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MDs vs. NDs: On the Regulation of Naturopathic Medicine

photograph of stethescope and blood pressure pump

While 16 states, plus the District of Columbia and Puerto Rico, license naturopathic doctors, many physicians have expressed strong opposition against this practice. These physicians point to naturopathic treatment as an unsafe alternative to modern medicine, because they argue that Naturopathic Doctors (N.D.s) are not qualified to diagnose and treat illness. On the other hand, N.D.s want increased legitimacy within the field of holistic health to ensure that patients go to qualified practitioners. It is evident that physicians and N.D.s share a mutual goal: ensuring that patients receive quality care. However, the two parties have different ideas of how to promote the just treatment of patients: either recognize N.D.s as licensed Naturopathic Doctors, or bar them from that distinction, lumping them together with untrained practitioners. The ethical concern lies with ensuring that patients have the proper information needed to access just and safe treatment. For the good of all those involved we must ask: should N.D.s be licensed and formally recognized?

First, some critics have argued that people practicing naturopathy are not sufficiently trained in the medical field. Naturopathic medicine can be practiced in two different ways: by naturopathic doctors and by unlicensed naturopaths. While they both sit under the umbrella of naturopathy, the difference between these two practices is significant. While N.D.s graduate from a four year naturopathic school and receive a license from the Council on Naturopathic Medical Education, unlicensed naturopaths might receive informal training and are only qualified to make “general lifestyle” recommendations. N.D.s want to be recognized as legitimate medical practitioners to increase their agency and distinguish themselves from non-licensed naturopaths. Being recognized as medical practitioners would allow N.D.s the power to write prescriptions and conduct medical tests more freely, which would increase their influence over the treatment of their patients. Nevertheless, their desire for greater authority is based on concern for the well-being of patients: N.D.s are worried that patients might be going to naturopaths without understanding the distinction between naturopaths and N.D.s. 

Prospective patients needs to know that naturopaths are only trained to provide general lifestyle advice. Patients should not visit a naturopath for questions regarding specific ailments. Individuals who work as naturopaths must actively work to protect prospective clients by turning them away when their inquiries stretch beyond this scope. Prospective patients must also understand that N.D.s cannot replace physicians; believing so could prove a great risk to the patient’s well-being.

While there are guidelines for what naturopaths can and cannot do, this varies depending on individual states’ laws and regulations. Due to the relative novelty of naturopathy in the U.S, many people are unaware of the possible risks and benefits of its practice. This affects whether lawmakers believe that wider recognition for N.D.s would have a positive impact on patients’ health outcomes. A possible solution would involve a commitment to patient education, prioritizing the agency of individuals by promoting free and ample access to information. If people are equipped to make truly informed choices, they can decide whether they best belong at the M.D., N.D., or naturopath’s office. Free and equitable access to information would mean that people are less at risk of being harmed without their knowledge. The issue with this suggestion, however, is that universal access to information is not a reality. For this reason, how N.D.s are recognized matters.

Organizations like the American Academy of Family Physicians oppose a special distinction for N.D’s, because they argue that it might assert an equal status between N.D.s and physicians. This, they argue, would put patients at risk. They point out that physicians attend medical school upwards of ten years, while N.D.s undergo nearly half of that. The AAFP outlines the difference they perceive in the training of family physicians and naturopaths. They include the similarities/differences between the two programs of study:

 

 

 

 

What the table above illustrates is that, by the standards used by the AAFP, physicians receive training for a longer period of time and are vetted as possible candidates for a degree with more rigor. For physicians, it is problematic to identify those who practice both fields under the same label, because it fails to appreciate the sizable difference in qualifications of the two professions. Physicians are trained in many subjects that N.D.s are not; this is significant when discussing an individual’s health outcomes. There is a concern that recognizing N.D.s as legitimate medical practitioners actually puts patients at a greater risk, because they are making decisions based on a lie. The “lie” being that a patient can go to physician or N.D regardless of the medical problem, since both professionals have the same expertise.

It should be clear that physicians and N.D.s do not possess the same knowledge. Both fields distinguish themselves as different from each other, and N.D.s continue to recognize the need for physicians, in cases requiring surgery, for example. Some N.D.s even specify that patients should seek advice from their doctors when they seek naturopathic care. N.D.s do not desire to obtain an equal status to physicians, which should appease many. Instead, N.D.s would like their title to reflect the services they can provide and distinguish them from those who merely offers advice as naturopaths.

N.D.s insist that without more public legitimacy, people might go to unlicensed naturopaths thinking they are consulting someone with a greater level of professional training and education. The reality is that a proper solution is not clear, and there is ambiguity regarding what policy best protects the safety of patients, a common value or goal shared by both “sides.” But the parties have strong beliefs about the proper way to reach that goal and, unfortunately they don’t coincide. The hope is that by evaluating where opponents are coming from and what they care about, we can begin to draw out common interests. Then, these common interests have the potential to lead to collaborative decision-making about action steps.

In this case, physicians and N.D.s seek to protect patients and promote their well-being. While N.D.s would like more recognition that legitimizes their practice as more legitimate, physicians oppose this. If physicians don’t believe N.D.s possess sufficient knowledge, it is interesting to consider whether they would like N.D.s to receive more training or have stricter regulation on what they can treat. Naturopathy has been around for thousands of years all over the world, and its recent surge in popularity within the U.S points to its time-tested resilience. Furthermore, it will become increasingly necessary to investigate how Naturopathic medicine can be integrated among the other branches of medicine as its influence increases. The way we label the field and its practitioners will have serious consequences going forward.

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The Perils of Globalizing Mental Health

Photograph of 1944 poster that says "mental health is your concern"

In an age where self-care is a commonly touted virtue, it’s easy to take for granted what a recent development the gradual de-stigmatization of mental illness is. Celebrities constantly come forward with harrowing stories of struggle and recovery, pop-psychology blogs and websites abound, and every day we see more open and honest discussions about the foundations of and treatment options for mental illness.

Perhaps the globalization of this phenomenon is even more surprising. Mental health has truly become a global concern, with researchers and psychiatrists from a diverse array of cultural backgrounds contributing to our understanding of mental illness. Counseling is now considered an essential part of post-disaster relief packages, trauma being an assumed result of natural disasters. In the wake of the earthquake and tsunami that devastated Indonesia in October of 2018, for one recent example, clinical psychiatrists and trained volunteers were deployed by the World Health Organization to administer psychological first aid. These changes seem to signify the end of stigma, indicating more effective approaches to treating nebulous and painful conditions that afflict people around the world.

But despite the growing global concern over mental illness, the West still acts as a dominant force in the discourse around mental health. The DSM, or the Diagnostic and Statistical Manual of Mental Disorders, a handbook of symptoms and treatment options for mental illnesses compiled by the American Psychiatric Association, is considered the gold standard for diagnosing mental illness around the globe.

We rarely stop to ask whether or not applying American understandings of mental health can have a detrimental effect on the way mental illness is treated in non-Western cultures. Our culture has come to consider conditions like depression and schizophrenia solely through a biomedical lens, as illnesses entirely dependent on a complex set of neurological misfirings rather than cultural causes.

But in his book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters examines the ways in which the biomedical approach taken by Western psychiatry can have a negative effect on those suffering from mental illnesses in places with different understandings of what it means to have a unified sense of self. He argues that importing Western cures for mental illness, which are deeply rooted in our own cultural mores, to other nations is unethical.

Watters distinguishes between the pathoplastic and pathogenic causes of mental illness. Mental illnesses don’t function in the same way that diseases like cancer do, where the  expression of the disease is completely independent of cultural context. There are two ways that mental illness can express itself; the pathoplastic causes, which are individualized and culturally-specific, and pathogenic causes, the underlying psychological imbalances.

The difference between pathoplasticity and pathogenicity is explored by novelist Esmé Weijun Wang in her collection of essays The Collected Schizophrenias. She sees a vital distinction between “explanations”, the “spiritual narratives” that color pain and illness with cosmic significance, and “causes”, the neurological reasons for mental illness that are uniform for humans across the board. In other words, the pathoplastic causes of a disease, the explanations can have meaning for the afflicted, whether these explanations are rooted in culturally-specific expressions of pain or find outlets in things like religion.

Most researchers dismiss the pathoplastic causes as irrelevant, but Watters posits that “culture and social setting play a more complicated role in the disease than simply influencing the content of the delusion.” In Western society, we push the narrative that mental illness is biomedical, an illness as removed from cultural influences as cancer, but research suggests that the biomedical approach, taken solely on its own, can be harmful and even heighten stigma against mental illness.

Despite our growing interest in helping the mentally ill, stigma against mental illness in the West has actually been increasing since the 1950’s. According to a 1996 study,

Among adults who associated mental illness with psychosis, the odds of describing a person with mental illness as violent in 1996 were 2.3 times the odds of describing a person with mental illness as violent in 1950 […] Perceptions of dangerousness were associated with causal attributions of mental illness. Causal attributions of genetics or chemical imbalance increased the odds of perceiving a person with schizophrenia as dangerous to themselves and others.

While “perceptions of dangerousness appear to have stabilized” between different illnesses from 1996 and 2006, with “no significant differences […] in the public’s perceptions of dangerousness of adults with schizophrenia or depression,” the perception of dangerousness hasn’t faded from mental illness as a whole. The biomedical perspective on mental illness, the study suggests, has insidiously increased stigmatization by casting the mentally ill as inherently dangerous, helpless prisoners of their own minds. Watters suggests that the Western approach, while offering valuable insights on the underlying causes of disease, can be dehumanizing for the afflicted. It reflects a very Western sense of the body as divorced from culture, a neutral space only affected by genetic predispositions. Watters argues that what we’re actually importing to other cultures is not Western psychiatry but the Western idea of the self, our conception of what it means to be a functioning member of society. In our culture, we tend to have a strongly internal locus of control, meaning most Americans view themselves as completely in control of their lives, whereas other cultures have a more external locus. Our approach towards mental illness reflects this; those with mental illness are often viewed as lacking the willpower to overcome their condition. Despite the biomedical approach most Westerners subscribe to, which should firmly place the cause of mental illness outside of the afflicted, these beliefs persist.

This issue is part of an important ongoing conversation about the impact of globalization and Western hegemony. In the next century, we’ll see more natural disasters caused by climate change, which will inflict trauma on large populations of those already disenfranchised by poverty and disease. More trauma means more counseling and medication, specifically Western counseling.

Diagnoses can stick, sometimes doing more harm than good. Esmé Weijun Wang remarks that in Western society, “it is easy to forget that psychiatric diagnoses are human constructs, and not handed down from an all-knowing God on stone tablets; to ‘have schizophrenia’ is to fit an assemblage of symptoms, which are listed in a purple book [the DSM] made by humans,” and therefore not infallible. While therapy is undoubtedly useful for many, we should be cautious before applying it as a universal cure-all, and encourage rather than discourage global diversity in the field of mental health.

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The Ethical Ramifications of Legalizing the Exotic Wildlife Trade

Photo of a rhino horn and several products claiming to have rhino horn in them

Recently China has taken steps towards preserving exotic wildlife that have become endangered species. In 2017, China closed its market of ivory to protect African elephants and stop the illegal wildlife trade. This step commenced “China’s reputation as a leader of conservation” according to a Tiger Campaign Leader at the Environmental Investigation Agency.  However, as of October 29, 2018, the state Council, under Premier Li Kequiang, made a public decision to permit the controlled sale of rhino horns and tiger bones for research or traditional medicine. In doing so, they ended the 25-year-old ban of these products. The announcement discloses that “Rhino horns and tiger bones used in medical research or in healing can only be obtained from farmed rhinos and tigers,” restricting the open trade to only legal farms and not risking the remaining wild endangered populations. Conservationists, such as the World Wildlife Foundation (WWF), consider this a major hindrance for the exotic animal populations.

Conservationists argue that this new law could lead to a surge of illegal wildlife hunting and trading which would further threaten the already vulnerable animal population. This legal market gives the illegal transactions a place to hide. “The resumption of a legal market for these products is an enormous setback to efforts to protect tigers and rhinos in the wild,” says Margaret Kinnaird, of the World Wildlife Fund (WWF). Selling legal rhino horns and tiger bones signals that it is ethically okay to buy the products. The price of a rhino horn has peaked at $65,000 per kg, which is already more valuable than gold and elephant ivory. Today, at least three rhinos die per day because of hunting for their horns. It is expected that as the demand rises for this trade, the threatened population will continue to decline. Speaking on behalf of WWF, Leigh Henry, Director of Wildlife Policy, “urgently calls on China to maintain the ban on tiger bone and rhino horn trade which has been so critical in conserving these iconic species. This should be expanded to cover trade in all tiger parts and products.” Conservationists clearly argue the value of protecting the wildlife, such as tigers and rhinos.

An important aspect of the new law is that the rhino horns and tiger bones can only come from farms. This approach has also been promoted by South Africa and other African governments that have been encouraging private farming of exotic animals.  The World Wildlife Fund says there are fewer than 4,000 tigers living in the wild, but there are some 6,000 captive tigers, farmed in about 200 government-sanctioned locations across China. Farms that house these wild populations could be protecting them from extinction. To support this, Lu Kang, the foreign ministry spokesman, said that China’s 1993 ban on the products did not take into account the “reasonable needs of reality,” adding that China has improved its “law enforcement mechanism.”

To enforce this new law, it has been found that rhino horns are relatively easy to microchip and can have samples taken for DNA analysis. It is this kind of DNA analysis that conservationists argue would be necessary to regulate the illegal trade from the legal farms. Although it’s possible that the horn can be traced back to an individual animal, it is not clear yet how to verify a powdered rhino horn, a product that would be used for medicinal purposes, which may come from more than one animal. After all, the purpose of the law was to preserve the culture of Traditional Chinese Medicine (TCM), which requires the usage of tiger and rhino products.

Recently, World Health Organization (WHO) took a stance to support TCM along with other traditional medicine practices as a step towards long term universal health care. Traditional treatments are less costly and more accessible than Western medicine for some countries. This would extend the scope of medicinal practices to include a larger amount of people. According to the director-general of WHO, there is a cost advantage of supporting TCM because treatments are more pioneered towards lifestyle changes, herbal remedies, and reducing stress levels. However, Western scientists are concerned that TCM practices are not supported by clinical trials and therefore could be dangerous. TCM treatments are based on Theories of Qi, which means vital energy to help the body maintain health. Common treatments include acupuncture or herbal remedies. The rhino and tiger are both animals that have connections to virility and strength, providing help to patients with back pain, arthritis, and even hangovers.

Part of the new law states that the purpose behind it was to allow research or usage for traditional medicine. Rhino horns are made from the protein keratin, which is advertised to help treat everything from cancer to gout. However, there is a lack of Western medicinal evidence that proves this. A rare study from 1990 found that rhino horns can lower fevers in rodents, very similar to aspirin or acetaminophen. Tiger bones in medicinal use are crushed and made into a paste that can treat rheumatism and back pain. Yet again, there is a lack of scientific Western studies that support this claim.

Western scientists have spent millions of dollars on trials of TCM with little success. Researchers at the University of Maryland School of Medicine surveyed 70 systematic reviews measuring the effectiveness of traditional medicine practices, like acupuncture. The studies couldn’t reach a solid conclusion that supported positive effectiveness. Going along with Western medicine viewpoints, one would argue that the intention behind China’s new policy is not supported with evidence that the rhino horns and tiger bones are an effective form of medicine.  Overall, there are ethical ramifications of this issue that lie beyond the scope of preserving wildlife. The ethical arguments extend to differences between western and traditional medicinal practices and the means to be able to practice both.