Professor Ernst raises an important question: How can we improve communication with CAM providers to promote our patients' understanding of their situation and options? Clearly, in the case of Ms. P., surgery would be life-saving, and ideally her CAM providers as well as her allopathic providers would encourage that choice. But as Professor Ernst notes, CAM providers are not always open to allopathic treatments or to partnering with allopathic providers, just as allopaths can be resistant to collaboration with CAM providers.

A truly integrative health care system would encourage such collaboration to the benefit of all concerned, and should be a primary goal as relationships between CAM and conventional providers evolve. I am convinced, however, that Ms. P. made her (fully informed) decision on the basis of her own values, not those of any of her providers, as evidenced by her statement, "Even if you told me I would die tomorrow without surgery, I still wouldn't have it." Therein lies the crux of the matter, and indeed, the dilemma for all providers when faced with a refusal of their carefully considered recommendations. Ms. P.'s decision was based on her own assessment of her options, and the influence of her health care provider was only one factor in her assessment.