An Ethical Dilemma
The New England Journal of Homeopathy
Spring/Summer 2000, Vol. 9 – No. 1
Amy Rothenberg ND, DHANP
This section, Quick Bytes, highlights some of the cases and discussions which NESH students and graduates have on their bulletin board. Other short cases, queries and thoughts of homeopathic nature are welcome to this section. Click Here for information about our email learning series,The Herscu Letter. For information about article submission click here.
So, a likable crotchety old guy comes into my office. Basic guy, salt of the earth, loves to do a good job, slightly to the edgy side, not a guy you would necessarily want to cross (definitely not twice.) He says, “Doc, I really believe in homeopathy. I’ve been being treated by homeopaths for most of my life and they have done good by me.” So I take his case. Mostly some minor arthritis issues and no major complaints. He has smoked a long time and I noticed his voice was kind of hoarse. “Yeah, it’s just been like that for the past few months.” My radar goes up. Further into the case, he mentions that he was treated for some prostate problem homeopathically years ago. The urologist recommended biopsy, but the homeopath told him not to worry and gave a remedy. He was having some dysuria at the time which resolved. His exam was pretty much okay until I checked the prostate which was 4 times normal size. I ordered a PSA which was 76 (normal is up to 4.)
This is the ethics part:
He says “Doc, I have total confidence in you.”
Me: “Yeah, but I really think a biopsy would let us know what this is, I think it is cancer.”
“No biopsy, Doc.”
“I think you should at least see the urologist to find out what other options there are, this could go to bone or to your brain if it’s cancer.”
“That’s okay Doc, I won’t do any surgery or radiation or chemo, I know you can cure me.”
“I wish I had your optimism, but I do not treat much cancer.”
“You can do it, I can tell.”
Pretty much goes on like this.
So, what to do?
1. Act like “no problem,” I can cure this guy?
2. Refuse to treat him until he gets a full workup?
3. Have him sign paperwork saying he is not following medical advice?
4. Refer him to the homeopath down the road?
5. Claim I developed a phobia and can no longer see patients with cancer?
6. Tell his wife and kids?
7. All the above?
Let me know what you think, I would really appreciate some dialogue on this one.
Frank Gruber MD of Norfolk, Virginia responded:
Great topic for discussion! I’ll tell you a story. I had a wonderful older woman patient who had been a surgical nurse. She had several friends with cancer who had gone the orthodox route and had died pretty bad deaths. She wanted to do only alternative things. She refused to go to any other doctors to evaluate the fungating vaginal obviously cancerous lesion she had. I opted to treat her. I documented in her chart that she wouldn’t go to see other doctors. Then I had her sign a statement that said she refused to see other doctors and documented that at every visit in her chart. I felt I had to make friends with everyone in the family so that everyone knew exactly what her preferences were and that everyone was on the same page. She eventually died and everything turned out all right for me and I was never sued-knock on wood-at least not until now. My point is this: during the whole time that I was treating her I felt like I was out on a limb. I felt like I couldn’t get information that might have been very helpful about managing her case from other specialists. Eventually as she got sicker she got herself an internist who admitted her when she needed it in the final hours. But I was very uncomfortable during the whole process and felt like I was the Lone Ranger. I spent an inordinate amount of time with the family to make sure I didn’t get sued. I swore after she died that I wouldn’t ever do that again, it was too nerve-wracking. It is always a comfort to know that you have others who can help you in caring for patients. That of course is why we have this bulletin board. But to be so alone in your community in taking care of a patient is very taxing. Now I just tell people that I like to work as part of a group, and that caring for cancer is a group effort. It consists of medical people, radiation therapy people and of course, me. So that’s my experience. Good luck!
Carleen Johnson of central Maine added:
Thanks for posting this issue as it’s something that should be continually discussed. The ethical dilemmas will come to us all in different ways from different patients. For me the issue is the patient’s inability to make what seem like appropriate choices. He’s putting all of his hopes in you and homeopathy without even knowing the whole picture. And that’s an unenviable position to be in as a practitioner. It’s as if he wants you to be the cure-all rather than taking some of that responsibility for himself. While there probably isn’t any one right course to take, if I were to continue treating this patient, it would only be under the condition that everyone involved start talking to each other. And that would include concerned family members, health care providers and any other practitioners that may be involved. Part of that process may have to be that referrals to the appropriate specialists are made. Good luck in trying to decide what to do and please let us know what happens.
Lysanji Edson ND of Portland, Oregon wrote:
Yikes! Really good topic for discussion! Here’s what I’m thinking, just my feelings and opinions (some influenced by living with an attorney.) I’m assuming that you already charted all of this discussion-most notably his refusal to see a urologist. A must! If you do see him again I would have him sign a document to that effect. Your #1 option would not be an option for me-foolhardy as a licensed physician. #2 and #5- Choosing not to see him again/treat him is always a personal choice and I feel must be an option if a professional is not comfortable with his/her client/patient for whatever reason. #4-Refer him to another homeopath, is not a good idea for a few reasons. The big one is that you could possibly get in trouble for negligent referral-meaning you’re partly culpable if something goes badly. If you do a referral of any kind it would be better to refer to a professional organization that has lists of homeopaths or give him a list of at least 3 to choose from on his own. Also, I’m betting you’re one of the best around there so if you can work out a plan that both of you are comfortable with (everything signed), I think he should stick with you! Regarding #6,-Telling family. Really dangerous legally, unless your state has a very unique disclosure law. Better to have the discussion with him about why you feel it’s important for him to tell them. And regarding #7, -well seven is a nice number. Looking forward to hearing from others. Best of luck.
Amy Rothenberg ND of Amherst, Massachusetts offered:
The problem is, I think homeopathy really can help in these situations but it’s the long term follow-up that bogs us down. I had a very similar situation with a fellow with rectal cancer who did everything to avoid surgery and chemotherapy/radiation; mind you he had an excellent prognosis to begin with. The first time I saw him was a few years into it and he was a clear Kali carbonicum-which helped him in general ways and temporarily with some of the cancer symptoms, but by then, the cancer itself had grown so much-it had a life of its own. I got a phone call recently from a mutual friend/colleague wondering if I would prescribe for him (by phone!!) as he was in the hospital bleeding from the rectum. I had denied service after treating him for a few months when I finally got the extent to which he was so entirely anti-allopathy. The real problem was this: we probably can help, even cure some of these people, but the liability is too great. We can’t put on the line all the other good work we do with patients for some heroic act for one person. They probably wouldn’t sue you if it didn’t work but there are always wives, husbands, children, etc. standing in the wings.
I have become quite comfortable turning patients away. Some of them fall into this sort of category, others just have different types of unrealistic expectations of me and of homeopathy. One gal with multiple chemical sensitivities was an interesting example. I told her after about a half hour that I didn’t think I could help her. Perhaps homeopathy could, but not me. In the course of that half hour she had told me of all the doctors she had sued, the major law suit she was in with a chemical company, etc. I did not charge her. A few weeks later, I got a bill from her for how much the transportation cost, her gas mileage, a day off work. One hundred and thirty bucks! I took out my checkbook and wrote her a check and sent it off with a nice note wishing her a speedy and complete recovery. The best $130 bucks I ever spent! Some might think it extreme and while I’ve never done that before or since, it felt appropriate at the time.
So, personally, I wouldn’t treat this fellow until I knew what I was treating -so I could make an appropriate prognosis and only then with full disclosure forms. Sounds like a nice guy but his mind is getting in the way.
Deborah Monat-White of Barrington, New Hampshire wrote:
Wow, what a situation! I couldn’t/wouldn’t treat until there’s been a diagnosis from a specialist-that much is clear. However, what to do if there is a cancer diagnosis and he still doesn’t want surgery, chemotherapy, radiation, etc.? I’m not sure what my decision would be if I had cancer. Depending on the type of cancer and prognosis, I might think: surgery maybe/probably, chemotherapy probably not, and yet whatever decision I would make, I would want to be treated by my homeopath. Method of treatment is/should be a very personal choice, but what worries me is when anyone thinks we can guarantee a cure with homeopathy. Nice to have a patient with faith in you and homeopathy, but! Lysanji, you made several good points re: legality. It’s difficult, unless you have in-house legal advise to be aware of all the possible angles. Very helpful, thanks. Anyway, step one for me would be finding out if it was cancer or notÚ step two would at least be some type of a waiver. Thanks for sharing this with everyone -please keep us posted.
Dane Sheperd DO of Chicago, Illinois added:
Absolutely do not treat him until a work-up is done! I’ve been there- you’ll get sued by him, a relative, brought before the medical board by an angry attending, etc.! Besides, in most of the old homeopathic writings they end up dying of cancer someplace in the body, someday anyway. What I’ve done more successfully is treat with orthodox approaches plus homeopathy-it takes care of the chemo & radiation side effects.
Christopher Ryan MD wrote:
For me, this is no different than the patient who says: “Gosh, I just know if you don’t refill this Xanax prescription I’ve been taking from my former, now-retired doctor, I’ll just have to go out and take a drink, and I’ve been sober for so many years…” I have this problem and now I’m making it YOUR problem by putting you in a perceived bind which you are only in if you agree to be!
I would tell him what you already know:
1. Even the correctly chosen remedy doesn’t always work, and particularly in cases with advanced pathology. We are only here to make the body-mind available to whatever amount of healing it is capable of at the moment, which may be much less than 100%.
2. It’s great to be at peace with the possibility that things may not work out, where you win a few, lose a few. However, he might feel differently at some future point and however well-intentioned, nothing he could sign can legally protect you from allegations of malpractice, brought by him after a change of heart, his family, or a 3rd party altogether. This is no different than someone signing a paper saying they won’t hold you responsible for any adverse effect from treatment, so you don’t need malpractice; not admissible!
PW responded to all the feedback:
I really thank you all for the input and the passionate responses that you all gave on my previous note. I feel as though you really engaged, and I appreciated the caring and concern.
But I wonder sometimes if we choose our actions more from a place of fear of consequences, or from a place of doing what we believe will be the “right” and most beneficial course. Are we putting our patient’s best interests first? And are we truly respecting our patient’s right to make an informed choice?
I spoke with a close friend who is a urologist. He said probably cancer, but maybe not. His overall response was “Just give him PC Spez, an herbal treatment for prostate cancer, that has some positive documented results.” He was likeÚwhat is the big deal? The guy doesn’t want the biopsy, you cannot make him get the biopsy. You may as well try to treat him at the maximum level that he is willing to do.
He saw no difference between this and a patient refusing surgery in favor of a treatment less likely to cure.
I see this as very similar to all the little kids who have parents that refuse vaccinations and then the pediatricians refuse to see the kids. The parents are exercising their legal rights and the doctors are, in a sense, punishing the kids by not seeing them for fear of reprisal or because the parents are choosing a course opposite the doctors’ beliefs.
So if I am hearing you all correctly, I should basically turn this guy with probable cancer into the street if he fails to yield to my strong arm tactics of “You have to get the biopsy or I won’t treat you.” I have generally tried to avoid yielding to my fears and follow my sense of service to the individual.
I will treat this fellow because I feel it is the right thing to do. I will be straight up about the likelihood of successes of various therapies. I will require his wife to attend his next visit. I will probably try the PC Spez. And I will try an end around using a “Prostascint” scan as a way to try to diagnose the possible cancer without the biopsy. And I will continue to push the need for a urologist. And maybe, at some point, I will change my mind.
Pam Helberg RN, of Amherst, Virginia shared:
I’ve been reading the responses to the ethical dilemma. It’s true when you said everyone was responding from fear. I think their fear is for your welfare, though, my friend. It’s sad, but it is the reality of the way things are today. I know that when you look at any patient, you only want to help them. I was the same way when I first started homeopathy, but have learned to say no to some patients. I know I have different limits as a nurse, but these same legal concerns are also very real for me. No one wants to see you or your practice hurt. It would be a great loss. I don’t think you are punishing him because you tell him you can’t help him. Just let him know the limits of what you can do. Just be honest with him, and if this herbal treatment is what he wants to do, then I’m sure he can get it on his own, over the counter, or from an herbalist.
Dane Sheperd DO of Chicago, Illinois reiterated:
Okay, but my last bit of advice is for you to speak with the legal council of your liability carrier for the exact way to proceed, which forms etc. so you are fully backed by them first. They can avoid paying if you do something they consider illegal, they can cancel you if you force them to settle with outside council. Would you do this if you were in a legal partnership with wife and kids and other patients you have? Be prepared! Other than that, ascertain God’s will and do it, torpedoes be damned! God be with you and all your patients.
One last follow up from Frank Gruber MD:
Good for you. You have the courage of your convictions. You took a poll and then allowed that to help you follow your own heart.
And one last note which did not appear on the bulletin board from Paul Herscu ND:
I enjoyed reading the different messages and thinking that has taken place on this issue. I want to talk about what I see as the two biggest issues this topic brings up. The two issues are around the topic of fanaticism in medicine, and about the position of homeopathy at this time, within our culture.
Fanaticism has no place in medicine. Not from our medical colleagues, not from us, and not from our patients. We all lose when we are too rigid. The medical community loses from learning too slowly that there can be other ways. We lose when we do not use and apply current medical knowledge. And of course, the patient loses when they limit their options. There is no way a patient can know all that is available to them, without knowing what the problem is. Treatment options are based on diagnosis in any form of medicine, homeopathy included. How are you supposed to have a proper case analysis and follow-up visit, if you do not know what the problem is? If it is cancer and the patient is telling you that they are slightly better in a month, that is great. If it is an acute illness and they tell you that they are slightly better in a month, that is terrible. Diagnosis informs your treatment options as well as your prognosis, in medicine in general as well as in homeopathy. And in this particular situation, an important point to consider is that this gentleman’s strong, rigid ideas, which go against current medical understanding, are part of his symptomatology. For instance, if he needed Conium maculatum, not an uncommon remedy in prostate cancer, he might be very stuck in his thinking and that idea itself would be used in the case analysis.
The second point involves the position we find ourselves in at this time in the world of medicine. Homeopathy finds itself on the very periphery of medical culture. As such, we are judged in a way that is different than other practitioners who are more in the mainstream. In many ways, if something good happens under the care of a homeopath, it will be considered incidental but if something bad happens, it is proof positive that what homeopaths do is dangerous.
This second point was made very forcefully to me recently. A friend of mine, a competent and compassionate internist, referred me a patient. This was one of the healthiest women I have ever had the pleasure of treating. The chief complaint was uterine cancer. She had gone through a very healthy menopause and my colleague had routinely placed her on estrogen replacement therapy (ERT) some 5 years before. Lo and behold, uterine cancer, a known risk factor for ERT. In this situation, my colleague did not have any second thoughts. Menopause, you give ERT; uterine cancer, you refer for a hysterectomy.
For many of our allopathic colleagues, it is so far from their consciousness that one action is related to a side effect down the road or that one treatment plan may actually lead a patient to a whole host of other, perhaps deeper problems. With something like the Thalidomide tragedy, it was so obvious it was unavoidable to see the damage done; but when it is more subtle or a few years later, it does not even appear on the screen of responsibility.
In contrast, the level of scrutiny we endure is so much higher, we are judged very differently; so much of what we do is suspect to our critics. It is against these stereotypes that we practice and it is because of them that we need to be that much more diligent in our diagnostic work, lab work, etc. so that there are outside observations done before and after our treatments-so that we can show our results with confidence and pride. And for the many professional homeopaths who do not do any of that sort of work, that’s fine but you need to encourage your patients to seek out state of the art diagnosis; or work along side the medical profession, so that you to may be able to offer up your results with some unbiased quantitative results. Which leads me to the refrain: the need for research in homeopathy has never been greater!
I would not treat this patient without full understanding of the condition and then only with very clear boundaries around what I thought I could actually offer.
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