DecisionMaking About Complementary and Alternative Therapies for Children and Youth: Legal, Ethical

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Decision-Making About Complementary and
Alternative Therapies for Children and Youth
Legal, Ethical and Clinical Issues

• Joan Gilmour, Osgoode Hall Law School
• Christine Harrison, The Hospital for Sick
  Children
• Sunita Vohra, CARE Program, University of Alberta
• Edward Mills, Canadian College of Naturopathic
  Medicine
• Michael Cohen, Harvard Medical School

Funded by The Hospital for Sick Children
Foundation
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Outline

• Purpose of the project
• What we have done and what we have found in the
  areas of Law and Ethics
• Policy Review
• Clinical Case Development

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Purpose of Project

• To identify current law, policies, and ethical
  norms regarding CAM and children
• To develop the basis for a coherent,
  well-grounded policy framework
• To inform and better support decision-making

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Canadian Law What we have done

• Research
• CAM and malpractice
• children and medical malpractice
• Research distinction between research and
  innovative therapy in health care

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Canadian Law What we have found

• Recognized CAM practitioners will be subject to
  same principles of negligence as medical
  practitioners, and measured by same standard of
  care as that of a reasonable practitioner of the
  same school, within scope of practice
• Outside scope of practice, or less recognized
  types of CAM, held to standard of reasonable
  person or reasonable medical practitioner
• Few decided cases

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Canadian Law What we have found

• Malpractice suits involving children follow the
  same negligence principles as those involving
  adults.
• The distinctions between innovative therapy and
  human research and between those and standard
  practice are fluid and not always clearly
  defined.

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U.S. Law What we have done

• Collect and analyze U.S. cases on abuse and
  neglect involving use of CAM therapies by
  children, U.S. cases on malpractice liability
  involving use of CAM therapies, and any new,
  reported U.S. cases on malpractice liability of
  providers for referral to CAM providers.

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U.S. Law What we have found

• Re. abuse neglect Courts will intervene if CAM
  therapy offers no viable alternative to
  conventional care, or if parents are rejecting
  necessary medical care and substituting a CAM
  therapy rejected by all responsible medical
  authority.
• Balance among interests of all concerned
  invasiveness/effectiveness of treatment

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Ethics What we have done

• Review of bioethics literature CAM and children
• Review of bioethics literature and seminal
  bioethics texts standards of decision making
  for children, by children

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Ethics What we have found

• Best Interests standard applicable to all care
  providers and substitute decision makers
  (parents)
•  

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Ethics What we have found

• We should presume that parents are motivated by
  what is doing best for their children, and treat
  them respectfully. This will encourage open and
  trusting relationships.

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Ethics What we have found

• Preservation of relationships is an important
  value (i.e. parent-child, health care
  professional-family, health care
  professional-child).

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Ethics What we have found

• There will be some situations where health care
  providers have a moral duty to the child to
  contact child protection authorities.

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Ethics What we have found

• As children mature they should be increasingly
  involved in decisions.

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Ethics What we have found

• There is the same moral imperative to research
  CAM as there is to research conventional therapy.
  

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Policy What we have done

• Over 100 letters sent to regulatory bodies
  seeking relevant policies, disciplinary decisions
• Response has been limited follow-up by
  CCNM collaborator in process

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Policy What we have done

• Over 114 letters sent to hospitals (paediatric,
  targeted, randomly selected)

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Clinical Case Development

• Development of clinical cases to illustrate/work
  through ethical legal issues
• Take into account acute chronic illness
• Include issues related to NHP
  as well as CAM therapies

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Sample Clinical Scenario

• CAM Therapy and Informed Consent
• 6-year-old Jake leukemia Tx causing nausea,
  vomiting, anxiety
• Physician prescribes various drugs (ineffective)
• Through Internet families of other children,
  Jakes family learns of acupuncture as effective
  Tx

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Sample Clinical Scenario

• Physician hospital unable to provide
  acupuncture
• Jake receives acupuncture while on passes nausea
  vomiting almost completely eliminated (MD
  placebo effect)

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Sample Clinical Scenario ISSUES

• Physicians Duty re. Informed consent/choice
• Physicians role in therapeutic relationship 
• Hospital/organizational duty and liability re.
  Providing and/or enabling CAM

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Acknowledgements

• Kristine Bittermann
• David Vitale
• Maya Goldenberg
• Dr. Kelly Walters
• Andrew Milroy
• Nicola Simmons
• Leyla Asadi
• Sick Kids Foundation

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Questions Discussion