In March 2000, President William Clinton signed Executive Order 13,147, establishing the White House Commission on Complementary and Alternative Medicine, to develop public policy proposals geared toward maximizing “the benefits to Americans of complementary and alternative medicine.” Disconcertingly, the Commission's charge presumed the safety and efficacy of complementary and alternative medicine (CAM). In so doing, it placed the proverbial cart before the horse by setting the Commission on a mission to “address education and training of health care practitioners in CAM; [coordinate] research to increase knowledge about CAM products; [provide] reliable and useful information on CAM to health care professions, and [provide] guidance on the appropriate access to and delivery of CAM.”The Commission's final report (“Commission Report”), issued in March 2002, similarly skirts the fundamental question of whether evidence exists that CAM interventions are safe or offer sufficient benefit to justify their proliferation.

The increased focus in recent years on the risks posed by conflicts of interest arising from financial relationships between physician-investigators and the pharmaceutical and medical device industries has led to a variety of measures that can broadly be described as "regulatory" interventions, including new federal and state laws, criminal prosecutions and private lawsuits, requirements attached to government funding, and institutional policies. Studies suggest, however, that physician-investigators have not internalized the message that financial conflicts of interest have the potential to influence their decision making. Simply informing physician-investigators of the content of relevant rules and the consequences of noncompliance - as appears to be the practice in many existing compliance training activities - is unlikely to lead to lasting changes in norms or behavior. Instead, we theorize that, for trainings to be maximally effective, they must appeal to the complex intrinsic and extrinsic motivations that contribute to individuals' willingness to comply with regulatory mandates. In addition, physician-investigators' beliefs that the risks posed by conflicts of interest do not apply to them need to be challenged. Rigorous evaluation of the newly-designed training programs will help determine whether these theories are borne out in fact.

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The market changes sweeping the U.S. health care industry have a distinctive impact on communities that rely on religiously affiliated health care providers. When a sectarian sponsor subsumes multiple providers, its assertion of religious beliefs can preclude the provision of certain health care services to the entire community. In addition, the sectarian provider's refusal to offer certain services may violate state certificates of need, licensing, Medicaid managed care, or even professional liability law. This situation challenges both the provider and the state: the provider seeks adherence to religious law, and the state seeks compliance with its law and citizens access to health care.I propose that the state attempt to ameliorate tensions between civil and religious laws through negotiated accomodation. This concept encourages the sectarian institution to reassess its mission in the current market and to identify alternative avenues of health care delivery that will preserve patients' access to care without excessively diluting religious identity or beliefs.

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