, 2002).

Sometimes a breach of boundaries starts when a patient or user attempts to change the nature of the relationship. Oerton's research (2004) on therapeutic massage indicates that it is very common for practitioners (often, but not always, female) to have problems with clients (often, but not always, male) misinterpreting massage as sexual. Massage practitioners have the added problem of being incorrectly associated with sexual massage services. Oerton found that practitioners often sanitise the encounter to minimise the possibility of misinterpretation by wearing white tunics or robes (mimicking the dress of medical personnel); adopting a professional attitude to the massage encounter; and demonstrating boundaries by leaving the room while the patient or user is undressing and dressing. Working in a group practice of CAM practitioners can also help deter people or their therapists from trying to breach acceptable boundaries.

The processes of transference and counter-transference make it natural and normal for attraction and desire to arise for both user and practitioner throughout the therapeutic relationship. Transference is the way in which a user's feelings and actions towards their therapist are influenced by early childhood experiences, especially relationships with parents. Therapists, in turn, exhibit counter-transference: their own unconscious fantasies and wishes about their patients. Practitioners need to be aware of these forces and use them constructively in the professional relationship (Stone, 2002). The onus is always on the practitioner to manage and maintain appropriate boundaries, however the user behaves. Mitchell and Cormack (1998, p. 102) note that users are most likely to be abused sexually: where the practitioner's general behaviour is anti-social or domineering; if the practitioner works alone; if there are drug and/or alcohol problems and/or other sources of distress in the practitioner's life; and if the practitioner can rationalise that it is acceptable to use the therapeutic relationship for intimacy. Clients who are ‘excessively dependent’ are the most likely to be sexually abused by practitioners, as are clients who feel sorry for the practitioner or who have a need to please the practitioner. People who have suffered sexual, physical or emotional abuse at other times in their lives are particularly vulnerable to an abusive dynamic in the therapeutic relationship (Mitchell and Cormack, 1998, p. 103).

2.11 The failure of CAM therapeutic relationships: complaints

The issue of complaints is uncomfortable for any health practitioner. CAM practitioners may be particularly reluctant to accept that their actions may give rise to complaints. Since many therapists do not perceive their therapy to be intrinsically harmful, they are unlikely to make provision for when it goes wrong. Moreover, the comparative absence of litigation against CAM practitioners may give a false sense of security, whereby therapists do not consider themselves above the law but see the law as of little concern to them. Similarly, the lack of power of many professional bodies in CAM means that practitioners may not believe they will be dealt with harshly, even if they are subjected to a formal complaint by a patient (Stone, 2002, p. 199).

Many therapists are reluctant to accept the idea that there can ever be failed therapeutic relationships. When a person consults a therapist only once and returns, the practitioner may assume this is a testament to their therapeutic skills. In the absence of a widespread audit of practice, few practitioners follow up why a patient has not returned. Although the comparative lack of complaints against CAM practitioners is encouraging, the following reasons may constrain dissatisfied individuals from expressing their concerns.

  • The person may not know where or to whom to complain.

  • The professional organisation of which the practitioner is a member may not have formal complaint procedures or the procedures may be very weak.

  • The practitioner may not be a member of a professional organisation. Remember, there are very few ‘protected titles’ in CAM, so anyone can call themselves a ‘masseur’ or ‘healer’, and they do not need training to use such titles.

  • The person may not be able to verbalise their complaint; for example, perhaps they felt threatened or uncomfortable. Therefore, it would be hard for them to present a firm case against the practitioner. Instead they may choose to ‘vote with their feet’ and not return for more treatment.

  • The person may be embarrassed, especially if their concern is of a sexual nature or involves humiliation or threats.

  • The amount of time and emotional energy a complaint takes may put people off following it through.

  • Lack of expertise or knowledge may mean the person does not realise they are being treated in an incompetent or unprofessional way. This issue is very important in the diverse world of CAM where, with over 200 modalities available, few people know precisely what to expect from treatment.

  • People may not want to initiate a complaint against someone they get on well with. Even when the therapy fails to deliver results or causes harm, people may be less likely to complain when they believe the therapist is fundamentally a good person.

The statutory bodies regulating osteopathy and chiropractic spend a considerable amount of their energy facilitating complaints from the public and investigating alleged practitioner abuses. The websites of some CAM professional organisations explicitly advise people how to bring a complaint (see, for example, General Chiropractic Council, 2004; General Osteopathic Council, 2004). In these professions, most complaints are about lack of communication and poor interaction between the practitioner and the user. However, note that, even in well organised complaint systems such as these, many users are unlikely to complain when they are unhappy because of the reasons outlined above.

2.12 The future of the therapeutic relationship

As discussed earlier in this extract, therapeutic relationships are subject to constant review and reinterpretation. As the culture changed, the predominant shift in health care was away from paternalistic forms of relationships based on professional expertise towards partnership models in which the patient has more rights but also more responsibilities. This final section looks to the future and considers some of the factors that can impact on therapeutic relationships in CAM.

2.12.1 Integration

One factor which is already influencing the nature of the therapeutic relationship is the move towards greater integration with orthodox medicine. Whether or not CAM practitioners welcome this development, it is inevitable. The impetus for this is partly about providing health care that gives patient satisfaction, and also stemming the tide of the spiralling costs of hi-tech, orthodox medicine and medical litigation. Stacey (1988) points out that, when the state funds parts of the nation's health care, it has interests in the accountability of the practitioners in terms of costs as well as outcomes of treatment. Therefore, the structural and organisational changes within the NHS will impact much more directly on CAM, including:

  • the introduction of auditing and risk management procedures

  • the development of more effective complaints mechanisms

  • improvements in accreditation

  • moves to enhance the public protection functions of self-regulatory bodies

  • a commitment to evidence-based practice.

How will this affect the therapeutic relationship? There could be a far greater emphasis on the safety and effectiveness of CAM than is currently the case. Integration is already prompting more funding for research into CAM. This will, in turn, influence training and practice, so that those aspects of practice which enhance good therapeutic outcomes are maximised, and those aspects which place patients in jeopardy are minimised.

2.12.2 Litigation

The level of litigation against CAM therapists is currently very low, particularly compared with corresponding actions being brought against doctors and other health care professionals. This, in turn, is reflected by the low annual indemnity insurance paid by most CAM practitioners. CAM therapists tend to attribute this to CAM's safety profile compared with orthodox medicine, together with CAM practitioners’ ability to forge better therapeutic relationships with users. However, other commentators argue that the lack of litigation, as with the lack of formal complaints, is more indicative of shortcomings in the legal system (Stone and Matthews, 1996). As suggested above, psychological and institutional barriers may prohibit a patient from complaining. An additional reason that may currently make people disinclined to sue a practitioner is their unwillingness to litigate against a person with whom they have had a close relationship. Yet people seem to have fewer qualms about suing the NHS, which is a more remote bureaucracy. Paradoxically, litigation rates may increase if CAM is provided by conventionally trained practitioners or on the NHS.

Fear of litigation has already altered the nature of the therapeutic relationship in medicine. Two ways in which this happens is through ‘defensive medicine’ and a highly legalistic approach to information giving and obtaining informed consent. The nature of the CAM relationship could similarly change if litigation rates increased.

2.12.3 Scientific advances

Advances in science may have dramatic effects on future therapeutic relationships. As specific funding becomes available for testing CAM, and as CAM practitioners start accepting the idea that their future sustainability may depend on them citing scientific research to establish their claims, more information will become available about which aspects of the therapeutic relationship are more, or less, beneficial. This may include research testing the hypothesis that elements of the CAM therapeutic relationship evoke a particularly powerful placebo response in certain conditions. In this case, both CAM practitioners and orthodox practitioners could learn how to harness the placebo effect in addition to the specific effects of treatment. Similarly, developments in psychoneuroimmunology and quantum physics may begin to provide answers to questions which, until now, have been elusive. They could explain how energy-based practices work, or provide a basis for explanatory models for CAM that oppose conventional scientific thinking (for example, providing a theoretical basis for homoeopathy).

2.13 Conclusion

All therapeutic relationships can harm as well as heal. In orthodox medicine, the bulk of the responsibility is placed on the doctor, because healing is attributed to specific effects brought about through the doctor's diagnostic and technical expertise. In CAM relationships, where users are expected to exercise self-responsibility, it may be inappropriate to focus solely on the shortcomings of the therapist (even though the law is unlikely to recognise mutual responsibilities when therapy goes wrong). That said, it is the therapist's responsibility to create the necessary conditions and boundaries for healing to occur. Despite CAM's user-centred rhetoric, holism can be as disempowering for users as reductionism. Dominant ideas link healing with the removal of physical symptoms. Conversely, harmful treatments tend to be associated with direct physical harm. However, harm can take several forms and be emotional as well as physical. While total failures of the therapeutic relationship are comparatively rare, therapeutic relationships can fail to achieve their potential in several ways. Despite the high levels of satisfaction in CAM, the absence of complaints is no cause for complacency; it may indicate that existing regulatory frameworks are ill suited to respond to the holistic relationship. It remains to be seen how shifts towards more integrated patterns of delivery, and scientific advances in understanding the link between mind and body, will affect the therapeutic relationship in the future.

Key points

  • CAM practitioners are not equally successful in forming healing therapeutic relationships. This can be because of personality and temperament but also through lack of training.

  • Despite a professed commitment to holism, practitioners may impose their own world views on patients. Being holistic is not synonymous with being user-centred, and practising holistically does not guarantee that practitioners will consider users' views of their bodies and illnesses.

  • CAM theories may offer new ways of understanding the body, which may or may not be helpful to users.

  • Therapeutic relationships that heal can also harm. The ways in which therapeutic relationships fail include: failing to deliver a desired outcome; failing to achieve the conditions in which healing can occur; and abusing trust.

  • Debates about placebo will continue to divide the supporters and detractors of CAM. Advances in psychoneuroimmunology will increasingly shed light on the ways in which the mind can directly influence the body.

2.14 Extract 2 References

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Jehu, D. (1994) Patients as Victims: Sexual Abuse in Psychotherapy and Counselling, London, Wiley.

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Pietroni, P. and Chase, H. D. (1993) ‘Partners or partisans?’, British Journal of General Practice, Vol. 43, No. 373, pp. 341–4.

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3. Extract 3 Ethics in complementary and alternative medicine

3.1 Introduction

This extract considers what it means to practise ethically; why ethics is so central to the health care relationship; and the responsibilities of practitioners, professional bodies, users and those making health care decisions for other people (for example, parents and carers of users who are unable to make their own decisions). This extract also explores the unique ethical issues raised by complementary and alternative medicine (CAM) and the extent to which ethical obligations and legal requirements overlap.

Aims of Extract 3

  • To understand the main ethical concepts in delivering health care.

  • To demonstrate a sound understanding of the roles of professional bodies in regulating CAM practitioners.

3.2 Ethics and health care relationships

Activity 9: Acting ethically

Timing: 0 hours 30 minutes

Write down a few sentences about what you think ‘acting ethically’ means.

Discussion

Most people understand ‘being ethical’ as having something to do with people acting in ‘the right way’. ‘Acting ethically’ embraces ideas about what people ought to do or what they should do, which presupposes there are rules of conduct or behaviour by which people expressly or implicitly agree to be bound. In this sense, acting ethically is similar to acting legally: following a set of rules that determine how people ought to behave. However, whereas the law lays down hard-and-fast rules, ethics presumes that people have a degree of choice about the decisions they make: they can choose to act either ethically or unethically. The notion of choosing to do ‘the right thing’ is important because society largely holds people accountable for the actions they take. So when a person's actions are judged, the pertinent questions are why did they act in the way they did, what were their motivations, and what did they hope the consequences of their actions would be? To be held accountable, people have to understand what they are doing. So, a child would not necessarily be called to account for doing something wrong, on the basis that they are considered to lack the capacity to understand the fundamental difference between right and wrong.

The term ‘ethics’ is often used interchangeably with ‘morality’, although people sometimes draw a distinction between them on the basis that morality is personal to each individual or to a particular group, for example Christian morality. There is probably a more relevant distinction between individual ethics and professional ethics. Each profession has a set of rules and obligations that are central to how professionals acting within that sphere of practice must behave. Many of the requirements of professional practice reflect the expected obligations of the ordinary citizen, including:

  • a duty to tell the truth

  • a duty to act honestly and fairly

  • a duty to respect people's wishes, and not to treat people as a means to an end, but as individuals with rights

  • a duty not to harm people.

Another way of thinking about ethics is to concentrate on people's rights, both in everyday life and specifically as health service users. As individuals, people have a right:

  • not to be harmed

  • not to be lied to

  • not to be touched without their permission

  • to be treated fairly and justly.

The obligations of a health professional embrace all of these rights. Ethics is important in health care for several reasons, but primarily because failing to act ethically can harm someone. Also, the unique vulnerability associated with being a patient leads people to trust that health practitioners will act ethically, by putting their best interests first. This includes taking their wishes into account, and not doing anything without their express permission (for example, by obtaining informed consent). Health care ethics concerns both professionals’ duties and users' rights. Ethics in health care tends to concentrate on the following four key principles (Beauchamp and Childress, 1994).

  1. The principle of respect for autonomy – giving competent adults the information they need to make their own decisions, based on their own values and their personal assessment of risk factors, free from coercion or undue influence.

  2. The principle of beneficence – benefiting or acting in the patient's best interests.

  3. The principle of non-maleficence – not deliberately causing the patient harm, or making sure that the benefits outweigh the harm if harm is unavoidable.

  4. The principle of respect for justice – treating all patients equally and providing mechanisms for when care goes wrong.

While these four principles underpin the range of duties that health professionals owe their patients, they do not provide an exact blueprint for how a practitioner ought to act in every given situation. However, they do provide a good starting point for making decisions, so that a practitioner faced with an ethically contentious choice does not make a decision solely on personal preference (for example, a doctor refusing to agree to a woman's abortion because of their personal opposition to it).

Sometimes these four ethical principles clash. For example, a doctor might be reluctant to tell patients they are dying, believing this will cause distress. In the past, doctors could override patients’ autonomy by withholding that information from them in what they perceived were the patients’ best interests. These might include keeping hope alive and encouraging the dying person to take the prescribed medication. Nowadays, such an action would be regarded as unacceptably ‘paternalistic’.

‘Paternalism’ has a distinct meaning in health care ethics. It describes the actions of a health care practitioner who overrides or does not seek the wishes of a competent person (that is, someone who has sufficient autonomy to make their own decisions), believing that they are better able to decide what is in the patient's best interests. A paternalistic action is always well intentioned but is ethically unacceptable because it usurps people's rights to make their own decisions, based on their own values and beliefs. Since the 1970s, there has been a cultural shift towards respecting rights and promoting self-determination. This means it is now considered more preferable for people to make their own choices on the basis of all the relevant facts than for other people to make decisions for them. This example also demonstrates that ethics is not static but reflects what is considered ethically appropriate by a society at different points in time, and that different cultures may have differing views on what is ethical. This explains why euthanasia can be lawful in the Netherlands but not in the UK: in the Netherlands, the emphasis is on respecting people's autonomy, whereas in the UK, the emphasis is on not causing harm.

Historically, health care ethics tended to concentrate on the responsibilities owed by the practitioner to an individual person. However, the true scope of health care ethics is considerably wider. Practitioners have duties not just to the individual in front of them but to all of their clients. They may even have duties to the public in general. For example, a practitioner who treats someone for a sexually transmitted disease has a duty to act in that person's best interests, but may also have a duty to that person's sexual partner, who could be a client. The practitioner may have a duty to warn third parties, who may not be clients, that they are at risk. Practitioners have ethical duties not just to service users but also to their profession and their employers. Users have ethical responsibilities as well as rights. These include doing what they can to maintain their own health; not drawing inappropriately on health services (for example going to the accident and emergency department with a routine or trivial complaint); and providing all necessary relevant information to a practitioner to facilitate an accurate diagnosis.

In the next activity you will reflect on your experiences as a user of health services and consider some of the ethical issues that arise in everyday health encounters.

Activity 10: Ethics in health care

Timing: 0 hours 25 minutes

Reflect on your last health care consultation (for example, a routine check-up with your GP or practice nurse, a visit to the dentist, a hospital appointment or a consultation with a CAM practitioner).

  1. Did any aspects of the encounter give rise to ethical issues? Focus on the positive as well as the negative aspects.

  2. Try to consider as broadly as possible, for example, whether the receptionist was polite to you, whether you felt confident to discuss personal information, whether the practitioner seemed genuinely interested in your problem or whether your appointment was on time.

Discussion

Ethics permeates every aspect of the health care encounter. Healing relationships are, at their heart, based on trust. When people are ill, they need to believe that everyone involved in providing their health care is acting appropriately and treating them in their best interests (for example, giving them the treatment that is best for their condition, not simply the cheapest or the quickest to administer). Acting ethically involves health carers respecting users' rights and supporting their choices (for example, giving them as much information as they want about the range of treatments available and the alternatives to treatment); being good at what they do (keeping up to date with and undertaking continuing professional development); refraining from actively harming users (by following approved and appropriate practices); and treating people in a fair and consistent manner (for example, not having ‘favourite’ users with whom they spend twice as long as they do with ‘difficult’ users).

In Activity 9, it was probably easier to think about instances of unethical practice than examples of ethical practice. The following list identifies some of the areas you may have considered as giving rise to ethical issues.

  • When you made your appointment did you feel that the initial contact with the receptionist or the professional was handled sensitively? Was the information you provided managed in a sensitive way, with respect for your privacy?

  • When you arrived for your appointment did the receptionist (if one was present) give you the chance to say why you were there (if relevant) and privacy in which to give your personal details?

  • Did the practitioner respect your autonomy, by asking you what you think is wrong and what you want to do about it, by gaining your consent to treatment, by respecting your personal health information as being confidential, by not discussing your details with anyone who does not need to know (other than to benefit your health), and by ensuring that written notes or computer records about you are kept safely?

  • Did the practitioner act in your best interests, by obtaining an adequate history from which to form a diagnosis and consider the right treatment plan, by providing treatment that should bring about the desired outcome with a minimum of side effects, and by keeping up to date with professional developments?

  • Did the practitioner act detrimentally towards you in any way: for example, being rude or dismissive, suggesting an inappropriate treatment, or charging you excessively for their services?

  • As far as you could tell, did the practitioner treat you fairly: for example, was the appointment on time, or were you or other people kept waiting? If your appointment was much later than the arranged time, were you given an explanation or apology? Did you feel that you could complain if there was anything you were unhappy about?

The above list shows that most interactions in health and social care have ethical dimensions, even if you did not necessarily consider them as ‘ethical’ issues. Most ethical issues concern the ordinary, everyday relationships between practitioners and users, although the media tend to focus on the more dramatic life-and-death issues, often presenting them in a highly polarised way. Almost all interactions have an ethical aspect, which spans encounters from what might appear to be simple questionnaires sent to people at home, through all the interactions they have with the service providers, including the treatment. There are ethics about how people are referred to a practitioner, and the treatment prescribed to them. As previously mentioned, users also have ethical responsibilities, for example telling their doctor they are also receiving treatment from a CAM practitioner, which might have a bearing on the doctor's recommended treatment and vice versa.

3.3 Why ethical behaviour is central to the health care relationship

The health care relationship is basically a relationship of trust. This implies that practitioners are motivated by the users' best interests; will not exploit the therapeutic relationship to satisfy their own ends; will behave in an appropriate manner that is conducive to the healing process; and will refrain from behaviour that could harm users, including being physically or psychologically unfit to treat them. The examples in Box 2 give a clearer idea of what this means.

Box 2 Examples of ethical situations

  • A patient may reveal extremely personal information to a practice nurse during a family planning consultation, even though the patient knows little about the practitioner.

  • A dental patient who is paying for private dental treatment needs to trust that they will not be subjected to unnecessary and painful procedures simply to increase the dentist's earnings.

  • An osteopathic patient needs to feel confident that she has been asked to undress down to her underwear only for the purposes of her treatment, and not for the practitioner's personal gratification.

  • A surgical patient takes it on trust that the surgeon's skills are up to date, and that they know about all the available options that might obviate the need for surgery.

All of these examples demonstrate that people would be uncomfortable in trusting or confiding in a practitioner unless they can believe the practitioner is worthy of respect and can be relied on not to abuse their trust. Ethical behaviour is central to the health care relationship because of the inherent power disequilibrium between user and practitioner. This is based largely on the relative disparity in knowledge between health carers and the people they treat. Health professionals are consulted precisely because they have skills that lay people do not have.

People increasingly expect to be informed and involved in all aspects of decision making about their medical treatment, which is acknowledged in the development of the ‘expert patient’ (Department of Health, 2001). At the same time, many people are much more knowledgeable about health-related matters than in the past. This is hardly surprising given the attention health issues receive in the media. The internet has also helped to narrow the knowledge gap between doctors and users. In addition, television series such as Casualty, ER, Holby City and Peak Practice have made people more familiar with medical terminology and seeing health carers working through fictionalised ethical dilemmas. They also see documentaries about, for example, the ethics of assisted reproduction, separating conjoined twins and end-of-life decisions.

In contrast, many people know relatively little about CAM unless they have had personal experience. When people consult a complementary practitioner for the first time, they may not know what the therapy involves or what outcomes to expect realistically. For example, although people are increasingly aware of being asked to give their consent to conventional medical procedures, they would not necessarily expect a chiropractor to ask them to sign a consent form. They might also be unaware of the level of information they need before they can give valid consent to their first acupuncture session. In these situations, and from an ethical standpoint, it is even more important for the practitioner to openly discuss the form of treatment being offered, what it entails, and what it could achieve in the given situation, as well as to discuss alternative treatment strategies.

Another obvious inequality between practitioners and users is that most people who are ‘ill’ (loosely defined) may be frightened, in pain and vulnerable, and need to be able to rely on the practitioner. Health givers, in contrast, should be in robust psychological and physical health and in no sense reliant or dependent on the user. When people are ill, they usually look for a health practitioner who has the skill and expertise to make them better, and who may, conceivably, impose their own professional judgement when appropriate. The autonomy of people who are ill is already compromised. They may be unable to work, or their mobility may be restricted, limiting their ability to get about as they would like. They may be in too much pain or discomfort to continue with their normal business. Depending on the severity of the diagnosis, they could be anxious and possibly depressed. All of these factors compromise autonomy. To regain their health and full autonomy, many people are prepared to depend on advice and allow themselves to be cared for by others. People who are used to managing their own affairs can feel uncomfortable being dependent on others. The loss of health interferes with people's ability to enjoy their lives. They invest significant trust and hope in the belief that the person they depend on can restore them to good health. While respecting autonomy is a very important part of health care, so is the ability to care and be dependable.

3.4 Myths about ethics

The media portray most ethical issues in highly charged terms, so it can be hard to understand what professional ethics is about, and what the full scope of ethical behaviour amounts to. In short, the media rarely explore the ‘grey’ areas of many ethical decisions. For example, the issue of abortion is viewed as either ‘pro choice’ or ‘pro life’. In this way the following myths about ethics are perpetrated.

3.4.1 Practitioners know intuitively what it means to act ethically

Many health practitioners claim they have never encountered an ethical dilemma during their practice. Is this credible, or does it suggest that some practitioners have an insufficiently developed awareness about what constitutes an ethical issue? How many people justify a hard decision simply by saying, ‘I did what felt right'? Gut instinct may currently guide practitioners through some of the complexities of therapeutic relationships, but this is not an adequate substitute for rigorous, reflective analysis of the ethical basis of the therapeutic encounter. Ethical deliberation attempts to make ethical decision making an explicit process, which can be externally evaluated, rather than relying on the intuitive or subjective views of practitioners. This is important because the practitioner's internal morality may be at odds with the user's values and wishes (for example, about abortion, recreational drug use, sexuality and lifestyle choices, or CAM therapies).

Paternalism arises when practitioners feel they know better than the users and impose their own views and values on the users. While there may be limited scope for benevolent paternalism within long-established caring relationships, many users state ‘dissatisfaction with medical paternalism’ as a reason for bypassing their doctor and choosing to see a CAM practitioner, precisely because they value being treated like equal partners in a therapeutic enterprise.

3.4.2 CAM practitioners are more ethical than conventional doctors

Proponents of CAM argue that because it is safer and has fewer side effects than conventional medicine, CAM practitioners must be inherently more ethical than doctors. This is a false argument in several respects. While CAM is generally very safe compared with some powerful conventional remedies (a point acknowledged in para. 4.21 of the House of Lords Report, 2000), all therapies can cause harm in unskilled hands. Some side effects of CAM are potentially serious, particularly if there is a clinical reason for not giving a user a form of treatment that the practitioner has not ascertained or lacks the medical knowledge to appreciate. For example, a CAM practitioner might give a remedy that increases the effect of a conventional drug that the user is also taking.

However, in terms of whether CAM practitioners are more ethical than doctors, ethical practice is not only about having necessary technical skills. Ethical practice requires appropriate knowledge, skills and attitudes, including the consideration of users' rights and values, being non-judgemental, developing listening skills, and delivering culturally sensitive care. All of these attributes need to be acquired during the process of professional training and/or apprenticeship. They are every bit as important as practitioners’ technical skills. To be a ‘good’ practitioner requires both technical skills and ethical awareness.

Every health profession has its share of unethical practitioners and CAM is no exception. Most CAM encounters involve a private practitioner seeing users either alone in his or her own home or behind closed doors in a clinic. Thus there may not be the collective responsibility found in a National Health Service setting. No one can look over a practitioner's shoulder all of the time. There is ample scope and opportunity for unethical practitioners to abuse their users' trust. Work in the UK with abused people suggests that abuse occurs across a range of CAM professions and that much poor practice currently goes unreported (POPAN, 2003). The absence of litigation against CAM practitioners is no indication of their propriety because of the practical and theoretical barriers to mounting a legal action. Unethical practice may only come to light in the aftermath of a dramatic legal case or disciplinary hearing which the media choose to report.

Also, despite the claim that CAM is patient-centred (that is, puts the user's views, wishes and needs at the heart of the therapeutic encounter), some CAM practitioners can be just as paternalistic as doctors, if not more so. As Cant and Sharma (1996, p. 12) observe, while commentators tend to focus on the liberating aspects of complementary medicine:

Complementary medicines have the capacity to be involved simultaneously in … both the increase and the decrease of dependence on therapeutic experts.

3.4.3 Respecting autonomy is the foremost ethical principle in health care

Some commentators believe the pendulum has swung so far in favour of respecting autonomy that it leaves little scope for users to be passive recipients of healing. The desire to make each user an active participant in their own healing process can make it hard, or even impossible, for a user to refuse to engage in active decision making, and leave the decision to the benevolent practitioner. In this case, the user may waive his or her rights, by choosing not to be kept informed about changes in their condition, or the results of tests, preferring to rely on the practitioner's clinical judgement.

In the present climate, users may feel they are weak if they fail to take an active role in their healing and that somehow it is wrong to depend on their practitioner. This is unfortunate because, as discussed earlier, some users prefer to be wholly passive or to surrender some of their autonomy in order to be cared for. Clearly, a balance has to be struck between users' autonomy and their desire for dependence at a time of already diminished autonomy.

3.4.4 Law imposes more stringent requirements than ethics

All health care practitioners, including those in CAM, must work within the laws of the country where they practise. Although the law does not always reflect what is considered ethical – indeed, ethical duties may be thought of as higher than legal duties – in most jurisdictions it ensures that practitioners are subject, at the very least, to minimal requirements vis-à-vis respect for users' dignity, user information, confidentiality, and maintaining professional boundaries.

However, the state has a crucial role in governing decisions about a range of ethical issues, such as what is permissible for in vitro fertilisation (IVF) and human embryology research. These matters are not decided solely by the medical establishment. Often, when there is very strong public opinion, the government introduces legislation to control health care practices (for example, prohibiting trade in human organs, or commercial surrogacy arrangements).

3.4.5 What can be agreed about ethics?

Even though every person has an idea about what acting ethically means, when faced with an ethically contentious problem, or when it is not clear what will bring about the best outcome, ‘good’ people will act in diverse, and often opposing, ways, while maintaining they are ‘doing the right thing’. While ordinary individuals also have ethical responsibilities to one another (for example, to tell the truth), the duties owed by professionals to their users go beyond everyday ethical responsibilities. For the reasons outlined above, users are in a uniquely vulnerable position when they are ill, which demands a higher standard of ethical propriety.

  • Professional ethics is about how responsible practitioners ought to act when faced with ethically contentious choices.

  • Practical ethics is about practitioners acting in an ethically appropriate way and being accountable for their actions.

It is worth reflecting on the idea that ordinary people are also accountable for their actions, in that they are held responsible for the outcome of their actions. A good example of this is acting within the law. When people seriously infringe the rules of society and break the law, they can be subjected to legal sanctions, such as a fine or even imprisonment. Mostly, though, people's decision to act ethically or not has little immediate comeback for them. It may affect how others think of them, but ordinary people are unlikely to be censured for acting unethically.

Health professionals are much more accountable for their actions because ethical duties form the foundation of their relationships with users. Infringements of those duties have serious consequences: for example, eroding the trust between users and practitioners. Accordingly, health professionals must be more accountable for their actions, because they have implicitly agreed to be bound by the rules and codes of their profession.

Accountability takes many forms, and practitioners are potentially answerable to their personal conscience, their professional body, an employment tribunal, or even a court of law. Being a practitioner is not easy. The freedom of health professionals to make choices goes hand in hand with being responsible for their consequences. The next activity shows how difficult these choices can be.

Activity ethical dilemmas
Timing: 1 hour 0 minutes

Consider the following three ethical dilemmas, which are drawn from real-life CAM practice. Each dilemma raises one or more of the ethical issues discussed so far in this extract. (To recap, they are respect for autonomy, a duty to benefit, a duty not to harm, respect for justice, and the concept of paternalism.) For each case, write a short paragraph saying what you would do if you were the practitioner. You do not need any technical knowledge to answer this. As you do this activity, try to take into account the aspects of good ethical practice that were discussed in Activity 9 ‘Acting ethically’.

  1. A chiropractor knows from past experience that if she explains to a user what the technique known as a high velocity thrust feels like before she applies it, the user will probably become tense and stiff. This would make it harder to do and possibly even dangerous for the user. Although the chiropractor was taught to explain in detail, she now acts first and explains later.

  2. A homoeopath treating a 14-year-old girl for recurrent urinary tract infection is concerned that the girl is being abused by her stepfather but is unsure whether this concern should be disclosed and, if so, to whom. The homoeopath asks the girl if she will agree to let him talk to her mother, but she adamantly refuses. What should the homoeopath do?

  3. A reflexologist suspects that the person he is treating has bowel cancer, but thinks the person's spirits will be damaged by disclosing bad news, so he keeps his opinion to himself. Although he is not a doctor, he is certain from his own one-year training that the user has cancer.

Discussion
  1. In this scenario the main ethical issue is paternalism. The chiropractor is trying to act in the user's best interests (the duty of beneficence) and not cause the user harm (the duty of non-maleficence). This is why the chiropractor withholds the information about applying a high velocity thrust. However, by withholding this information the chiropractor is overriding the user's autonomy in not giving full information about what is being done (or, in this case, about to be done) to their body. Note that the chiropractor has been taught to give detailed explanations. Providing adequate information is essential if a practitioner is to gain a user's consent to treatment. Note, also, that the chiropractor's motivation for withholding the information is well intentioned but none the less ethically objectionable, since it removes the user's decision-making ability (in this case, to say they would rather not be given a high velocity thrust).

  2. This case concerns both respect for autonomy and the duty of beneficence. The question is whether the homoeopath should respect the teenager's confidentiality as she insists. You may think that, if the teenager is old enough to consult the homoeopath and apparently give her consent to treatment, she is also old enough for her confidences to be respected. Respect for confidentiality is an aspect of respect for autonomy. A person being able to control who knows what about them is fundamental to their being in charge of their life. In UK law, a teenage or young person can consent to treatment as soon as they are sufficiently mature to understand fully what the treatment involves. However, at the same time, the homoeopath has a duty to benefit the user and a duty to protect from harm, which might be construed as a duty to report suspected abuse to the relevant authority. This case is an example of where ethical principles conflict. One solution might be for the homoeopath to persuade the young person to tell her mother. Certainly, the homoeopath ought to inform her whether he intends to disclose her personal information against her wishes. Remember, a paternalistic decision to go over the young person's head may be misguided. The homoeopath may not know all the facts and the decision to disclose these concerns could have unforeseen and bad consequences.

  3. This case is also about paternalism and raises additional questions about the reflexologist's competence, an issue that goes to the heart of the duty of beneficence and the duty of non-maleficence. The reflexologist is acting paternalistically in withholding a suspicion that the user has bowel cancer. To withhold a potentially serious diagnosis from someone is a clear breach of their autonomy, even if it is aimed at protecting them from distress. It assumes that the practitioner knows better than the user: in this case, that the user would rather not know they have cancer, than know and be able to make decisions accordingly. Nowadays, in conventional medicine, withholding a serious diagnosis is almost always seen as unwarranted paternalism. In addition, in this case the reflexologist may be inadequately trained to diagnose bowel cancer (especially on the basis of one year of training). Unless the reflexologist has the necessary training to diagnose cancer, he is exceeding his limit of competence. To give a user an unsubstantiated diagnosis is a clear example of causing the user harm, and breaching the duty of non-maleficence.

So, knowing what to do or taking the ‘correct’ course of action is not always straightforward. In each situation, practitioners have to weigh up conflicting ethical issues and make an ethical deliberation, deciding what is the best course of action, allowing for all the circumstances. Practitioners are accountable for the decisions reached, and so have to be able to justify why they acted in this way. In each scenario, the problem is an ethical dilemma and not a technical problem. Being a ‘moral agent’ (someone who makes ethical decisions) requires the practitioner to consider the interests and rights of all relevant parties, any applicable laws, professional duties or regulations that might apply, and the likely outcome or consequences of choosing one course of action over another. The examples highlight that sometimes all the available options are problematic, in which case the best solution is to follow the course of action that will result in the least harm.

However, it is important to bear in mind that ethical dilemmas have cross-cultural dimensions. The comments on the three scenarios in the activity ‘Ethical dilemmas’ reflect western values. These stress individual autonomy and the rights of individuals to determine their own fates. The prevailing cultural preference in the UK and the USA is to respect an individual's right to self-determination. Accordingly, when health professionals override a patient's autonomy, it is seen negatively. However, not all cultures in the UK stress the rights of the individual in the same way. Some groups think of the family or even the community as the relevant decision-making unit. Here, ethical values may be interpreted differently, and a greater weight may be given to acting beneficently than to respecting the person's autonomy.

3.5 The principles underlying ethical practice

Box 3 describes four principles that are central to an understanding of acting ethically.

Box 3 The principles of acting ethically

Principle one

Ethics is not solely about rare dramatic conflicts. It concerns all aspects of the therapeutic encounter, including the practitioner's competence, boundaries between the practitioner and patient, the patient's right to make decisions based on informed choices, respect for the patient's culture and values, and confidentiality. The fact that CAM rarely involves life or death decisions does not mean that there are fewer ethical issues in CAM therapeutic relationships [than in conventional health care relationships]. Any interaction with a patient (including a potential patient or a former patient) can give rise to ethical tensions.

Principle two

Ethical awareness is an ongoing process requiring active deliberation. Therapists can learn, through a process of reflection, how to apply a range of ethical theories to assist their decision-making and, indeed, have a moral duty to do so. Even though there may be no ‘right answer’ to a given dilemma, therapists have a moral responsibility to consider their options in the light of existing ethical theories, and to be sure that their decisions are ethically defensible and will stand up to external scrutiny. Since practitioners make most of their ethical decisions behind closed doors, practitioners must regulate their own conduct.

Principle three

Acting ethically requires a practitioner to be aware of all relevant professional codes and to know about any particular laws governing his or her sphere of practice, since these are additional mechanisms for regulating the individual therapist's conduct. The rules contained in codes of ethics represent standards of conduct which society expects professionals to follow. These may impose more onerous duties on health professionals than those which apply to ordinary members of the public, but to be a professional is a privilege, which confers both rights and responsibilities. The shortcomings of both ethical codes and law as a means of regulating the professional relationship make it all the more important that practitioners are aware of their ethical responsibilities, and become habituated to making good moral choices.

Principle four

Health care ethics involves benefiting patients and not causing them harm. Acting ethically requires practitioners to be aware of professional developments and research underpinning their therapy to ensure competence. It will rarely be ethical for practitioners to work in complete isolation from their professional colleagues and with little regard for developments in their field. In order to provide patients with a range of options, therapists should be aware of developments in health and social care generally.

(Source: Stone, 2002, pp. 37–8)

So far this extract has considered some of the principles underpinning the ethical decisions of individual practitioners. This is important because most health care encounters are between an individual practitioner and an individual user. Clearly, there also needs to be consensus within a profession about what constitutes acceptable professional standards. If not, individual practitioners could take arbitrary and inconsistent decisions, with different practitioners adopting very different notions of what they consider ethical. Stone (2002) highlights that individual practitioners must act within the norms of their profession, as well as work within the law. This is important if the ethical principle respect for justice is to be met. The next section shows how professional bodies set relevant professional standards, and provide mechanisms for what happens when things go wrong.

3.6 Ethical practice and accountability: the role and function of professional bodies

The UK's medical profession is regulated by the General Medical Council (GMC). One of the main ways in which the GMC, and other regulatory bodies, influences its members is through its code of ethics. This sets out broad principles, rather than detailed guidance, for how practitioners should behave in specific circumstances. This is necessary because a practitioner retains individual accountability and ultimate responsibility for decisions taken during professional practice. Not all breaches of an ethical code result in disciplinary action being taken against the practitioner. However, the most fundamental breaches can lead to a disciplinary hearing, in which the professional conduct committee can remove the practitioner's licence to practise. In this way, a code of ethics can be a deterrent: that is, practitioners follow its principles because otherwise they could be ‘struck off’.

A code of ethics is only one way of encouraging and promoting ethical practice. The functions of a regulatory body go much further than disseminating codes of ethics. Regulatory bodies need to set and enforce educational standards, keep a register of members, and have in place processes for practitioners whose performance is below par and rehabilitative procedures for those whose performance is marred by ill health. Many of these broader aspects of ethical practice can only be co-ordinated at a collective level if they are to protect users adequately, which is the key function of professional self-regulation. Box 4 summarises some of the main responsibilities of regulatory bodies.

Box 4 Functions of regulatory bodies

  • Determine educational requirements for safe and competent practice at pre- and post-registration levels.

  • Encourage research and professional development.

  • Set standards through codes of ethics and codes of practice.

  • Maintain and make available a register of members so that the public can distinguish regulated practitioners from unregulated practitioners.

  • Maintain professional disciplinary procedures so that unethical practitioners can be held accountable for their actions.

  • Have a complaints mechanism so that users' grievances can be heard and any appropriate reparation made.

  • Install mechanisms for dealing with practitioners who are unfit to practise through ill health.

  • Provide information to members of the profession, including information about the standards of care they should expect.

  • Provide information to members of the public and promote user self-awareness.

Professionals have a special ethical responsibility to other people. Being a professional involves rights (respect from others and considerable freedom over what to do and how to do it) but also responsibilities (to act in the user's best interests at all times, and to surrender personal values if they conflict with providing optimum care). However, health professionals work mostly in an unsupervised context because another advantage of working in a professional capacity is relative autonomy over their work. This means it is extremely important for individual practitioners to be motivated and taught how to act responsibly and professionally in their dealings with service users. Equally, ‘good’ professionals may hold very different moral views. What then is the role of professional ethics and how does it relate to personal morality?

In essence, professional ethics refers to the ethos, rules and principles underpinning professional practice. In joining a professional body and assuming a professional title, a practitioner expressly agrees to be bound by the rules of that profession. Professional codes of ethics set down many general rules about how practitioners are expected to behave. This is an important aspect of professional self-regulation because it means there is a recognised standard against which professional practice can be measured, and an explicit statement about the level of commitment and behaviour the public is entitled to expect. A code of ethics represents the ethos of any given profession. Stone (2002) describes a code of ethics as a synthesis of minimal legal requirements and statements of ethical ideals, backed up with professional statements that represent the shared political and economic ideals of that particular group.

Currently, the only CAM professions that are statutorily regulated in the UK are osteopathy and chiropractic. Each profession has established a body with very similar functions to the GMC. As with the GMC, the General Osteopathic Council and the General Chiropractic Council have the right to remove or suspend practitioners from their registers. However, the usefulness of any regulatory body depends on the extent to which it is willing to exercise its range of regulatory powers. A professional body which is consistently soft on its members, and allows little scope for lay input, will fall short of its duty to protect the public.

3.7 Ethical practice and accountability: individual practitioners’ responsibilities

The dynamics and working practices of many CAM practitioners mean the therapeutic encounters are rarely supervised and no one looks over the practitioner's shoulder. This places the responsibility to act ethically squarely with the individual practitioner. A European study of the practice of CAM states:

Ethical issues are just as pertinent for conventional and unconventional medicine, alike. The labelling of a therapy as natural does not provide an excuse for practitioners to set aside standards of behaviour and ethical practice that are expected of all who care for the well being of individuals.

(Research Council for Complementary Medicine, 1999)

Acting ethically means far more than following a code of ethics. Practitioners have individual ethical responsibilities towards their clients, and collective ethical responsibilities to foster and promote the ideals of the profession. This includes taking responsibility for the conduct of other practitioners, and exposing examples of misconduct or poor practice.

3.8 The centrality of consent

In the last 30 years there has been a strong move away from paternalism towards an emphasis on users' rights and involvement in the decision-making process. Nowadays, few users would accept treatment without knowing what it was or a health carer who withholds information about other treatment options. The importance of involving the user is exemplified by the need for practitioners to gain informed consent. This need to gain consent is enshrined in law, as well as being a central aspect of most professional codes of ethics. Competent users must be given a thorough explanation of what will be done, the risks involved in going ahead or not going ahead with the proposed treatment, and information about alternatives to the treatment. Therefore, the practitioner should have effective communication skills, because the information needs to be conveyed so that the user understands it. When giving consent, the user's decision must be voluntary and not subject to coercion. Failure to obtain consent is considered an extremely grave matter. If consent has not been obtained, and the user is harmed, they can sue the practitioner for medical negligence (for gaining inadequate consent). If the user has not been given any information or has been treated against their express wishes, they can sue the practitioner for battery (for not gaining consent at all). In addition, failure to gain consent can lead to disciplinary proceedings and the removal of the practitioner's right to practise.

So far, very few users have sued CAM practitioners, which is often attributed to CAM being more ‘patient-centred’. It is debatable what this means in terms of information exchange. CAM practitioners have the same duty to obtain consent to treatment as other health professionals (Stone, 2002).

3.9 Acting ethically: tools for analysis

Do the usual principles underpinning conventional health care ethics provide an adequate or acceptable framework for the discussion of ethics in the CAM relationship? Most bioethics teaching in medical schools in the UK and USA draws on the principles-based approach to considering ethical dilemmas. To recap, the four principles are:

  • respect for autonomy

  • the duty to benefit (beneficence)

  • the duty not to harm (non-maleficence)

  • respect for justice.

As well as principles, practitioners need to be aware of the three types of ethical theory. Ethical theories are ways of judging whether an action is right or wrong. Two of the main theories were touched on earlier in this chapter: they are duty-based ethics and consequence-based ethics. The third theory is virtue ethics. Some ethicists believe that the practitioner's moral character is the most important basis for making good ethical decisions. According to this theory the focus is less on the facts of the particular scenario and more on the moral qualities required of the ethical practitioner. Virtuous practitioners, they argue, are inclined to make right decisions.

The ethical theories are described in Box 5.

Box 5 The three ethical theories

1 Duty-based ethics

The duty-based theorist (or ‘deontologist’) believes that an action is ethically right to the extent that it conforms with rules or duties. This theory prioritises certain duties, most notably, the duty to respect people's autonomy by treating people not as a means to an end but as an end in themselves. Within this theory, when a duty is considered to be important, it must be applied in all situations, regardless of the outcome. If, for example, a practitioner has a duty to respect confidentiality, this duty must be applied absolutely, in all situations. A duty-based theorist would not consider it acceptable to breach confidentiality even where this is necessary to protect the life or wellbeing of a third party. In health care ethics, the professional duties set out in a code of ethics are considered to be an important source of duties which the practitioner must comply with. For the duty-based theorist, the four principles become ‘duties’ which the practitioner has to apply absolutely.

2 Outcome-based ethics

An outcome (or ‘consequence’) based theorist believes that an action is ethical to the extent that it brings about a good rather than a bad outcome. Put another way, an action is good to the extent that it maximises happiness and minimises suffering. You may have heard this theory described as the theory of ‘the greatest good for the greatest number, at the cost of the least suffering’. Unlike a duty-based theorist, an outcome theorist may sometimes override duties to an individual, if doing so would create a greater good. The outcome theorist is not compelled to apply a duty in the same way in every situation, if this would cause harm (for example, an outcome theorist might decide that it is ethically acceptable to breach the confidentiality of a sex offender who has threatened to attack a third party if breaching confidentiality will protect that person from harm). For the outcome-based theorist, the four principles provide a starting-point for moral deliberation, but a principle can be waived if its application would cause more harm than good. Since the outcome theorist judges an action to be right or wrong on the basis of anticipated risks or benefits, it is important to ascertain all relevant facts in advance.

3 Virtue ethics

Virtues are habituated character traits that predispose people to act in accordance with worthy goals and the role expected of them. Virtues include candour, fidelity, compassion, discernment and integrity. Virtues are an important component of ethical decision making:

Principles do not provide precise or specific guidelines for every conceivable set of circumstances. Principles require judgment, which in turn depends on character, moral discernment, and a person's sense of responsibility and accountability. Often what counts most in the moral life is not consistent adherence to principles and rules, but reliable character, moral good sense, and emotional responsiveness.

(Source: adapted from Beauchamp and Childress, 1994)

It is hard to quantify the extent to which any of these theories are applied in real-life situations. Generally, health practitioners are not expected to justify the basis for every decision they make. Motives are not usually questioned unless something has gone wrong. For this reason, it may not necessarily be known whether a decision was made because of the practitioner's assessment of risks and benefits (outcome-based decision making), or because of the practitioner's perceived sense of duty towards the parties involved (duty-based theory), or because of what sort of person the practitioner is (virtue-based decision making). Medical decision making is no different from the ethical decisions that ordinary people make in everyday life. Sometimes ethical decisions are made through gut instinct, although if scrutinised in greater detail, even gut instinct involves a complex interplay of ethical decision making. Few people would be happy if the basis of their decision making was questioned, and most people are defensive when asked to justify why they behaved in a certain way. Trainee practitioners may believe they will know intuitively what to do in an ethically contentious situation. This may make health care students reticent about being taught how to make ethical decisions formally. Some practitioners may regard any instruction in professional ethics as an affront to their own personal sense of morality and a slur on their sense of propriety. This is misguided, since the obligations health professionals owe to their users go beyond normal moral obligations. Whereas everyday life usually requires nothing more than common decency, the health care relationship requires practitioners to consider their users' best interests at all times. This involves respecting the wishes about treatment of users who can participate in the decision-making process and acting in the best interests of users who cannot give consent for themselves.

3.10 Difficulties in applying conventional bioethics to the CAM relationship

Much of the literature in bioethics views the doctor/patient relationship as the paradigmatic example of a health care encounter. Various assumptions are made about the roles of ‘good’ doctors and ‘good’ patients, gender, dominant cultural values, patient expectations and a shared (western) understanding of health and disease. These assumptions may not be shared by many CAM practitioners or, indeed, CAM patients. Can the language and constructs of bioethics be invoked in analysing CAM relationships? Bioethics is grounded in, and a product of, the dominant biomedical paradigm. Western values and western preoccupation with the rights of the individual underpin traditional discussions of what it means to be an ethical health practitioner.

(Stone, 2002, pp. ix–x)

In view of Stone's words, it may not make sense to apply conventional medical ethics to such diverse CAM practices as traditional Chinese medicine or shamanistic healing. If this is done uncritically, several problems emerge, including the following.

  • There is no reason to assume that the autonomy-focused ethics of western, liberal democracies should automatically provide the theoretical underpinnings for CAM, much of which is grounded in different, non-rational, non-scientific cosmologies.

  • The dynamics of the CAM therapeutic relationship may mean users are far more willing to trust their CAM practitioner than their conventional doctor and are less inclined to take a hostile, litigious approach if the therapy is unsuccessful. This requires an ethical framework that goes beyond the confines of most duty-based, professional codes of ethics and embraces the notion of mutual trust and mutual responsibility, in which users are active participants in their own healing process.

  • Much of the current debate about ethics concerns the use of hi-tech, orthodox medicine. The low-tech or relatively low-cost nature of CAM interventions raises fewer of these issues, although the therapeutic relationship may generate as many, if not more, ethical issues than the typical doctor–patient relationship.

  • Many aspects of CAM treatment are not evidence-based, so it may be very difficult to provide information, for example about known side effects, to users and to provide that information in the percentage terms preferred by law.

  • Not all users of CAM are ill. The ethics of preventive medicine and wellness maintenance may require a separate ethical approach. In conventional ethics, the duties of the practitioner derive specifically from the fact that the patient is ill and their autonomy and decision-making ability may be compromised. This may not be the case when the user seeks treatment to prevent ill health and to maximise their autonomy.

3.11 Key ethical issues for CAM practitioners

Although CAM practitioners’ duties may vary in nature from other health professionals’ duties, the types of ethical concern remain broadly similar. The rest of this extract considers the key ethical areas underpinning standards of best practice in CAM. Although CAM practice varies dramatically in scope, all the issues listed in Box 6 are central to ethical practice. Each one is considered further below.

Box 6 Key ethical issues

  • Competence

  • Research

  • Negotiation of contracts with users

  • Respect for autonomy and consent

  • Consent for children receiving CAM

  • Respect confidentiality

  • Maintain professional boundaries

  • Professional etiquette and whistleblowing

  • An effective complaints mechanism

3.12 Key ethical issues for CAM practitioners: competence

Practitioners must have a sufficient level of competence to benefit users. The proliferation of training bodies, and the diversity of qualifications available, make it harder to know what represents an appropriate standard of pre-registration training or continuing professional development (CPD). Bringing a therapy under a single regulatory body makes it easier to set national educational standards in which diversity can be maintained, but a basic level of competence to practise is ensured. A subsidiary factor is the extent to which CAM practitioners need to be aware of orthodox medicine, and vice versa. Given the extent to which users are increasingly integrating different therapeutic modalities in seeking health care, all practitioners need to understand the possible interactions between different treatments.

3.13 Key ethical issues for CAM practitioners: research

Every therapy needs to have a sound theory underpinning it. Without it, a therapy cannot grow and mature. Research may extend and improve the knowledge base for a given therapy but not all practitioners are willing or able to participate in useful, well designed research. The issues are related to the ethical principles of benefiting (beneficence) and not harming (non-maleficence). Without evidence to support the claims that are being made, how can practitioners be sure that they are doing good rather than doing harm? What is at issue are ethical questions that go to the heart of knowledge, and how competing knowledge systems are assessed. Several CAM therapies still adhere to the teachings of their founder. Their knowledge base is passed down through the generations, remaining true to original principles. Such therapies have not made the transition to a knowledge base that can be externally validated and modified in the light of new findings. It remains to be seen whether public support for such therapies will continue in these increasingly evidence-based times.

3.14 Key ethical issues for CAM practitioners: negotiation of contracts with users

To benefit users, the user and the practitioner must work towards common goals that have been explicitly discussed. It is especially important for the user to understand the limits of what the therapy can deliver and not be under any delusions about the likely extent of recovery. What should CAM practitioners tell users about the therapy and about themselves? Practitioners cannot assume that users know what their therapy entails. A useful starting point might be to give users an introduction to the therapy itself. The practitioner's responsibilities might also include:

  • to agree a fee per session (the first session can be more expensive because it takes much longer than future appointments)

  • to discuss how many sessions to have before progress is reviewed

  • to indicate how long therapy is likely to continue

  • to give users a copy of the notes at the end of the treatment so they can use them in the future when pursuing other or further therapies.

If the user is expected to contribute materially to the success of the therapy by exercising self-responsibility and following the practitioner's recommendations about diet and exercise, this should be made clear to them at the start of the therapy.

The user's responsibilities include:

  • to attend appointments

  • to follow reasonable advice given by the practitioner

  • to show courtesy and respect for the practitioner as an individual

  • to pay promptly for all therapy sessions (including cancelled sessions if this was agreed).

3.15 Key ethical issues for CAM practitioners: respect for autonomy and consent

Many practitioners claim that the patient-centred nature of their therapy means they automatically respect the user's autonomy. On closer inspection, CAM practitioners’ commitment to respecting the users' wishes and values may be less patient-centred than they would like users to believe. Some CAM practitioners may fail to acknowledge users' rights, particularly in the area of risk disclosure and gaining consent to treat, or even touch, the user. Some CAM practitioners mistakenly believe that the mere fact the user has consulted them counts as implied consent and that it is not necessary to seek any further consent. Many health professionals (both conventional and CAM) also mistakenly think that the primary function of obtaining consent is to stop them from being sued. Some CAM practitioners assume that, because hardly any practitioners are sued, their users do not need to give express consent, even to invasive and potentially dangerous procedures.

As a matter of ethics and law, consent requirements include giving users adequate information, ensuring that they are competent to consent, and making sure the decision is voluntary. Ernst (1996) argues that, if the practitioner does not have evidence about risks and side effects, it is not possible to gain consent. Certainly, not all therapies have the sort of scientific evidence necessary to give a meaningful risk:benefit ratio. Then again, many of the procedures that users consent to in conventional medicine are only just starting to be evaluated scientifically.

Stone (2002) argues that a better interpretation of the information requirement is to provide as much information as the user feels is necessary to make an informed decision. This fits in with the consent process being fundamentally about enhancing and facilitating a user's autonomy, including the absolute right of competent people to make decisions for themselves that others would regard as foolhardy. It is, arguably, a user's right as an autonomous agent to deliberately choose a therapeutic modality that has not been scientifically validated to give risk:benefit ratios with any precision or to identify the full range of possible side effects. By moving outside a more empirically researched, reductionist framework, users must accept that the risks and benefits will be expressed within the paradigmatic framework of that therapy only.

3.16 Key ethical issues for CAM practitioners: consent for children receiving CAM

Growing numbers of parents seek CAM for their children, as witnessed by the development of paediatric specialities in some CAM therapies, such as neonatal and paediatric osteopathy. A key ethical issue is that, in the UK, as in other jurisdictions, parents are entrusted to act as proxy decision makers for their children's health decisions until they can make their own choices. Parents are bound by law to make decisions in their children's best interests. Although most CAM therapies are relatively safe and have few side effects, there may not be evidence to establish that the treatment is in the child's best interests, which is the supposed requirement of any treatment. In the UK there is an additional factor: the Children and Young Persons Act 1933 requires parents to provide ‘medical aid’ for their children. It has never been definitively tested whether this means parents should seek conventional medical treatment before seeking CAM, or should seek only conventional medicine when their child is seriously ill.

Significantly, the civil liberties aspect of parents’ right to prefer CAM over conventional medicine has not been adequately discussed. Since the courts are likely to adopt a more restrictive attitude than a liberal stance when a child's welfare is at stake, extra care is needed in making decisions for those who cannot decide for themselves. It is always wise for a practitioner to seek parental consent for immature minors and to explore the least risky therapeutic options first. The same cautious stance should be taken with a person who cannot give informed consent. In the case of an incompetent adult, nobody can consent to medical treatment (including CAM) on their behalf.

3.17 Key ethical issues for CAM practitioners: respect confidentiality

During their professional practice, practitioners will be told a lot of personal information about their clients. This information is imparted in the context of a trusting relationship in which users trust that the information they have conveyed will be used only in their best interests and divulged only with their consent. The duty to respect users' confidentiality flows from the duty to respect their autonomy. People cannot make their own choices and control their lives if they cannot control who has access to personal health information about them. While regulated health care practitioners (including osteopaths and chiropractors) are statutorily bound to comply with data protection legislation, all practitioners must regard their ethical duty to respect client information as central and should safeguard users' medical notes accordingly. However, the duty of confidentiality is not absolute and most codes of ethics recognise various exceptions to the duty of confidentiality, most notably when disclosure is required to protect third parties, or is in the public interest, or is required by a court of law. Practitioners need to make it clear that they cannot offer an absolute duty of confidentiality and they should discuss any proposed disclosure with the user.

In particular, CAM practitioners should not contact a user's general practitioner without that person's consent.

3.18 Key ethical issues for CAM practitioners: maintain professional boundaries

All practitioners have a duty to create and maintain safe boundaries, irrespective of their therapeutic orientation, training or individual way of practising. The therapeutic relationship is based on trust and practitioners must never exploit users for their own ends. Practitioners should be aware that they may be working with users who have difficulty respecting boundaries, whether emotional, sexual or financial. Practitioners also need to be very clear about making their own boundaries explicit. While CAM practitioners are not necessarily more likely to abuse than any other health professionals, the context in which CAM is often delivered may increase the potential for abuse. Practitioners who work from home or see people in their houses should be particularly sensitive to this issue, and take whatever precautions are necessary to avoid any possible misunderstandings that might lead to an allegation of professional abuse.

3.19 Key ethical issues for CAM practitioners: professional etiquette and whistleblowing

In the past, professional bodies cautioned their members against disparaging other members of the same profession in front of a user. In the UK many codes of ethics still discuss professional etiquette from the perspective of safeguarding the interests of the practitioner rather than the user. Sensitivity is required when treating a user who is dissatisfied with a previous practitioner, but this should not prevent a practitioner being critical of someone else's obviously unacceptable treatment or behaviour. All practitioners have a duty to protect users. This may impose positive duties on practitioners to help users access complaints mechanisms if appropriate.

3.20 Key ethical issues for CAM practitioners: an effective complaints mechanism

Effective relationships require strong communication skills. A good therapeutic relationship allows users the space and security to air their dissatisfaction without recourse to an external body. However, not all users enjoy such open relationships with their practitioners and may prefer to end the relationship than voice a complaint. This is why it is crucial for professional bodies to have accessible and user-centred complaints mechanisms in place. Complaints panels must include a significant lay presence to avoid professionals in disciplinary contexts from being ‘soft on their own’ (or being perceived as such). Where a therapy has several registering bodies, it is constructive for the various disciplinary boards to institute reciprocal arrangements, so that a practitioner who has been prevented from practising cannot simply apply to join another professional register.

3.21 Conclusion

This extract has shown that CAM practice raises a variety of ethical issues. Although ethical considerations have different dimensions when applied to CAM, this extract demonstrated that ethical issues – such as consent, competence, boundaries and effective communication – remain central to good practice. CAM practitioners, like all other responsible health care workers, must be taught and encouraged to recognise the ethical dimensions of their work. All practitioners must be accountable for their own actions. Non-affiliated practitioners may escape accountability to a professional body, but they remain accountable to their users and to their own ethical standards. Professional codes of ethics are only a partial basis for ethical practice, but they may prove to be too vague for use in specific situations. As well as having ethical responsibilities, all practitioners must work within the law. They must be up to date with the law on informed consent, confidentiality and data protection, as well as provisions affecting their specific sphere of practice. Practitioners need to understand both the legal and the ethical implications of their duty of care and to remember that the privileges of being a professional depend on honouring and upholding the values and ethics of the profession.

Key points

  • Ethics is as important to the CAM relationship as it is to health care relationships within orthodox medical practice.

  • Western bioethics prioritises respect for autonomy over the duty of beneficence. This is demonstrated by the requirement to obtain explicit consent. Respect for autonomy is important to CAM practitioners and users, although the duty of beneficence also underpins CAM relationships.

  • The professional relationship is a relationship of trust, which confers rights and responsibilities. Autonomous practitioners are accountable to their users, themselves, their professional body, their employers and society.

  • Codes of ethics and conduct give basic guidance on what counts as ethical practice, but they must be supplemented by professional judgement.

  • Sometimes ethical responsibilities for health care workers, including CAM practitioners, are more stringent than legal requirements.

3.22 Extract 3 References

Beauchamp, T. and Childress, J. (1994) Principles of Biomedical Ethics (4th edition), Oxford, Oxford University Press.

Cant, S. and Sharma, U. (eds) (1996) Complementary and Alternative Medicines: Knowledge in Practice, London, Free Association Books Ltd.

Department of Health (2001) The Expert Patient: A New Approach to Chronic Disease Management for the 21 st Century, London, DoH.

Ernst, E. (1996) ‘The ethics of complementary medicine’, Journal of Medical Ethics , Vol. 22, pp. 197–8.

House of Lords (2000) Complementary and Alternative Medicine, London, The Stationery Office[accessed 9 January 2008].

POPAN (2003) Response to Sexual Offences Bill (HL) 2003 [online], www.popan.org.uk/policy/lb01.htm [accessed 4 December 2003 – page no longer available].

Research Council for Complementary Medicine (1999) Final Report of the European Commission Sponsored COST Project on Unconventional Medicine [online], [accessed 9 January 2008].

Stone, J. (2002) An Ethical Framework for Complementary and Alternative Therapists, London, Routledge.

Acknowledgements

This unit is taken from Perspectives on Complementary and Alternative Medicine (Course Reader) which forms part of the core text for the Open University course K221 Perspectives on Complementary and Alternative Medicine, (eds Tom Heller, Geraldine Lee-Treweek, Jeanne Katz, Julie Stone and Sue Spurr) (The Open University) published by Routledge, Taylor and Francis in association with The Open University. Copyright © The Open University 2005.

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.

Grateful acknowledgement is made to the following sources for permission to reproduce material in this unit:

Figure 1 Sally and Richard Greenhill;

Figure 2 Science Photo Library;

Figure 3 Courtesy of Hay House, Inc.;

Figure 4 The Wellcome Trust.

John Haynes: [Details correct as of 15th January 2008]

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