The contemporary resurgence of complementary and alternative medicine (CAM) is not necessarily a movement toward a more effective form of health care. Proof of its efficacy is still being debated. Rather, this resurgence reflects a stinging critique of the practices and values of conventional medicine and the adoption of a new set of values.¹ While continuing to seek care from conventional practitioners, some patients are demanding a new form of health care—one that is sensitive to the full range of their humanity, not just the maladies of their bodies. Patients are challenging not the science of medicine, but the values and ethics of the biomedical paradigm.

Traditional health care and healthcare ethics have been under siege for some time, with many critics attacking the dominant understanding of bioethics as limited and inadequate to meet the needs of patients and their families.² In this sense, the movement toward integrating conventional and alternative medicine provides us with an opportunity to reflect on the nature and limits of our current understanding of healthcare ethics and to consider the insights afforded by the values of complementary and alternative medicine. Discussing the values of CAM allows us to address not just the tragic moral dilemmas, but also the ethics of the everyday—the daily interactions that can have a profound effect on our health and our lives. They do so because CAM is radically oriented towards the nature of human existence in the world. In lieu of an analytic rationality that seeks to categorize and problematize the world, CAM urges an immersion into the world's depth and complexity. Against the pride of science, it offers humility.

In this paper, I will be exploring what we may learn from the movement toward integrated medicine, or new forms of medical practice involving both conventional medicine and CAM. I start by offering an inclusive definition of ethics—one that looks beyond the limits of dilemma ethics to an ethics that seeks to integrate the whole social being and welfare of every individual. I then consider how conventional medicine has shaped the approach and values of conventional bioethics. I will argue that while bioethics meets the demands of conventional medicine, it also suffers from the limits imposed by conventional medicine. I will then consider the values offered by complementary and alternative medicine. Does an understanding of complementary and alternative medicine identify limits in the bioethics paradigm of principlism? What values does complementary and alternative medicine bring to the treatment of patients? Based upon the answers to these questions, I will then propose a set of five values that may provide a more comprehensive understanding of ethics for health care. I will demonstrate how they may be applied to create a more inclusive form of integrated bioethics.

INTEGRATIVE ETHICS: THE PARADIGM
The term "integrative ethics" was originally developed in a Park Ridge Center for the Study of Health, Faith, and Ethics research project on integrated medicine, which sought to identify the ethical concerns arising in or created by this new approach to health care. The first challenge of the project was to define the term "integrated medicine." Was it simply a collection of unrelated therapeutic practices sharing the same offices and operating under a common financial arrangement? We found that that was not the case for many of the practices we studied.³ Conventional practitioners were not only adopting the techniques of CAM, they were adopting the values and orientation of CAM that view patients as holistic beings and reject the idea that healing can be isolated as a specific physical therapy. Conventional practitioners, even if they did not perform CAM therapies themselves, were integrating the values of CAM into their practice.

However, there is more to this approach than integration of values. It allows us to conceptualize ethical health care as a way of caring for the whole person and resisting the temptation to dichotomize or fragment the person into such categories as body and soul, physical and mental, or secular and sacred. It provides a rich understanding of healthcare ethics applicable irrespective of whether or not CAM practices are involved.

The critique of fragmentation arises not only from CAM practitioners. Many within conventional medicine itself are dissatisfied with conventional approaches to health care that do not attend to the whole patient.⁴ They have sought ways to integrate health care into the life of the patient. Moreover, the concept of integration recognizes not only the new values offered by CAM but also the legitimate values present in current conventional medicine. There are questions that arise within conventional medicine that have no place within CAM. For example, it is only within conventional medicine that the issues associated with life-sustaining treatment arise and must be addressed. The challenge for integrative ethics is to find ways to identify and use the best of both approaches.

THE VALUES OF CONVENTIONAL MEDICINE AND BIOETHICS
Moral values do not exist as some sort of free-standing metaphysical entity that can be applied in any context. Instead, they grow out of a community of interest and are tangibly embodied in the practices of that community. Honesty is not simply a Platonic form or a Kantian ideal; it is a necessity for the creation and sustenance of a close human relationship or community. That community, in turn, defines the contours of that value, including when white lies are justified, when absolute truth is required, and what truth is owed to outsiders. While not calling for a strict relativism, this argument does call for close attention to how values are expressed within the concrete reality of particular lives and communities.⁵

As an applied field of ethics, bioethics reflects the values of traditional biomedicine. The focus in bioethics is on such issues as patient autonomy, medical paternalism, and managing medical technology at the end of life, because these issues are prevalent within the practice of traditional biomedicine and the traditional relationship between physicians and their patients.

For example, one of the most successful approaches to conventional bioethics is that of principlism. Principlism is a form of bioethical analysis in which caregivers attempt to resolve moral problems by drawing upon four principles or values: autonomy, beneficence, nonmaleficence, and justice.⁶ The principlist model succeeds because it embodies the values and adopts the practices of traditional conventional medicine.

These values can be easily summarized in the context of the dominant model of medical practice. The expert caregiver acts for the benefit of a patient suffering from a biological problem—an illness, injury, or biological/genetic malfunction. The ailment is the result of an empirically identifiable biological cause, and the caregiver seeks to intervene within that cause-and-effect chain either to treat the ailment or to alleviate the symptoms of the ailment using techniques that have been scientifically proven to be efficacious. Hence, the focus of principlism is on the dynamic interaction of the caregiver and the patient in addressing an isolatable physical function. The physician, as an actor upon the patient, is ethically obligated to act for the benefit of the patient (beneficence) and not to harm the patient (nonmaleficence). In order to place limits upon the caregiver's power, the caregiver is obligated to respect the autonomous wishes of the patient (autonomy) and to be cognizant of their obligations to society (justice).

Moreover, principlism succeeds because it reflects the practices of conventional medicine. Indeed, principlism resembles clinical practice. "It provides a framework not too different from differential diagnosis or [from] the algorithms of clinical decision making like those posted on the wall of the cardiac care unit related to the treatment of potential fatal arrhythmias."⁷ Like any treatment plan, principlism facilitates coming up with answers because questions are asked in a way that is satisfying to the typical pragmatic clinician.

THE NATURE AND VALUES OF CAM
As commonly used, the term "complementary and alternative medicine" is applied to a multitude of practices, ranging from chiropractic and midwifery to aromatherapy and homeopathy. Some are very ancient and some are of relatively recent development. Some, like acupuncture, have complex theories of health and treatment, while others, like Swedish message, lack an overarching theoretical understanding.⁸ There are even arguments that the term "complementary and alternative medicine" is not one, but two terms awkwardly combined.⁹ Complementary medicine constitutes those practices that are seen by practitioners and patients as complements to the practice of conventional medicine, while practitioners of alternative medicine see their practices as alternatives to conventional medicine. The one feature that all of these practices obviously share is that they are not traditional parts of conventional biomedicine. Yet there is a consensus within and outside the field that it is legitimate to talk about a single field of complementary and alternative health care.¹⁰

Indeed, in reviewing the many articles on CAM, certain themes emerge. Even though CAM practitioners use varied techniques to address the health concerns of their patients, they share a common orientation toward the patient, health, and health care. As it emerges in a variety of sources,¹¹ CAM can be described as:

• holistic—it views the person as an integrated system that is interactive with the environment and that is constituted not just by one's biological makeup, but by one's emotions and spirit as well;
• integrative—illness or injury is often conceived of as the result of failing to balance properly life or spiritual energy and resources, and healing requires finding a way to reintegrate those forces;
• naturalistic—health is part of the natural processes of life, and healing is simply finding ways to empower those processes;
• relational—as interactive integrated systems, the relations between the patient and her social world, including the healer, are all part of the process of healing; and
• spiritual—the self-healing, integrative power of the individual is not fully measured or even measurable by empirical means; this power rests at least in the individual's relationship to the transcendent—whether characterized as God or as Paul Tillich's¹² "ultimate concern"—which has an integral place in the individual's health.

These characteristics justify recognizing complementary and alternative medicine as fundamentally different from conventional medicine. Nonetheless, these values are not, for the most part, antagonistic to the values of conventional medicine. They supplement them. They hint not only at the limitations of current healthcare ethics, but also at how current norms may be expanded to embrace a more holistic, integrated model of care.

TRANSFORMING HEALTHCARE VALUES
Health care that integrates CAM and conventional medicine has at its core five values: integrated humanity, ecological integrity, naturalism, relationalism, and engaged spirituality. Although these values can be described individually, they are inseparable in practice. They are elements of a whole.

Integrated Humanity
The concept of integrated humanity recognizes that people are not simple biological machines. They are a unified whole, constituted by their bodies, their intellect, their spirit, and their relationship to the world, to the transcendent, and to others. Illness and health cannot be measured solely according to biochemical measurements nor does healing always result when pathogens are overcome.¹³ Illness and injury may result in emotional or spiritual distress. Serious illness inevitably affects the individual's sense of self and security. True healing may require mental or spiritual care as much as it requires a physical treatment.¹⁴

This understanding of human healing is not totally absent from conventional medicine. We can find hints of it in the World Health Organization's (WHO's) definition of health, which looks beyond mere symptomatology,¹⁵ and in the movement in bioethics that stresses the importance of addressing the whole person—the psychosocial dimensions of health care as well as the biological.¹⁶

The concept of integrated humanity also embodies the conventional idea of autonomy, a quality respected within CAM as well.¹⁷ In identifying a person as an integrated whole, there is some sense that this person is inherently unique and special. Such an individual deserves respect—a response that is greater than simply honoring autonomy. However, also explicitly present in this concept is the recognition that each unique individual is the product of his relationships within the world, with the transcendent, and with others within his community, particularly those most intimate to him. Thus, any attempt to consider the individual in isolation from those relationships is artificial and fails to reflect the reality of that individual's life. Autonomy is not and cannot have the preeminence granted to it within conventional bioethics except insofar as it serves as a pragmatic way of resolving conflicts; in the absence of any principled way to resolve a values conflict, we may choose to defer to the wishes of the patient. However, this reflects a pragmatic judgment rather than an elevation of autonomy as a preeminent value.

At a fundamental level, integrated humanity calls upon the caregiver to treat the patient respectfully and as a full and equal participant in his or her own health care. Prosaically, this recognizes that ethics touches our everyday interactions. Being respectful of a patient's time and commitments, greeting her courteously, and providing her with comfortable surroundings all reflect an attitude of respect. In contrast, expecting patients to conform to the schedule of the healthcare provider by double or triple booking appointments, missing appointments, or requiring that the patient address the caregiver with an honorific while the caregiver addresses the patient by their first name, are all practices reflecting fundamental disrespect for the patient and self-aggrandizing by the healthcare professional.¹⁸ While these types of ethical concerns may not possess the drama or seriousness of life and death decisions, they exist at the threshold of the whole experience of health care for patients.

At a deeper level, integrated humanity urges the caregiver to seek to identify not only biological information but also psychological and social information about conditions that may have caused or contributed to the biological problem and also the effects of the problem on the person's psychological and social world. For example, in the treatment of pain, it is not enough simply to categorize pain according to an arbitrary numeric self-assessment scale and to adjust medications accordingly, as is commonly practiced in conventional medicine. The caregiver needs to consider how pain is affecting the patient's life: How does it affect his daily routine and the tasks of life, such as dressing, working, preparing meals, etc.? How does it affect his self-image and self-understanding?¹⁹ What is important to the patient that needs to be addressed? The caregiver should also seek to identify the patient's own resources for treating pain. How might he alter his environment or his self-understanding of himself to accommodate or overcome the problems caused by the pain?

Ecological Integrity
The concept of ecological integrity reflects the fact that patients do not live in isolation. They exist as members of important social communities: family, work, religious, economic, and political. In turn, these communities can help or harm the health of the patient by, for example, supporting or hindering recovery from illness or injury. The prospects that a patient living alone in poverty will recover from a serious illness are poorer than those for a wealthy patient living in a supportive family environment. Healthcare treatment plans must attend to these environmental concerns in order to be effective.

For example, in developing a healthcare plan, the caregiver needs to consider whether or not the patient has a family capable of helping to care for the patient, if needed. Are there family dynamics that may have caused or exacerbated the patient's physical problems? If so, how can they be addressed? Does the patient have the financial resources necessary to follow the treatment plan? If the patient doesn't have private insurance or resources, does the patient know of public resources that may be available?

Again, conventional medicine and bioethics are aware of these relationships.²⁰ There is an increasing body of research that looks at environmental and social factors affecting health, and there are many efforts to find ways to incorporate social and economic concerns within the context of healthcare planning. Similarly, family practice medicine has emerged as a significant discipline in recent years as doctors have come to recognize the important interconnection between the patient and the social and economic environment.²¹

Part of the difficulty for conventional biomedicine in dealing with this issue resides in the dominance of the autonomous patient model and the isolated view of medical practice as interaction between a patient and the physician. Both of these practices tend to isolate the patient and the physician from the rest of the world, focusing our attention on a limited set of actions and circumstances. For example, the simple principle of patient privacy, while reflecting an important value, sets prima facie limits on the engagement of a family or social community in the patient's health care. To involve a patient's family means sharing private information about the patient.

In order to address this ecological concern, a caregiver needs to pay close attention to the social and economic world in which the patient resides. It is important to identify potential sources of social support as well as those environmental conditions that may be causing or contributing to the patient's health problems. While a caregiver cannot be expected to solve all of the social ills of the world on her patient's behalf, this value of ecological integrity justifies the effort to make sure that the patient knows about social services and the social activism of healthcare providers who lobby on behalf of their patients.

Naturalism
The concept of naturalism points us away from a too narrow, mechanistic understanding of health. It places our understanding of health and health care within the context of our existence in the natural world and assumes that human resistance to that natural world can create health problems. We are not simple biological machines to be controlled by physicians, but rather complex biological systems deeply integrated into our natural environments.

There are three aspects or features within this value:

• normality—it is assumed that health is a normal condition and that natural processes are inherently oriented towards the norm of health. Emblematic of this concept is the naturalistic approach to childbirth exhibited by midwifery and the natural childbirth movement within conventional medicine. These practices treat childbirth as a natural process in which careful attention to the natural responses of the body tend to conform to the best methods of child delivery. For example, instead of trying to place the woman in a position convenient for the physician, natural childbirth recognizes that delivery is assisted by the ability of the mother to move around and assume the position that works best for that individual.
• complexity—nature and health cannot be reduced to simple elements. They are inherently complex and multi-layered. This conviction contradicts the reductive tendency of empiricism, which attempts to understand the world by reducing it to individual cause-and-effect relationships. Because of CAM's orientation toward the interrelationship of all aspects of life, it is resistant to this form of reductionism.²²
• dynamism—life is dynamic and interactive. It cannot be fixed or reduced to commonality. Any change in the environment alters the starting point of analysis, so that treatments must always be adjusted to reflect the unique and individual environment of each patient and their reactions to any plan of treatment and care.²³

This concept of naturalism does not deny the value of empirical research; it simply cautions us against an overvaluation of the results of that research. A double-blind trial, while valuable in measuring the effects of a particular drug within a class of patients, may not be able to evaluate treatments of unique individuals or treatments that involve multiple interactive interventions. Experience in clinical practice may be the best source of useful information on certain types of treatment. Clinical experience is, for many physicians, a prominent guide to practice.²⁴ The challenge for scientific medicine is to find ways to improve the collection and analysis of this type of data as opposed to focusing solely upon the randomized clinical trial.

Relationalism
The concept of relationalism recognizes that the patient and the caregiver are not isolated from each other, but rather enter inherently into a relationship. As characterized by Douglas McNair: "Within each episode of care, there is a two-way flow of desire between the giver and receiver of care . . . An important part of quality as a measure of caring for others consists in the matching of needs: the needs of the recipient, but also the needs of the giver—a . . . recognition of the symmetry and commingling of giving and receiving."²⁵ The relationship is not one of friendship or equivalency; CAM emphasizes that this is a healing relationship. Relationalism does not ignore the fundamental relation in which the patient seeks care and the caregiver wields power of knowledge. It asserts, however, the simultaneous existence of a deeper, interactive, mutual relationship that is part of the healing process itself.

Conventional medicine has traditionally denied this interactive relationship, favoring instead the traditional understanding of science and the disinterested observer.²⁶ As argued by William Osler, the father of modern medicine, "objectivity is the essential quality of the true physician."²⁷ The only relationship commonly recognized by conventional medicine and bioethics is that based on the dynamics and disparities of power between the patient and the physician.

Much of the emphasis on patient autonomy and the newly emerging focus on organizational ethics is, in fact, an effort to counterbalance historical abuses of the patient's position of dependence.²⁸ For example, the concepts of patient self-determination and informed consent counteract the historic paternalism of medicine where the doctor acted solely according to the doctor's judgment about the best interests of the patient. Both self-determination and informed consent have empowered the patient to act contrary to the wishes of the physician and/or hospital. Nonetheless, both individuals and institutions view the relationship as moving in only one direction—that of affecting or acting upon the patient. The doctor or the organization remains aloof from the relationship save only as one experiencing a sense of power over the patient.

Some conventional practitioners appreciate the value of personal, engaged relationships with their patients.²⁹ They recognize that physicians are human and cannot help but be affected by their patients. However, more importantly, they assert that a personal relationship can have a positive role in health care. Research indicates that warm, empathetic care by a doctor has a positive therapeutic effect.³⁰

Applying this relationalism can affect issues such as informed consent. In a relationship, we share more than in a confrontation with strangers. Hence, in participating in an informed consent process, the caregiver is justified in sharing her opinions as well as strict information. This fosters greater patient confidence in caregivers; research indicates that patients want a doctor who "cares" for them and appreciates them as whole persons.³¹

The value of relationship also provides a new way of understanding organizational ethics and the role of the employee in the organization and the delivery of health care. Conventional bioethics gives little guidance or justification for attention to the relationships between an organization and its employees or agents. Because of its focus on the singular patient-caregiver professional relationship and the assumption that a professional relationship is, or should be, substantially disengaged or objective, the argument that an organization should respect its employees because of the potential effect on patient care is relatively weak or attenuated. The employee's professional ethics are expected to take precedence, creating a protective barrier between the organization and the patient.³²

By contrast, if we recognize that the relationship between a caregiver and the patient is engaged and interactive, then we begin to appreciate that all relationships can play a role in health care. This includes not only the relationship between the caregiver and the patient but also the relationships involving the caregiver, coworkers, managers, loved ones, etc. This supports the maxim of organizational ethics that abuse or mistreatment of one employee flows down a chain of authority until it reaches the patient or customer.

Moreover, as with the relationship between physician and patient, the nature of the relational concern is not just in the negative, i.e., avoiding abuse. CAM practitioners in the Park Ridge Center study stressed the importance of developing strong, positive relationships on the caregiving team because those relationships contribute to the healing relationship. As one participant put it, these relationships contribute to the healing energy of the treatment center.³³ Thus, concern about how caregivers are treated has a direct bearing on how patients are cared for.

Engaged Spirituality
Humans are spiritual beings. They are inevitably, in some sense, oriented towards the transcendent, whether that is defined as the cosmos, God, or something that is simply greater than the individual alone. Caring for a patient in an integrative way requires attention to this spiritual realm. This is significant in two ways.

First, the spiritual dimension can be an active force in patient care. Within conventional medicine, there is a growing body of research supporting the efficacy of prayer and other spiritual interventions upon health care.³⁴ Nonetheless, it is unclear how conventional medicine is to handle these types of interventions within its epistemic understanding or practical organization. For example, conventional medicine has long recognized that a patient's or caregiver's belief in the effectiveness of a particular treatment affects the outcome of that treatment. Known as the placebo effect, it is a real and measurable effect on patients.³⁵ However, given conventional medicine's focus on biomechanical treatments, practitioners are unable to incorporate coherently the placebo effect into their treatments. Indeed, with conventional medicine's orientation toward patient autonomy, an intention by the caregiver to create a placebo effect by inducing the patient to believe in a treatment that is not proven to be efficacious violates the caregiver's duty of honesty to the patient. While the "belief" might effect a cure, creating the belief would require lying.

Complementary and alternative practitioners include the use of the mind and spirit in treatment. They teach that health is significantly affected by the mental and spiritual states of a person. Their treatments, though often couched in terms of physical interventions—take this vitamin, insert the needle here, or manipulate this joint—have also stressed the need to bring the mind or spirit into harmony with the body. Because they have not linked treatment to a tight focus on the efficacy of isolated agents, their whole process of treatment can be considered an effort to engage the total person of the patient in the treatment. This approach avoids the dilemma of the placebo effect.36

The second important feature of attending to the spiritual care of patients is that it reminds us that healing is more than the simple correction of bodily ailments. A patient whose spiritual needs are not met may not be truly "healed" no matter what the condition of the body at the end of treatment.³⁷ Moreover, there are many instances in which physical cure is impossible—yet spiritual comfort is needed by the patient and can be provided. An integrative understanding of health care appreciates the importance of meeting these spiritual needs.³⁸

INTEGRATIVE MEDICINE AND THE ETHICS OF THE EVERYDAY
The ethics of integrative medicine does not depend on incorporating alternative practices in conventional medicine, nor does integrative ethics deny the virtues of existing medical practices and principles of bioethics. Existing values within conventional healthcare ethics already support the five core values identified above. The movement toward integrated ethics merely emphasizes the importance of moving beyond the more limited understandings of conventional bioethics.

We must not discard existing bioethical insights. Many practices within both conventional medicine and CAM continue to reflect the values and concerns addressed by conventional bioethics. Whether as a practitioner of CAM or conventional medicine, for example, the caregiver is the expert, providing care for a person in need. Caregivers will continue to be concerned with protecting the patient and balancing this dynamic of power. Similarly, caregivers will continue to have the power to intervene in natural processes of life and death in ways that provoke controversy and conflict. Conventional bioethics is well-suited to addressing these controversies.

However, integrated ethics stresses the importance of looking beyond this tendency to focus upon individual conflict and crisis. As described within the core values, many aspects of care do not necessarily involve conflict—they involve engagement and caring for the totality of the human before us. In this sense, integrated ethics adopts the position supported by Aristotle and many feminists:³⁹ that ethics is concerned with the totality of life and relationships and the nature of the good in human life. The goal of ethics is to support the good of individuals in relationship insofar as that is possible. This approach allows us not only to address areas where there is a conflict between individuals, but also to seek to identify and support particular goods that may be missed by focusing solely upon conflict. This approach looks beyond the ethical dilemmas that guide conventional bioethics to incorporate an understanding of the ethics of the everyday.

We live in a complex, interactive web of relationships involving ourselves, our communities, our environment, and our understanding of the transcendent that creates the fabric of our lives. Integrative ethics seeks to understand and embrace the totality of that web of relationships, seeking those features that promote human flourishing. It understands that even small variations and frictions in one corner of that fabric can create profound consequences in other areas. Thus, what is often simply called good manners—treating another respectfully, listening to him, addressing him politely—is an exercise in basic ethical behavior.⁴⁰ In health care, such simple behavior can help or hinder a patient's recovery from illness or injury. As such, it is as deserving of attention as that accorded the more obvious ethical conflicts normally identified by bioethics.

NOTES
1. See, e.g., John A. Astin, "Why Patients Use Alternative Medicine," Journal of the American Medical Association 279, no. 19 (1998): 1548–1553; Claire M. Cassidy, "Chinese Medicine Users in the United States: Part I: Utilization, Satisfaction, Medical Plurality," Journal of Alternative and Complementary Medicine 4, no. 1 (1998):17–27.