Integrative Mental Healthcare: Legal and Ethical Issues

Integrative mental healthcare can be defined as integration in mental healthcare of conventional and complementary and alternative (CAM) therapies for which there is some high-quality scientific evidence of safety and effectiveness. The legally responsible and ethically defensible practice of complementary and alternative medical (CAM) approaches in mental health care is a fundamental concern.

Here are some typical questions a clinician might ask:
• Am I responsible if patients use CAM therapies without informing me, and are thereby injured?
• What do I do when patients demand and expect to use CAM therapies that lack a sufficient base in the medical evidence to justify my recommending these therapies?
• What do I do when patients insist on making their own decisions, against medical advice?
• What are my obligations to discuss the risks and benefits of various therapies?
• What if the patient asks me for a referral to a CAM therapist and I feel this is not in the patient's best medical interest?
These questions provide an opportunity to construct some guidelines to facilitate the legally defensible, ethically appropriate, and clinical practice of integrative care.
The law governing CAM providers and therapies (and, by extension, integrative care) grows out of, and overlaps with, at least seven different areas of law governing conventional care: (1) licensure; (2) scope of practice; (3) malpractice liability; (4) professional discipline; (5) access to treatments; (6) third-party reimbursement; and (7) fraud. Cohen MH, Complementary and Alternative Medicine Legal Boundaries and Regulatory Perspectives (Johns Hopkins University Press, 1998).

Licensure refers to the requirement in most states that health care providers maintain a current state license to practice their professional healing art. Scope of practice refers to the legally authorized boundaries of care within the given profession, usually defined by state licensing statutes and/or accompanying regulations and cases. Malpractice or healthcare negligence is defined as failure to use due care, and thereby injuring the patient. Professional discipline refers to the power of the relevant professional board--in the oncologist's case, the state medical board--to sanction a clinician, most gravely by revoking the clinician's license.
Access to treatments refers to the interest by patients in obtaining therapeutic substances outside typical clinical delivery, such as either dietary supplements, or drugs not approved by the federal Food and Drug Administration (FDA). Third-party reimbursement involves the role of insurance in reimbursing for, and thus governing access to, CAM therapies. Fraud refers to rules targeting intentional deception of patients, and is related to misrepresentation and false advertising.
Although situations can be generalized through case studies, it is useful and appropriate to ask legal counsel to give legal advice or opinion in any given situation. Mental healthcare providers practicing in a hospital setting may have opportunity to ask the hospital's legal counsel for advice or guidance. Individual clinicians, with input by an attorney familiar with these issues, can address how these general rules apply to a specific clinical scenario. Better yet, this can be accomplished more broadly through the establishment of legal guidelines by institutions and professional associations wishing to guide their staff and members (e.g., psychiatrists and others) who treat patients using CAM modalities or refer patients to professional CAM practitioners.

The table of potential grounds for liability in CAM may also be a useful guide, together with the discussion of Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice by the Federation of State Medical Board.