ABSTRACT
The practice of integrative oncology raises imponant legal issues for clinicians and institutions. Integrative oncology can be defined as a comprehensive, evidence-based approach to cancer care which addresses the whole person. An integrative approach will often use a combination of conventional with complementary and alternative (CAM) therapies. In general, institutions must consider potential liability issues involved in hiring CAM providers as part of an integrative care team 1, as well as credentialing mechanisms for these providers2• Most clinicians are less involved in credentialing decisions but remain keenly concerned about the possibility that they might share liability with other members of the integrative care team (e.g. the neurologist and chiropractor, or the oncologist and acupunCturist, or the osteopath and massage
therapeutic advice concerning CAM therapies, is enrolled in a clinical trial that uses such therapies, or, perhaps, has determined to use such therapies with or without medical advice. Each of these scenarios presents differing yet parallel complexities; overall, the advent of integrative care presents situations in which clinicians sometimes can find themselves caught between the different demands of patient expectations, clinical judgement and liability considerations. Such complex scenarios often leave the clinicians with legitimate concern yet little professional guidance, either ftom their home institutions or ftom relevant professional groups. This is because clinical algorithms or pathways for integrative care do not yet exist; nor have many US hospitals, by and large, created a system of rational policies and procedures to help guide their clinicians through various liability dilemmas4•
This environment might seem discouraging at first. The good news is that the field of CAM therapies has sufficiendy shifted past the blackand-white rhetoric of 'proven' and 'unproven', 'conventional' and 'unconventional', 'orthodox'
and 'unorthodox,' to serious, clinical consideration of integrative strategies, with appropriate disclosure and discussion of risks and benefits5•
This means that the decision as to how to guide the patient deserves serious, extended discussion; it is no longer a matter of simply approving or disapproving of inclusion of CAM therapies generically. In short, a century of rhetoric has shifted into a fluid conversation of how to engage multiple clinical disciplines in a way that is 'clinically responsible, ethically appropriate, and legally defensible'6•
The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) currendy defines integrative medicine as health care that 'combines mainstream medical therapies and CAM therapies for which there is some highquality scientific evidence of safety and effectiveness>?. Such a definition implicidy recognizes the potential value of combining conventional and CAM therapies, provided that such therapies have 'some high-quality' evidentiary base. The NCCAM definition does not set an evidentiary threshold, thus leaving the clinician to make delicate judgements at the borderland of good clinical and legal sense.
