Joan M. Gilmour

Pediatric Use of Complementary Therapies: Ethical and Policy Choices

Objective. Many pediatricians and parents are beginning to integrate use of complementary and alternative medical (CAM) therapies with conventional care. This article addresses ethical and policy issues involving parental choices of CAM therapies for their children. Methods. We conducted a literature search to assess existing law involving parental choice of CAM therapies for their children. We also selected a convenience sample of 18 states of varying sizes and geographic locations. In each state, we inquired within the Department of Health and Human Services whether staff were aware of (1) any internal policies concerning these issues or (2) any cases in the previous 5 years in which either (a) the state initiated proceedings against parents for using CAM therapies for their children or (b) the department received telephone calls or other information reporting abuse and neglect in this domain. We asked the American Academy of Pediatrics and the leading CAM professional organizations concerning any relevant, reported cases. Results. Of the 18 state Departments of Health and Human Services departments surveyed, 6 reported being aware of cases in the previous 5 years. Of 9 reported cases in these 6 states, 3 involved restrictive dietary practices (eg, limiting children variously to a watermelon or raw foods diet), 1 involved dietary supplements, 3 involved children with terminal cancer, and 2 involved religious practices rather than CAM per se. None of the professional organizations surveyed had initiated proceedings or received telephone calls regarding abuse or neglect concerning parental use of CAM therapies. Conclusions. Pediatric use of CAM therapies raises complex issues. Clinicians, hospitals, state agencies, courts, and professional organizations may benefit from a policy framework to help guide decision making.

Childhood Immunization: When Physicians and Parents Disagree

Persistent fears about the safety and efficacy of vaccines, and whether immunization programs are still needed, have led a significant minority of parents to refuse vaccination. Are parents within their rights when refusing to consent to vaccination? How ought physicians respond? Focusing on routine childhood immunization, we consider the ethical, legal, and clinical issues raised by 3 aspects of parental vaccine refusal: (1) physician counseling; (2) parental decision-making; and (3) continuing the physician-patient relationship despite disagreement. We also suggest initiatives that could increase confidence in immunization programs.

Opening the Door to Complementary and Alternative Medicine: Self-Regulation in Ontario

This paper examines the steps that three complementary and alternative medicine (CAM) groups - naturopaths, acupuncturists/traditional Chinese medicine practitioners, and homeopaths - are taking to achieve statutory self-regulation in the province of Ontario. The regulatory framework created by the Regulated Health Professions Act of 1991 is outlined, and the differing approaches taken by each of the three groups to gain inclusion under its umbrella are compared and contrasted. The paper assesses the influence of current regulatory and socio-political environments, and queries the extent to which the paradigms of health and health care of these different groups can be accommodated in a regulatory regime heavily reliant on the conventional medical model.

Complementary and Alternative Medicine Practitioners' Standard of Care: Responsibilities to Patients and Parents

In this article we explain (1) the standard of care that health care providers must meet and (2) how these principles apply to complementary and alternative medicine practitioners. The scenario describes a 14-year-old boy who is experiencing back pain and whose chiropractor performed spinal manipulation but did not recognize or take steps to rule out serious underlying disease—in this case, testicular cancer—either initially or when the patients condition continued to deteriorate despite treatment. We use chiropractic care for a patient with a sore back as an example, because back pain is such a common problem and chiropracty is a common treatment chosen by both adult and pediatric patients. The scenario illustrates the responsibilities that complementary and alternative medicine practitioners owe patients/parents, the potential for liability when deficient care harms patients, and the importance of ample formal pediatric training for practitioners who treat pediatric patients.

Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners.

In this article we discuss steps that clinicians should take after deciding to include a complementary and alternative medicine (CAM) treatment that is beyond the clinicians expertise in a patients treatment plan. We use the example of an adolescent patient with chronic recurrent headaches that have not been relieved by medication or other therapies and whose physician refers her to an acupuncturist for treatment. We focus on (1) circumstances under which referral is appropriate, (2) the nature of the relationship between the referring clinician and the practitioner to whom the referral is made (considering conventional health care and CAM, regulated and unregulated practitioners), and (3) considerations when undertaking shared or collaborative care with other health care practitioners (conventional health care or CAM). We also suggest best practices in managing such relationships.

Concluding Comments: Maximizing Good Patient Care and Minimizing Potential Liability When Considering Complementary and Alternative Medicine

Our goal for this supplemental issue of Pediatrics was to consider what practitioners, parents, patients, institutions, and policy-makers need to take into account to make good decisions about using complementary and alternative medicine (CAM) to treat children and to develop guidelines for appropriate use. We began by explaining underlying concepts and principles in ethical, legal, and clinical reasoning and then used case scenarios to explore how they apply and identify gaps that remain in practice and policy. In this concluding article, we review our major findings, summarize our recommendations, and suggest further research. We focus on several key areas: practitioner and patient/parent relationships; decision-making; dispute resolution; standards of practice; hospital/health facility policies; patient safety; education; and research. Ethical principles, standards, and rules applicable when making decisions about conventional care for children apply to decision-making about CAM as well. The same is true of legal reasoning. Although CAM use has seldom led to litigation, general legal principles relied on in cases involving conventional medical care provide the starting point for analysis. Similarly, with respect to clinical decision-making, clinicians are guided by clinical judgment and the best interests of their patient. Whether a therapy is CAM or conventional, clinicians must weigh the relative risks and benefits of therapeutic options and take into account their patients values, beliefs, and preferences. Consequently, many of our observations apply to conventional and CAM care and to both adult and pediatric patients.

Policy Tensions in Regulatory Reform: Changes to Regulation of Health Professions in Australia, the United Kingdom, and Ontario, Canada

Introduction This article provides a comparative analysis of recent reform to the health profession regulatory frameworks in three jurisdictions: Australia, the United Kingdom, and Ontario, Canada. Aims The goal of this study was to present case studies on the reform in each jurisdiction and provide cross-case comparisons and analysis. Method A comparative multiple case study analysis was conducted to identify the factors influencing reform and underlying aspects to current reform proposals. Policy documents and legislation were analyzed using qualitative content and thematic analyses. Results In Australia, the desire for national uniformity needed to be balanced against achieving adequate accountability. In the United Kingdom, the primary struggle was between balancing appropriate autonomy and flexibility for the health profession regulators with legislated consistency. In Ontario, the government has been increasingly willing to step into areas traditionally within the self-regulatory ambit. Common themes existed across the reforms: a shift in each jurisdiction towards a more overt primacy of the public interest over professional interests, greater independence of regulation from the professions, a push towards collaboration and consistency between professional regulators, and a focus on articulating principles to aid in assessing regulatory quality. Conclusion These findings allow regulators and policymakers to understand the factors and forces that influenced these divergent reforms and the common underlying themes contributing to reform proposals internationally.

Legal Considerations in Paediatric Patient and Family-Centred Health Care

Paediatric patient and family-centred care is both facilitated and constrained by law. This chapter traces some of the ways in which law both affirms and limits this model of caregiving. It outlines the legal framework in which patients, parents, healthcare providers and health facilities function. It explains the extent of and limits on parents’ authority when making decisions about their child’s treatment, as well as healthcare professionals’ and health facilities’ responsibilities, and when the state will intervene. It explores what is meant by making decisions in the “best interests” of a child. Turning from decision-making about care to how care is actually provided, the chapter assesses the legal issues that may be raised when responsibility for care is shared or delegated to parents, family members, or the patient. It reviews key considerations to ensure continued delivery of safe, quality healthcare. It concludes that although the legal frameworks governing healthcare were not developed with this model of caregiving in mind, the law can certainly accommodate and encourage its development.