Many Patients Use Complementary and Alternative Medicine. For Their Dermatologists, That Presents Knotty Ethical Issues

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Patient autonomy needs to be balanced with an obligation to educate patients about the risk and benefits of the complementary and alternative medicine treatments, say the authors of an article in the Journal of the American Academy of Dermatology.

Many people choose to use complementary and alternative medicines (CAM) for skin diseases. They may find a “natural” remedy more appealing than conventional medications — and a good deal less expensive. Perhaps conventional medication hasn’t worked very well or has serious side effects. CAM for skin diseases may seem like a safer bet than CAM for cancer or heart disease.

Regardless of the reasons, the use of CAM medication poses a welter of ethical issues for dermatologists. A preprint article posted in the Journal of the American Academy of Dermatology (JAAD) last week discussed some of them.

The authors, Akash Rau of Michigan State University College of Human and Jane M. Grant-Kels, M.D., of the University of Connecticut School of Medicine, note the large proportion of dermatology patients who use CAM for skin conditions, citing survey results published in JAAD and elsewhere: 41% of patients with psoriasis, a similar percentage of those with eczema and large numbers of patients with alopecia areata.

Some CAM treatments are ineffective and a waste of money but do no harm. Rau and Grant-Kels observed, though, that other may exacerbate skin conditions. There is also the possibility of interaction with conventional prescription medicines.

As for the ethical issues, Rau and Grant-Kels said dermatologists run the risk of maleficence. Patients have autonomy to try CAM treatments, they wrote, but physicians are ethically obliged to research the treatments and to educate patients about the evidence for the risk and benefits.

Rau and Grant-Kels caution against rejecting CAM treatments without due diligence. Doing so, they said, could negatively affect dermatologists’ relationships with their patients.

But they also argue for “truthfulness” when there is a lack of research and uncertain efficacy of CAM, so “patients can make the best decision for themselves. "They also invoke the principle of beneficence, or doing what is best for the patient, noting that “CAM may be the only treatment option left for patients who have exhausted options for current prescriptions treatments.”

Social media is likely to result in more, not less, use of CAM, observed Rau and Grant-Kels, who held out some hope for FDA assessing the safety and efficacy of CAM treatment and pointed to the National Institute of Health’s National Center for Complementary and Integrative Health website as “useful resource.” They note, though, that the “purveyors of CAM may not have a strong interest in pursuing FDA approval as it is expensive and if their product does not withstand rigorous testing, they no longer have plausible deniability.” More research needs to be done before CAM can be recommended, wrote Rau and Grant-Kels.

In the meantime, they called for understanding and communication as a way to "dismantle misinformation and spare many from risks associated with CAM."

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