- Email: [email protected]
Development of ethical rules for boundaries of touch in complementary medicine – outcomes of a Delphi process
Complementary Therapies in Clinical Practice 16 (2010) 194e197
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctnm
Development of ethical rules for boundaries of touch in complementary medicine e outcomes of a Delphi process Elad Schiff a, b, c, *, Eran Ben-Arye d, e, Margalit Shilo f, Moti Levy g, Leora Schachter h, Na’ama Weitchner b, c, Ofra Golan b, c, i, Julie Stone j a
Department of Internal Medicine, Bnai-Zion Hospital, Haifa, Israel The Department for Complementary/Integrative Medicine, Law and Ethics, Israel The International Center for Health, Law and Ethics, Haifa University, Israel d The Complementary and Traditional Medicine Unit, Department of Family Practice, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel e The Integrative Oncology Program, Haifa and Western Galilee Oncology Service, Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Israel f Leumit Health Services, Israel g Clalit Complementary Medicine, Israel h “Maccabi” Health Care Services, Israel i Unit for Genetic Policy and Bioethics, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel j Peninsula Medical School, United Kingdom b c
a b s t r a c t Keywords: Touch Boundaries Code of ethics Complementary medicine
The practice of complementary medicine (CAM) often involves touch. The unique philosophy of many CAM therapies, and the setting in which treatments are provided create a therapeutic space which may be less clearly defined than in conventional settings e a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The aim of the process described in this article, was to develop ethical guidelines for boundaries of touch that will promote the safety and protection of the public which use CAM. Through a modified Delphi process, a diverse group of CAM practitioners, physicians, ethicists, legal consultants, health policy specialists, and representatives from the public, developed Ethical Rules for Boundaries of Touch in CAM. These guidelines may be implemented in ethical codes of professional CAM organizations, and also serve as a foundation for curriculums in ethics in CAM schools. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction Most complementary medicine (CAM) modalities involve physical touch. The dependency and intensity of physical touch in CAM can be divided into three types. In the first group are therapies where touching is the primary healing mechanism. This would include various kinds of massage (e.g. Swedish, Thai, medical and other massage types), osteopathy and chiropractic, as well as Far Eastern touch therapies such as Shiatsu and Tuina. The second group includes modalities in which touch is a secondary component of the healing activity, where touch is used as a vector or carrier of the primary therapy, e.g. to apply therapeutic oils. This
* Corresponding author. Department of Internal Medicine B, Bnai Zion Medical Center, PO Box 4940, Haifa 31048, Israel. Tel.: þ972 4 8359775; fax: þ972 4 8359773. E-mail address: [email protected] (E. Schiff). 1744-3881/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2010.05.009
group would include aromatherapy, Ayurveda, and various kinds of energetic healing therapies. The third group includes disciplines that require a certain degree of physical exposure and partial contact for purposes of diagnosis and treatment, such as acupuncture, yoga therapy and branches of movement education such as Alexander and Feldenkreis. There are disciplines in complementary medicine that do not necessarily require physical touch for diagnosis and treatment, for example, homeopathy, guided imagery and Bach flowers. CAM therapies require particularly clear boundaries regarding appropriate touch in light of the fact that these therapies are: 1) Holistic in character, meaning they involve the practitioner relating to the patient’s personal needs, including the patient’s emotional and spiritual processes. This may increase the likelihood of patient transference and create greater dependence on the therapist, heighten the power differential between practitioners and patients, thereby increasing the potential for abuse.
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
2) Unlike conventional practitioners, CAM practitioners often work in sole, private practice and non-supervised settings, posing risks for patients of inappropriate behaviour, and risks for practitioners in terms of harassment and unfounded allegations. 3) In some cases the therapies are given while creating an atmosphere that encourages intimacy, such as quiet music, candles, incense, and so on, which may lead to patient and practitioner disinhibition. The combination of factors, such as encouraging emotional exposure, an intimate atmosphere, and a focus on physical contact, create a therapeutic space which may be less clearly defined than in conventional settings e a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The most problematic ethical issue in relation to therapeutic contact is the proximity between professional touch i.e. treatments, and what might be construed by a patient as sexual contact. Therapeutic physical touch, especially in massage, has a sexual context that cannot be ignored. Notwithstanding the overt distinctions between therapeutic massage and sensual massage, the entire skin can be considered an erotic organ, and touching it can arouse sexual stimulation regardless of the therapist’s initial intention; something which has even led several therapists to claim that working with sexual stimulation should be part of the therapeutic process. The complexity of this subject is caused by the fact that the sexual instinct is one of the strongest urges in human experience. Physical contact, which can be perceived as quasi-sexual, may open up huge emotional issues for patients, in some, unleashing the depth of their need for emotional warmth and closeness, and in others, exposing them to flashbacks and bodily association of previous abuse. All therapies involving touch, and in particular, direct physical touch therapies are particularly vulnerable to exploitation of these sexual and emotional needs, and the therapeutic milieu is fertile ground for all kinds of latent and overt sexual acting out on both sides. This can have disastrous consequences for patients and therapists alike.1,2 Although precise prevalence is hard to ascertain, reports of complaints concerning cases of sexual harassment in CAM treatments are not rare.3 Usually this involves sexually inappropriate behaviour on the part of therapists, but it may also involve harassment of therapists by patients. Given the large number of therapists in practice, and the diverse range of touch modalities to which the public is exposed, together with the absence of supervision and regulation in CAM, clear ethical definitions of the boundaries of touch in complementary medicine are timely. During the last years, the authors (JS, NW, OG) lead workshops on Boundaries of touch, and developed educational material on the topic for CAM students, and practitioners in England and Israel. Based on these educational experiences, the authors strived to develop ethical guidelines that will promote the safety and protection of the public which use CAM. Moreover, it was our intent that such principles will inspire CAM regulatory boards to develop respective codes of ethics and conduct. Building upon these insights, we conceived a process that may generate clear and practical ethical rules for safe touch, based on a wide consensus.
195
and revisions. The Modified Delphi Technique described here uses email, group meetings followed by feedback, and report of conclusions. 2.1.1. Expert panel In 2005, a core expert panel of six members came together to include experienced integrative physicians (N ¼ 2), CAM practitioners (five, having the following specialties: acupuncture, homeopathy, Ayurveda, reiki & healing touch, herbology, shiatsu, reflexology, antrophosophy), and legal (N ¼ 3) end ethics (N ¼ 2) specialists (most participants had multiple specialties). The heterogeneity of panel members helped generate a wide spectrum of opinions and a greater proportion of high-quality and highly acceptable solutions. In addition, the inclusion of both physicians and non-MD CAM practitioners in the leading expert panel reflected the honoring of the value of medical pluralism.4 Following a literature review and group discussions of the core expert panel, preliminary guidelines for safe touch were developed. 2.1.2. Extended expert panel The preliminary guidelines were distributed via email to 25 experts from mixed backgrounds, including physicians (N ¼ 9) with various specialties (Internal medicine, family medicine, GP’s, neurology), CAM practitioners from a range of therapies (N ¼ 14: mindebody, energy-based, body-manipulative, Traditional, and biologic based approaches), ethicists (N ¼ 2), legal consultants (N ¼ 4), representatives from the four HMO’s (N ¼ 4) in Israel, and health policy specialists (N ¼ 2). A face-to-face meeting with the extended expert panel was held and safe touch guidelines were further refined. The refined guidelines were further circulated for feedback between the extended expert panel until agreement was obtained. Thereafter, national medical and CAM organizations representatives in Israel were asked to reflect on the extended expert panel suggested guidelines. These organizations included the Israel Society for Complementary medicine in the Israel Medical Association, professional CAM organizations affiliated with the Chamber for Complementary Health Professions, executives of the leading CAM colleges in Israel, representatives of health medical organizations, and representatives of the public, coming from various health consumer organizations. Their comments were distributed again to the extended expert panel via emails, and modifications were done according to feedbacks until agreement was obtained. 2.1.3. Conference discussion forum In March 2006 a conference titled “CAM, ethics & Law”5 was held in Israel with the participation of 247 professionals in the fields of CAM (N ¼ 153), conventional medicine (N ¼ 68), law (N ¼ 36), ethics (N ¼ 13), and health policy (N ¼ 8). A full conference day was dedicated for discussion on the safe touch guidelines. The discussion was moderated by a lawyer specializing in medical ethics. A panel of 6 specialists (other than the core expert panel, 5 CAM practitioners, 1 public representative, 1 ethics & law specialist) commented on the guidelines. Conference participants had the opportunity to comment too. A further refinement of the guidelines was done accordingly. An approval to the final version of the guidelines was provided by 12 professional organizations of CAM and conventional medicine.
2. Methods
3. Results
2.1. Modified Delphi process
3.1. Position paper
The Delphi Technique enables group problem-solving using an iterative process of problem definition and discussion, feedback,
Following the Delphi process described above, a position paper on boundaries of touch in CAM was formulated. The paper was
196
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
constructed to include three sections; the goal of the ethical rules, the guiding principles, and the practical rules themselves. 3.1.1. Goal of the ethics rules To protect the patients from any form of inappropriate touch that is liable to harm the patient To protect practitioners from sexual harassment or allegations of inappropriate behaviour To protect the reputation of the profession To set guidelines to inform fitness to practice and professional disciplinary processes regarding boundaries of touch in CAM To create clear rules, deviation from which is liable to lead to disciplinary proceedings To create a basis for the teaching of ethics in the framework of CAM studies
3.1.2. Guiding principles No treatment in CAM is allowed to include contact or stimulus of a sexual nature of any kind whatsoever. Practitioners must refrain from acting sexually in any way with patients. For example, practitioners should refrain from inappropriate sexual humour or language. Erogenous zones of the body must not be touched. These include genitals, nipples, and the anus, whether by direct contact or through a cover. If the patient requests, the therapist will allow another person to be present in the room to act as a chaperone. 3.1.3. Ethical rules 1) Children 1.1 In touch therapies, children under the age of 16 will be accompanied by an adult who will be present in the room during the entire treatment. 2) Clarifications before and during treatments 2.1 In cases of touch therapies, the therapist will define clearly for the patient the desired clothing to be worn. Should the treatment be done with partial physical exposure, the therapist will let the patient choose the degree of exposure suitable for him. In any case, the exposure will not be imposed by the therapist, and alternatives will be presented to remain fully or partially clothed, based on the patient’s choice, whilst pointing out any effect this may have on the efficacy of the treatment. 2.2 In case the need arises for touching sensitive body parts, including the mouth area, thighs, buttocks or chest, the therapist must explain the therapeutic need for this contact and ascertain the patient’s consent for it in advance. 2.3 The therapist will make it clear to the patient that at any stage of treatment the patient may ask to discontinue the treatment if he feels uncomfortable. 3) Guidelines for touch therapies 3.1 In cases of treatment via unclothed massage, it is recommended to strictly ensure that the patient is completely covered at all times by a sheet or towel, exposing solely the body part being treated at that time. 3.2 The therapist must wear professional clothing which is not sexually provocative. 3.3 The therapist must leave the room when the patient gets undressed or dressed, or must allow him to do so behind a concealing partition, allowing maintenance of privacy during the treatment. 3.4 A CAM therapist will not have sexual relations with his patients throughout the entire time of the therapeutic relationship between them.
4 Patient complaints 4.1 All allegations of sexual impropriety made by a patient against a CAM therapist will be investigated and ordinarily give rise to a hearing. 4.2 Proven allegations of sexual boundary violations should result in erasure from the professional register an/or discontinuance of membership of the therapist’s professional organization. Disciplinary bodies may publicize the outcome of a case, subject to maintaining the anonymity of the complainant. 4.3 These rules shall not detract from any order of legislation, including laws for the prevention of sexual harassment, prohibitions against sex with vulnerable persons, and the penal code/criminal law. 4. Discussion The aim of the process and its outcomes, as described in this paper is to serve as a basis for formulating a code of professional ethics around the use of touch in CAM. It is hoped that the principles contained in the code will be incorporated into the preregistration curriculum for complementary therapists and that the code will be adopted by professional organizations within CAM, including regulatory bodies, guilds and membership organizations and employers. Once agreed, this code will set out the expectations which can reasonably be placed on therapists in relation to touch, deviation from which will form a basis for disciplinary action. Defining the boundaries of therapeutic touch becomes critically important in the professionalizing process of complementary medicine. This position paper is not intended to serve as a general code of ethics for complementary medicine as a profession, but rather to define ethical boundaries in one of the more problematic areas of complementary medicine, namely the boundaries of touch. For the reasons outlined above, the need has arisen for clear ethical definitions in regard to what is permitted and what is forbidden in touch therapies. This includes the need on the part of the therapist to explain to the patient, as accurately as possible, what is required during the therapy session and what degree of touch and physical exposure is necessary to achieve maximal treatment effectiveness. No less important is the need for therapists to make it clear to patients that they have the right to stop the treatment the moment the touch or exposure crosses their personal “red” boundaries. Furthermore, this position paper emphasizes the vital need for training therapists in the ethics of touch during their complementary medicine studies. This subject must be included in the college curriculum, with the aim of instilling in students an understanding of boundaries, a zero tolerance for patient abuse, a clear stance vis-à-vis the intimate nature of therapeutic touch, and how to cultivate appropriate and empathetic use of touch, whilst ensuring that the therapeutic space remains safe. Some of the ethical rules were strongly debated throughout the Delphi process. The absolute exclusion from touching erogenous zones of the body was felt by some participants to impede therapeutic delivery. As an example, osteopaths may need to treat patients with coccydinia, through digital rectal manipulation of the coccyx.6 Moreover, some therapists suggest working directly on pelvic surfaces to treat past abuse.7 However, through the Delphi process it became evident for the group, that in the current status of CAM, clear lines should be drawn for the benefit of the public. However, it was stated that if certain professional CAM organizations feel strongly about specific exclusions to these guidelines, then exemptions should be explicitly described in the professional rule of ethics, and patients diligently informed. Some of the suggested guidelines reflect an ethical “threshold” rather than an ethical aspiration. Such an example is the guideline
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
of refraining from sexual contact with a current patient. A desired guideline would have been refraining from relationships with current and former patients that may carry a power differential. The compromise was done in order to receive wider consensus and implementation of the guidelines. In conclusion, following a comprehensive, pluralistic and professional process, suggested ethical rules for touch boundaries were formulated to provide a safe therapeutic environment for CAM practitioners and their patients. The applicability and benefit of these guidelines should be assessed by both practitioners and patients and refinements should be done accordingly. Acknowledgments We thank the following people and organizations for their assistance in developing the ethical guidelines: Department for Complementary/Integrative Medicine, Law and Ethics at The International Center for Health, Law and Ethics; representatives of Clalit, Leumit, and Maccabi Health Services; members of the
197
Chamber for Complementary Health Professions and associated CAM colleges (Broshim, Reidman), especially Mr. Yair Shemmer; participants in the expert panels; representatives of the public and health consumer organizations; representatives of the Israel Medical Association; and Dr Ronit Leiba for the statistical analysis. References 1. Luepker E. Effects of practitioners’ sexual misconduct: a follow-up study. J Am Acad Psychiatry Law 1999;27:51e63. 2. Galletly CA. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Med J Aust 2004;181(7):380e3. 3. 2002 report on sexual harassment in Israel including allegations against CAM practitioners, http://www.macom.org.il/abuse_alternative.asp [accessed 13.11.08]. 4. Complementary and alternative medicine (CAM) in the United States. Institute of Medicine, The National Academies Press; 2005. 5. http://medlaw.haifa.ac.il/almed/ [accessed 13.11.08]. 6. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine 2001;26(20):E479eE483. 7. Ventegodt S, Morad M, Hyam E, Merrick J. Clinical holistic medicine: holistic sexology and treatment of vulvodynia through existential therapy and acceptance through touch. Scientific World Journal 2004;4:571e80.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctnm
Development of ethical rules for boundaries of touch in complementary medicine e outcomes of a Delphi process Elad Schiff a, b, c, *, Eran Ben-Arye d, e, Margalit Shilo f, Moti Levy g, Leora Schachter h, Na’ama Weitchner b, c, Ofra Golan b, c, i, Julie Stone j a
Department of Internal Medicine, Bnai-Zion Hospital, Haifa, Israel The Department for Complementary/Integrative Medicine, Law and Ethics, Israel The International Center for Health, Law and Ethics, Haifa University, Israel d The Complementary and Traditional Medicine Unit, Department of Family Practice, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel e The Integrative Oncology Program, Haifa and Western Galilee Oncology Service, Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Israel f Leumit Health Services, Israel g Clalit Complementary Medicine, Israel h “Maccabi” Health Care Services, Israel i Unit for Genetic Policy and Bioethics, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel j Peninsula Medical School, United Kingdom b c
a b s t r a c t Keywords: Touch Boundaries Code of ethics Complementary medicine
The practice of complementary medicine (CAM) often involves touch. The unique philosophy of many CAM therapies, and the setting in which treatments are provided create a therapeutic space which may be less clearly defined than in conventional settings e a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The aim of the process described in this article, was to develop ethical guidelines for boundaries of touch that will promote the safety and protection of the public which use CAM. Through a modified Delphi process, a diverse group of CAM practitioners, physicians, ethicists, legal consultants, health policy specialists, and representatives from the public, developed Ethical Rules for Boundaries of Touch in CAM. These guidelines may be implemented in ethical codes of professional CAM organizations, and also serve as a foundation for curriculums in ethics in CAM schools. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction Most complementary medicine (CAM) modalities involve physical touch. The dependency and intensity of physical touch in CAM can be divided into three types. In the first group are therapies where touching is the primary healing mechanism. This would include various kinds of massage (e.g. Swedish, Thai, medical and other massage types), osteopathy and chiropractic, as well as Far Eastern touch therapies such as Shiatsu and Tuina. The second group includes modalities in which touch is a secondary component of the healing activity, where touch is used as a vector or carrier of the primary therapy, e.g. to apply therapeutic oils. This
* Corresponding author. Department of Internal Medicine B, Bnai Zion Medical Center, PO Box 4940, Haifa 31048, Israel. Tel.: þ972 4 8359775; fax: þ972 4 8359773. E-mail address: [email protected] (E. Schiff). 1744-3881/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2010.05.009
group would include aromatherapy, Ayurveda, and various kinds of energetic healing therapies. The third group includes disciplines that require a certain degree of physical exposure and partial contact for purposes of diagnosis and treatment, such as acupuncture, yoga therapy and branches of movement education such as Alexander and Feldenkreis. There are disciplines in complementary medicine that do not necessarily require physical touch for diagnosis and treatment, for example, homeopathy, guided imagery and Bach flowers. CAM therapies require particularly clear boundaries regarding appropriate touch in light of the fact that these therapies are: 1) Holistic in character, meaning they involve the practitioner relating to the patient’s personal needs, including the patient’s emotional and spiritual processes. This may increase the likelihood of patient transference and create greater dependence on the therapist, heighten the power differential between practitioners and patients, thereby increasing the potential for abuse.
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
2) Unlike conventional practitioners, CAM practitioners often work in sole, private practice and non-supervised settings, posing risks for patients of inappropriate behaviour, and risks for practitioners in terms of harassment and unfounded allegations. 3) In some cases the therapies are given while creating an atmosphere that encourages intimacy, such as quiet music, candles, incense, and so on, which may lead to patient and practitioner disinhibition. The combination of factors, such as encouraging emotional exposure, an intimate atmosphere, and a focus on physical contact, create a therapeutic space which may be less clearly defined than in conventional settings e a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The most problematic ethical issue in relation to therapeutic contact is the proximity between professional touch i.e. treatments, and what might be construed by a patient as sexual contact. Therapeutic physical touch, especially in massage, has a sexual context that cannot be ignored. Notwithstanding the overt distinctions between therapeutic massage and sensual massage, the entire skin can be considered an erotic organ, and touching it can arouse sexual stimulation regardless of the therapist’s initial intention; something which has even led several therapists to claim that working with sexual stimulation should be part of the therapeutic process. The complexity of this subject is caused by the fact that the sexual instinct is one of the strongest urges in human experience. Physical contact, which can be perceived as quasi-sexual, may open up huge emotional issues for patients, in some, unleashing the depth of their need for emotional warmth and closeness, and in others, exposing them to flashbacks and bodily association of previous abuse. All therapies involving touch, and in particular, direct physical touch therapies are particularly vulnerable to exploitation of these sexual and emotional needs, and the therapeutic milieu is fertile ground for all kinds of latent and overt sexual acting out on both sides. This can have disastrous consequences for patients and therapists alike.1,2 Although precise prevalence is hard to ascertain, reports of complaints concerning cases of sexual harassment in CAM treatments are not rare.3 Usually this involves sexually inappropriate behaviour on the part of therapists, but it may also involve harassment of therapists by patients. Given the large number of therapists in practice, and the diverse range of touch modalities to which the public is exposed, together with the absence of supervision and regulation in CAM, clear ethical definitions of the boundaries of touch in complementary medicine are timely. During the last years, the authors (JS, NW, OG) lead workshops on Boundaries of touch, and developed educational material on the topic for CAM students, and practitioners in England and Israel. Based on these educational experiences, the authors strived to develop ethical guidelines that will promote the safety and protection of the public which use CAM. Moreover, it was our intent that such principles will inspire CAM regulatory boards to develop respective codes of ethics and conduct. Building upon these insights, we conceived a process that may generate clear and practical ethical rules for safe touch, based on a wide consensus.
195
and revisions. The Modified Delphi Technique described here uses email, group meetings followed by feedback, and report of conclusions. 2.1.1. Expert panel In 2005, a core expert panel of six members came together to include experienced integrative physicians (N ¼ 2), CAM practitioners (five, having the following specialties: acupuncture, homeopathy, Ayurveda, reiki & healing touch, herbology, shiatsu, reflexology, antrophosophy), and legal (N ¼ 3) end ethics (N ¼ 2) specialists (most participants had multiple specialties). The heterogeneity of panel members helped generate a wide spectrum of opinions and a greater proportion of high-quality and highly acceptable solutions. In addition, the inclusion of both physicians and non-MD CAM practitioners in the leading expert panel reflected the honoring of the value of medical pluralism.4 Following a literature review and group discussions of the core expert panel, preliminary guidelines for safe touch were developed. 2.1.2. Extended expert panel The preliminary guidelines were distributed via email to 25 experts from mixed backgrounds, including physicians (N ¼ 9) with various specialties (Internal medicine, family medicine, GP’s, neurology), CAM practitioners from a range of therapies (N ¼ 14: mindebody, energy-based, body-manipulative, Traditional, and biologic based approaches), ethicists (N ¼ 2), legal consultants (N ¼ 4), representatives from the four HMO’s (N ¼ 4) in Israel, and health policy specialists (N ¼ 2). A face-to-face meeting with the extended expert panel was held and safe touch guidelines were further refined. The refined guidelines were further circulated for feedback between the extended expert panel until agreement was obtained. Thereafter, national medical and CAM organizations representatives in Israel were asked to reflect on the extended expert panel suggested guidelines. These organizations included the Israel Society for Complementary medicine in the Israel Medical Association, professional CAM organizations affiliated with the Chamber for Complementary Health Professions, executives of the leading CAM colleges in Israel, representatives of health medical organizations, and representatives of the public, coming from various health consumer organizations. Their comments were distributed again to the extended expert panel via emails, and modifications were done according to feedbacks until agreement was obtained. 2.1.3. Conference discussion forum In March 2006 a conference titled “CAM, ethics & Law”5 was held in Israel with the participation of 247 professionals in the fields of CAM (N ¼ 153), conventional medicine (N ¼ 68), law (N ¼ 36), ethics (N ¼ 13), and health policy (N ¼ 8). A full conference day was dedicated for discussion on the safe touch guidelines. The discussion was moderated by a lawyer specializing in medical ethics. A panel of 6 specialists (other than the core expert panel, 5 CAM practitioners, 1 public representative, 1 ethics & law specialist) commented on the guidelines. Conference participants had the opportunity to comment too. A further refinement of the guidelines was done accordingly. An approval to the final version of the guidelines was provided by 12 professional organizations of CAM and conventional medicine.
2. Methods
3. Results
2.1. Modified Delphi process
3.1. Position paper
The Delphi Technique enables group problem-solving using an iterative process of problem definition and discussion, feedback,
Following the Delphi process described above, a position paper on boundaries of touch in CAM was formulated. The paper was
196
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
constructed to include three sections; the goal of the ethical rules, the guiding principles, and the practical rules themselves. 3.1.1. Goal of the ethics rules To protect the patients from any form of inappropriate touch that is liable to harm the patient To protect practitioners from sexual harassment or allegations of inappropriate behaviour To protect the reputation of the profession To set guidelines to inform fitness to practice and professional disciplinary processes regarding boundaries of touch in CAM To create clear rules, deviation from which is liable to lead to disciplinary proceedings To create a basis for the teaching of ethics in the framework of CAM studies
3.1.2. Guiding principles No treatment in CAM is allowed to include contact or stimulus of a sexual nature of any kind whatsoever. Practitioners must refrain from acting sexually in any way with patients. For example, practitioners should refrain from inappropriate sexual humour or language. Erogenous zones of the body must not be touched. These include genitals, nipples, and the anus, whether by direct contact or through a cover. If the patient requests, the therapist will allow another person to be present in the room to act as a chaperone. 3.1.3. Ethical rules 1) Children 1.1 In touch therapies, children under the age of 16 will be accompanied by an adult who will be present in the room during the entire treatment. 2) Clarifications before and during treatments 2.1 In cases of touch therapies, the therapist will define clearly for the patient the desired clothing to be worn. Should the treatment be done with partial physical exposure, the therapist will let the patient choose the degree of exposure suitable for him. In any case, the exposure will not be imposed by the therapist, and alternatives will be presented to remain fully or partially clothed, based on the patient’s choice, whilst pointing out any effect this may have on the efficacy of the treatment. 2.2 In case the need arises for touching sensitive body parts, including the mouth area, thighs, buttocks or chest, the therapist must explain the therapeutic need for this contact and ascertain the patient’s consent for it in advance. 2.3 The therapist will make it clear to the patient that at any stage of treatment the patient may ask to discontinue the treatment if he feels uncomfortable. 3) Guidelines for touch therapies 3.1 In cases of treatment via unclothed massage, it is recommended to strictly ensure that the patient is completely covered at all times by a sheet or towel, exposing solely the body part being treated at that time. 3.2 The therapist must wear professional clothing which is not sexually provocative. 3.3 The therapist must leave the room when the patient gets undressed or dressed, or must allow him to do so behind a concealing partition, allowing maintenance of privacy during the treatment. 3.4 A CAM therapist will not have sexual relations with his patients throughout the entire time of the therapeutic relationship between them.
4 Patient complaints 4.1 All allegations of sexual impropriety made by a patient against a CAM therapist will be investigated and ordinarily give rise to a hearing. 4.2 Proven allegations of sexual boundary violations should result in erasure from the professional register an/or discontinuance of membership of the therapist’s professional organization. Disciplinary bodies may publicize the outcome of a case, subject to maintaining the anonymity of the complainant. 4.3 These rules shall not detract from any order of legislation, including laws for the prevention of sexual harassment, prohibitions against sex with vulnerable persons, and the penal code/criminal law. 4. Discussion The aim of the process and its outcomes, as described in this paper is to serve as a basis for formulating a code of professional ethics around the use of touch in CAM. It is hoped that the principles contained in the code will be incorporated into the preregistration curriculum for complementary therapists and that the code will be adopted by professional organizations within CAM, including regulatory bodies, guilds and membership organizations and employers. Once agreed, this code will set out the expectations which can reasonably be placed on therapists in relation to touch, deviation from which will form a basis for disciplinary action. Defining the boundaries of therapeutic touch becomes critically important in the professionalizing process of complementary medicine. This position paper is not intended to serve as a general code of ethics for complementary medicine as a profession, but rather to define ethical boundaries in one of the more problematic areas of complementary medicine, namely the boundaries of touch. For the reasons outlined above, the need has arisen for clear ethical definitions in regard to what is permitted and what is forbidden in touch therapies. This includes the need on the part of the therapist to explain to the patient, as accurately as possible, what is required during the therapy session and what degree of touch and physical exposure is necessary to achieve maximal treatment effectiveness. No less important is the need for therapists to make it clear to patients that they have the right to stop the treatment the moment the touch or exposure crosses their personal “red” boundaries. Furthermore, this position paper emphasizes the vital need for training therapists in the ethics of touch during their complementary medicine studies. This subject must be included in the college curriculum, with the aim of instilling in students an understanding of boundaries, a zero tolerance for patient abuse, a clear stance vis-à-vis the intimate nature of therapeutic touch, and how to cultivate appropriate and empathetic use of touch, whilst ensuring that the therapeutic space remains safe. Some of the ethical rules were strongly debated throughout the Delphi process. The absolute exclusion from touching erogenous zones of the body was felt by some participants to impede therapeutic delivery. As an example, osteopaths may need to treat patients with coccydinia, through digital rectal manipulation of the coccyx.6 Moreover, some therapists suggest working directly on pelvic surfaces to treat past abuse.7 However, through the Delphi process it became evident for the group, that in the current status of CAM, clear lines should be drawn for the benefit of the public. However, it was stated that if certain professional CAM organizations feel strongly about specific exclusions to these guidelines, then exemptions should be explicitly described in the professional rule of ethics, and patients diligently informed. Some of the suggested guidelines reflect an ethical “threshold” rather than an ethical aspiration. Such an example is the guideline
E. Schiff et al. / Complementary Therapies in Clinical Practice 16 (2010) 194e197
of refraining from sexual contact with a current patient. A desired guideline would have been refraining from relationships with current and former patients that may carry a power differential. The compromise was done in order to receive wider consensus and implementation of the guidelines. In conclusion, following a comprehensive, pluralistic and professional process, suggested ethical rules for touch boundaries were formulated to provide a safe therapeutic environment for CAM practitioners and their patients. The applicability and benefit of these guidelines should be assessed by both practitioners and patients and refinements should be done accordingly. Acknowledgments We thank the following people and organizations for their assistance in developing the ethical guidelines: Department for Complementary/Integrative Medicine, Law and Ethics at The International Center for Health, Law and Ethics; representatives of Clalit, Leumit, and Maccabi Health Services; members of the
197
Chamber for Complementary Health Professions and associated CAM colleges (Broshim, Reidman), especially Mr. Yair Shemmer; participants in the expert panels; representatives of the public and health consumer organizations; representatives of the Israel Medical Association; and Dr Ronit Leiba for the statistical analysis. References 1. Luepker E. Effects of practitioners’ sexual misconduct: a follow-up study. J Am Acad Psychiatry Law 1999;27:51e63. 2. Galletly CA. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Med J Aust 2004;181(7):380e3. 3. 2002 report on sexual harassment in Israel including allegations against CAM practitioners, http://www.macom.org.il/abuse_alternative.asp [accessed 13.11.08]. 4. Complementary and alternative medicine (CAM) in the United States. Institute of Medicine, The National Academies Press; 2005. 5. http://medlaw.haifa.ac.il/almed/ [accessed 13.11.08]. 6. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine 2001;26(20):E479eE483. 7. Ventegodt S, Morad M, Hyam E, Merrick J. Clinical holistic medicine: holistic sexology and treatment of vulvodynia through existential therapy and acceptance through touch. Scientific World Journal 2004;4:571e80.