Prime Example: The True Story of the Case that Saved Alternative Medicine in New York State

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Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical ethics have been in use for centuries. Similarly, considerations of respect for persons and for justice have been present in the development of societies from the earliest times.

However, specifically in regard to ethical decisions in medicine, in Tom Beauchamp and James Childress published the first edition of Principles of Biomedical Ethics, now in its seventh edition , popularizing the use of principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect for persons, beneficence, and justice were identified as guidelines for responsible research using human subjects in the Belmont Report Thus, in both clinical medicine and in scientific research it is generally held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.

Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear application.

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For example, the notion that the physician "ought not to harm" any patient is on its face convincing to most people. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity to make an informed choice about his or her care.

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Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness, an important concept in the light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and medications. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration.

Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery.

Further, we are willing to put this working hypothesis to the test of rational discourse, believing that other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and benefits becomes an essential component of the reasoning process in applying the principles. In other words, in the face of no other competing claims, we have a duty to uphold each of these principles a prima facie duty. However, in the actual situation , we must balance the demands of these principles by determining which carries more weight in the particular case.

Ross, claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's actual duty is determined by weighing and balancing all competing prima facie duties in any particular case Frankena, Since principles are empty of content the application of the principle comes into focus through understanding the unique features and facts that provide the context for the case.

Therefore, obtaining the relevant and accurate facts is an essential component of this approach to decision making. Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress , include the:. Respect for Autonomy Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act.

See also Informed Consent. Case 1 In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of that person.

For example, Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed. The consequences of refusing a blood transfusion must be made clear to the patient at risk of dying from blood loss. Desiring to "benefit" the patient, the physician may strongly want to provide a blood transfusion, believing it to be a clear "medical benefit. Discussion In analyzing the above case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit.

In this case, informed by community practice and the provisions of the law for the free exercise of one's religion, the physician gave greater priority to the respect for patient autonomy than to other duties. By contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse permission for a life saving blood transfusion, in the State of Washington and other states as well, there is legal precedence for overriding the parent's wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently.

Thus, in the case of the vulnerable minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers McCormick, See Parental Decision Making.

They quoted one of these scientists, Steven Salzberg , a genome researcher and computational biologist at the University of Maryland, as saying "One of our concerns is that NIH is funding pseudoscience. Writers such as Carl Sagan , a noted astrophysicist, advocate of scientific skepticism and the author of The Demon-Haunted World: Science as a Candle in the Dark , have lambasted the lack of empirical evidence to support the existence of the putative energy fields on which these therapies are predicated.

Sampson has also pointed out that CAM tolerated contradiction without thorough reason and experiment. Some critics of alternative medicine are focused upon health fraud, misinformation, and quackery as public health problems, notably Wallace Sampson and Paul Kurtz founders of Scientific Review of Alternative Medicine and Stephen Barrett , co-founder of The National Council Against Health Fraud and webmaster of Quackwatch. Many alternative medical treatments are not patentable , [ citation needed ] which may lead to less research funding from the private sector. English evolutionary biologist Richard Dawkins , in his book A Devil's Chaplain , defined alternative medicine as a "set of practices that cannot be tested, refuse to be tested, or consistently fail tests.

CAM is also often less regulated than conventional medicine. According to two writers, Wallace Sampson and K. Butler, marketing is part of the training required in alternative medicine, and propaganda methods in alternative medicine have been traced back to those used by Hitler and Goebels in their promotion of pseudoscience in medicine.

In November Edzard Ernst stated that the "level of misinformation about alternative medicine has now reached the point where it has become dangerous and unethical. So far, alternative medicine has remained an ethics-free zone. It is time to change this. Some commentators have said that special consideration must be given to the issue of conflicts of interest in alternative medicine.

Edzard Ernst has said that most researchers into alternative medicine are at risk of "unidirectional bias" because of a generally uncritical belief in their chosen subject. Christian laying on of hands , prayer intervention, and faith healing. Indian Ayurvedic medicine includes a belief that the spiritual balance of mind influences disease.

Traditional medicines in Madagascar. Shaman healer in Sonora, Mexico. There was, nevertheless, evidence that both real acupuncture and sham acupuncture were more effective than no treatment, and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain. In the Senate Appropriations Committee responsible for funding the National Institutes of Health NIH declared itself "not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices.

From Wikipedia, the free encyclopedia. This is the latest accepted revision , reviewed on 18 September Quackery and Traditional medicine. How alternative treatments "work": The conviction makes them more likely to get better. This decreases the likelihood standard treatment will work, while the placebo effect of the "alternative" remains.

This can both cause worse effect, but also decreased or even increased side effects, which may be interpreted as "helping". Researchers such as epidemiologists , clinical statisticians and pharmacologists use clinical trials to tease out such effects, allowing doctors to offer only that which has been shown to work. Alternative medicine Quackery Health fraud History of alternative medicine Rise of modern medicine Pseudoscience Pseudomedicine Antiscience Skepticism Skeptical movement. Fringe medicine and science. Alternative medical systems Mind—body intervention Biologically-based therapy Manipulative methods Energy therapy.

This section needs expansion. You can help by adding to it. History of alternative medicine. Regulation of alternative medicine and Regulation and prevalence of homeopathy. List of herbs with known adverse effects. Assorted dried plant and animal parts used in traditional Chinese medicine. CAM includes such resources perceived by their users as associated with positive health outcomes.

There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work Most of these practices are used together with conventional therapies and therefore have been called complementary to distinguish them from alternative practices, those used as a substitute for standard care. Until a decade ago or so, "complementary and alternative medicine" could be defined as practices that are neither taught in medical schools nor reimbursed, but this definition is no longer workable, since medical students increasingly seek and receive some instruction about complementary health practices, and some practices are reimbursed by third-party payers.

Another definition, practices that lack an evidence base, is also not useful, since there is a growing body of research on some of these modalities, and some aspects of standard care do not have a strong evidence base. Although the Commissioners support the provision of the most accurate information about the state of the science of all CAM modalities, they believe that it is premature to advocate the wide implementation and reimbursement of CAM modalities that are yet unproven.

Alternative Medicine in America said, "By the mids, the notion that some alternative therapies could be complementary to conventional medicine began to change the status of The 21st century is witnessing yet another terminological innovation, in which CAM and conventional medicine are becoming integrative. British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care".

Ludmerer noted in By scientific method, he meant testing ideas with well-planned experiments to establish accurate facts. The clinician's diagnosis was equivalent to the scientist's hypothesis: Flexner argued that mastery of the scientific method of problem solving was the key for physicians to manage medical uncertainty and to practice in the most cost-effective way.

Public Attitudes and Public Understanding, Section: Belief in Alternative Medicine".

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Science and Engineering Indicators. Archived from the original on New England Journal of Medicine. Annals of the New York Academy of Sciences.

Pseudoscience and the Paranormal 2nd ed. Medical Journal of Australia. Canadian Medical Association Journal. National Center for Complementary and Integrative Health. Extracted from WHO Sointu , pp. John Wiley and Sons. A Theoretical Elaboration and Empirical Test".

Doctrine of Double Effect

Israel Journal of Health Policy Research. Archived from the original on 10 May Retrieved 6 June US Government Printing Office. Uses authors parameter link Chapter 2 archived Journal of the Royal Society of Medicine. Complementary medicine, defined as health care which lies for the most part outside the mainstream of conventional medicine. Journal of Cancer Research and Clinical Oncology. Journal of Pain and Symptom Management.

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National Center for Complementary and Alternative Medicine. Medicine, Health Care, and Philosophy. Retrieved 25 October A brief history of alternative medicine in America". Retrieved 25 Dec Oxford English Dictionary 3rd ed. Subscription or UK public library membership required. Archived PDF from the original on 26 September Archived from the original on 20 April National Council Against Health Fraud. Annals of Internal Medicine. Do You Believe in Magic?: The Sense and Nonsense of Alternative Medicine. IOM Report , p. The Skeptics Dictionary Online ed.

What's In a Name? In Callahan , p. Quoted in IOM Report , p. Alternative Medicine in Britain. Science and Technology Committee , Chapter 1: American Journal of Health Promotion. Alternative Therapies in Health and Medicine. This article incorporates text from this source, which is in the public domain. A United Kingdom survey of infertility patients".

Roberti di Sarsina, P. The contribution of CAM to healthcare and healthgenesis". Evidence-based Complementary and Alternative Medicine. International Seminars in Surgical Oncology. Ethics and Epistemology Converge". In Callahan , pp. Journal of Clinical Gastroenterology. How strong is the evidence? How clear are the conclusions? What it is and what it isn't". Archived from the original PDF on University of Maryland website.

An Evidence-based Guide to Practice. J Altern Complement Med. Archived from the original on 3 April Retrieved 20 Nov British Journal of Clinical Pharmacology. Science and Technology Committee 22 February HC 45, Fourth Report of Session — Comparative study of placebo-controlled trials of homoeopathy and allopathy", The Lancet , Sex and Herbs and Birth Control: Women and Fertility Regulation Through the Ages.

Explicit use of et al. Committee for Skeptical Inquiry. Cambridge and New York: Tongue Diagnosis in Chinese Medicine. Indian Journal of History of Science. Putting the house in order" PDF. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Ancient Superstition, Not Ancient Wisdom". Retrieved 1 February International Journal of Occupational and Environmental Health. Probably the most commercially successful and widely used branch of alternative or complementary medicine is 'phytotherapy'.

These are the tablets, powders and elixirs, otherwise known as herbal medicine, that are sold in most countries, through health shops and pharmacies as 'nutritional supplements' Only a tiny minority of these remedies have been shown to have mild-to moderately beneficial health effects So why are affluent, otherwise rational, highly educated people for this is the average user profile so hungry for phytotherapy? Equally, what's so safe about consuming substances that need meet no standards of contents?

National Center for Complementary and Integrative Medicine. Retrieved 4 June The belief that palliative care hastens death is counter to the experience of physicians with the most experience in this area. The appropriate conclusion, then, is that double effect plays no role whatsoever in justifying the use of opioid drugs for pain relief in the context of palliative care. Why is double effect so frequently mentioned in discussions of pain relief in the context of palliative care if its application rests on and thereby perpetuates a medical myth?

The popularity and intuitive appeal of this alleged illustration of double effect may have two sources. First, the point of mentioning the permissible hastening of death as a merely foreseen side effect may be to contrast it with what is deemed morally impermissible: Second, the myth that pain relief hastens death might have persisted and perpetuated itself because it expresses the compassionate thought behind the second assumption: Yet even this apparently compassionate assumption may be unduly paternalistic. Patients receiving palliative care whose pain can be adequately treated with opioid drugs may well value additional days, hours or minutes of life.

It is unjustified to assume that the hastening of death is itself a form of merciful relief for patients with terminal illnesses and not a regrettable side effect to be minimized. Recall that the most plausible formulations of double effect would require agents to seek to minimize or avoid the merely foreseen harms that they cause as side effects. On this point, popular understandings of double effect, with the second assumption in place, may diverge from the most defensible version of the principle.

Some members of the U. Supreme Court invoked double effect as a justification for the administration of pain-relieving drugs to patients receiving palliative care and also as a justification for the practice known as terminal sedation in which sedative drugs are administered to patients with intractable and untreatable pain in order to induce unconsciousness Vacco et al. If artificial hydration and nutrition are not provided, sedation undertaken to deal with intractable pain may well hasten death. If death is immediately imminent, then the absence of hydration and nutrition may not affect the time of death.

The most plausible and defensible version of the principle of double effect requires that the harmful side effect be minimized, so the principle of double effect provides no justification for withholding hydration and nutrition in cases in which death is not immediately imminent. The decision to withhold hydration and nutrition seems to depend on a judgment that death would not be a harm to the patient who has been sedated. In circumstances in which it would not be a harm to cause a person's death, the principle of double effect does not apply.

Terminal or full sedation is a response to intractable pain in patients suffering from terminal illness. It involves bringing about a set of conditions sedation, unconsciousness, the absence of hydration and nutrition that together might have the effect of hastening death if death is not already imminent. In any case, these conditions make death inevitable. Two important moral issues arise concerning this practice.

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First, is terminal sedation appropriate if it is necessary to relieve intractable pain in patients diagnosed with a terminal illness, even if death is not imminent? This is what Cellarius calls early terminal sedation because it does not satisfy the requirement that death is imminent that is typically cited as a condition of the permissibility of terminal sedation.

Early terminal sedation could be expected to hasten death as a side effect of providing palliative care for unusually recalcitrant pain. A second issue concerns the moral significance of the fact that once sedation has occurred, death is inevitable either because it was imminent already or because the withholding of nutrition and hydration has made it inevitable. Would it be permissible to increase the level of sedation foreseeing that this would hasten the death that is now inevitable?

Traditional applications of the principle of double effect rest on the assumption that the death of an innocent human being may never be brought about intentionally and would rule against such an action. Yet the assumptions that inform the popular understanding of double effect — that the physician's guiding intention is to relieve pain, that the hastening of death would not be unwelcome in these very specific circumstances, and that this course of action should be distinguished from a case of active euthanasia that is not prompted by the duty to relieve pain — might seem to count in favor of it.

It may obscure rather than clarify discussion of these situations to view the principle of double effect as a clear guideline. In this discussion, as in many others, the principle of double effect may serve more as a framework for announcing moral constraints on decisions that involve causing death regretfully than as a way of determining the precise content of those decisions and the judgments that justify them. Aquinas, Saint Thomas consequentialism doing vs. Formulations of the principle of double effect 2.

One principle or many loosely related exceptions? Formulations of the principle of double effect Thomas Aquinas is credited with introducing the principle of double effect in his discussion of the permissibility of self-defense in the Summa Theologica II-II, Qu. The New Catholic Encyclopedia provides four conditions for the application of the principle of double effect: The act itself must be morally good or at least indifferent. The agent may not positively will the bad effect but may permit it.

If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary. The good effect must flow from the action at least as immediately in the order of causality, though not necessarily in the order of time as the bad effect.

In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed. The conditions provided by Joseph Mangan include the explicit requirement that the bad effect not be intended: A person may licitly perform an action that he foresees will produce a good effect and a bad effect provided that four conditions are verified at one and the same time: Applications Many morally reflective people have been persuaded that something along the lines of double effect must be correct.

No doubt this is because at least some of the examples cited as illustrations of DE have considerable intuitive appeal: The terror bomber aims to bring about civilian deaths in order to weaken the resolve of the enemy: The tactical bomber aims at military targets while foreseeing that bombing such targets will cause civilian deaths. When his bombs kill civilians this is a foreseen but unintended consequence of his actions.

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Even if it is equally certain that the two bombers will cause the same number of civilian deaths, terror bombing is impermissible while tactical bombing is permissible. A doctor who intends to hasten the death of a terminally ill patient by injecting a large dose of morphine would act impermissibly because he intends to bring about the patient's death. However, a doctor who intended to relieve the patient's pain with that same dose and merely foresaw the hastening of the patient's death would act permissibly.

The mistaken assumption that the use of opioid drugs for pain relief tends to hasten death is discussed below in section 5. A doctor who believed that abortion was wrong, even in order to save the mother's life, might nevertheless consistently believe that it would be permissible to perform a hysterectomy on a pregnant woman with cancer. In carrying out the hysterectomy, the doctor would aim to save the woman's life while merely foreseeing the death of the fetus.

Performing an abortion, by contrast, would involve intending to kill the fetus as a means to saving the mother. To kill a person whom you know to be plotting to kill you would be impermissible because it would be a case of intentional killing; however, to strike in self-defense against an aggressor is permissible, even if one foresees that the blow by which one defends oneself will be fatal.

It would be wrong to throw someone into the path of a runaway trolley in order to stop it and keep it from hitting five people on the track ahead; that would involve intending harm to the one as a means of saving the five. But it would be permissible to divert a runaway trolley onto a track holding one and away from a track holding five: Sacrificing one's own life in order to save the lives of others can be distinguished from suicide by characterizing the agent's intention: Misinterpretations Does the principle of double effect play the important explanatory role that has been claimed for it?

Criticisms Those who defend the principle of double effect often assume that their opponents deny that an agent's intentions, motives, and attitudes are important factors in determining the permissibility of a course of action. They also include protections denied to minimize harm to civilians: End of Life Decision-Making The principle of double effect is often mentioned in discussions of what is known as palliative care, medical care for patients with terminal illness in need of pain relief.

Three assumptions often operate in the background of these discussions: The side effect of hastening death is an inevitable or at least likely result of the administration of opioid drugs in order to relieve pain. The hastening of death is a not unwelcome side effect of providing pain relief in the context of palliative care. It would be impermissible to hasten death intentionally in order to cut short the suffering of a terminally ill patient.

Bibliography Anscombe, Elizabeth, American Catholic Philosophical Association, pp. Aquinas, Thomas 13 th c.