Commentary: an examination of the public justifications for the expansion of Canadian naturopaths' scope of practice.
The popularity of naturopathic medicine has recently increased among Canadians. (1) In 1997, about 39 percent of Canadians had visited a naturopath in the previous twelve months, and by 2006 this number increased to 49 percent. (2) The average number of visits per user per year has also increased from 4.9 to 5.6. (3) However, despite this increase in popularity, controversy still exists around the efficacy and scientific legitimacy of many naturopathic treatments, including, for example, homeopathy, hydrotherapy and various forms of detoxification. (4)
Health-related practice regulations are a matter of provincial legislative jurisdiction in Canada. In the context of naturopaths, there is a high level of variability in adopted approaches to regulation. (5) In recent years, Canadian naturopaths have sought to increase the number of provinces in which they are regulated, while simultaneously attempting to broaden their scope of practice to certain activities traditionally reserved for medical doctors, such as testing for allergies and prescribing pharmaceuticals. (6)
The purpose of this analysis is to present and critique the publicly available justifications provided by proponents of recently-passed regulatory amendments that expand the scope of practice for naturopaths practicing in the provinces of British Columbia and Ontario. In particular, our team sought to assess the type of arguments used to support such regulatory changes, specifically exploring whether any empirical evidence (defined here as non-anecdotal research, including categories set out by the Ontario Health Professions Regulatory Advisory Council: randomized control trials, analytic cohort or case control studies, time series analyses, and expert reports) supporting the efficacy of naturopathic medicine was used. (7) Over the past decade, there has been a general movement toward both evidence-based health care and evidence-based health policy. Indeed, many traditionally-recognized health professionals are required by their professional bodies to adopt an evidence-based approach, and provincial governments have stated a commitment to such an approach. (8) From a scientific perspective, this is logical. Determinations of medical efficacy in a scientific context require an evidence-based or, at least, evidence-informed, approach--one that is based upon established empirical principles (the double blind, three arm clinical trial is often viewed as the "gold standard"). (9) As such, it seems appropriate to gain an understanding of the degree to which evidence of efficacy served as an argument for legitimacy in this context. Our analysis, however, showed that arguments as to the efficacy of naturopathic medicine were either unsubstantiated or missing altogether. Given the aforementioned movement toward evidence-based healthcare, and given the controversy surrounding the efficacy of naturopathic medicine, the evidence should have been more transparent, informing and directing the policy debate.
The Nature of Naturopathy
The traditional scope of practice for a naturopath focuses on natural remedies and lifestyle alterations that are meant to be preventive in nature. The Canadian Association of Naturopathic Doctors (CAND) states that "Naturopathic Medicine emphasizes disease as a process rather than as an entity." (10) One particular core philosophical tenet of naturopathy is medicatrix naturae, which means "the healing power of nature." (11) Naturopaths traditionally oppose what they perceive to be an excessive use of pharmaceuticals and synthetic treatments, arguing instead that with proper stimulation the body can heal itself of almost any ailment. (12) According to the CAND, treatments normally provided by naturopaths fall under the categories of clinical nutrition, botanical medicine, homeopathic medicine, traditional Chinese medicine, physical medicine (massage and spinal manipulation), prevention and lifestyle counseling, and other therapies such as chelation, colonic irrigation, and IV therapies. (13) The British Columbian Health Professions Act's Naturopathic Physicians Regulation defines naturopathic medicine in s.1 as "the health profession in which a person provides the services of prevention, assessment and treatment of an individual's diseases, disorders and conditions using education and naturopathic techniques, therapies or therapeutics to stimulate or support healing processes and promote, maintain or restore the overall health of the individual." (14)
Scope of Practice Expansion in British Columbia and Ontario
On December 12, 2008 the British Columbia government proposed new regulatory changes that would give naturopaths in the province the authority to write prescriptions for many restricted medications (i.e., those not available over the counter due to the Federal Food and Drugs Act and associated regulations), excluding certain powerful Schedule 1 drugs. (15) While the impetus for this was originally to restore naturopaths' ability to treat with certain natural products that had recently become restricted under the Federal Food and Drugs Act's Natural Health Products Regulations, other powerful synthetic drugs like antibiotics were also included in the granted prescription range. (16)
The government requested feedback from the medical and general health community within a month's time. The British Columbia Medical Association (BCMA) responded formally and details were disseminated through the media; BCMA president Dr. Bill Mackie claimed that the changes "were introduced despite commitments from the provincial government to consult with the [medical] profession before releasing them." (17) He stated that "Providing 30 days for input that included Christmas holidays is not a meaningful period of time for considerate feedback." (18)
Various commentators, including representatives of the BCMA, made public their objections throughout the process of enactment. (19) Despite the controversy, the regulations were passed on April 9, 2009. Many continue to voice their concern today. The new BCMA president, Dr. Ian Gillespie, stated in 2011 that "Naturopaths are not trained to make medical diagnosis and prescribe medical treatment, so we can't support independent prescribing by naturopaths." (20) Serious safety concerns arise from this, he said, including the possibility of misdiagnoses and/or improper treatments. (21)
While British Columbia has led the way when it comes to expanding Canadian naturopaths' scope of practice, Ontario has also been very supportive of the profession. The latter province passed Bill 179 during December of 2010, amending the Naturopathy Act and granting naturopaths the right to prescribe pharmaceuticals; this occurred despite the fact that the Ontario Medical Association (OMA) had opposed the bill in September, stating that "the use of pharmaceuticals or synthetic drugs is completely outside naturopathy's educational framework and scope of practice." (22) Regulations setting out what can be prescribed will not be complete until late 2012. (23)
Our analysis focused on three categories of documentation: (1) official policy reports published by provincial health regulation councils; (2) transcripts of provincial legislative debates (i.e., Hansard), and; (3) media reports, specifically print news articles and editorials. It is important to note the research limitations in this instance. The intent was to compile works available to the public. There are likely internal health ministry documents further detailing justifications for expansion, but these were not accessible except through filing a formal freedom of information request. Nevertheless, what is available provides us with a fairly clear picture of the public debate and of the public justifications for the policy change. Once collected, the works were scanned for justifications for expansion of naturopaths' rights, and for references to evidence, whether cited or implied.
Several reports on naturopaths have been published by provincial health profession regulatory councils over the past fifteen years. (24) These reports differ with regards to their recommendations. Some recommend an expanded scope of practice, suggesting corresponding changes to the related legislation and regulation. Others suggest that naturopaths are insufficiently trained to provide many forms of care that exceed their traditional activities.
The British Columbian Health Professions Council (BCHPC) released a preliminary report on naturopaths' scope of practice in December of 1998. It initially suggested granting naturopaths the right to test allergies, to administer remedies by injection, and to partake in "a limited range of laboratory testing," inter alia. (25) Moreover, it spoke of the need to approve a schedule of substances that naturopaths could prescribe. (26)
The BCHPC report was updated in March of 2001, after a hearing with both the Association of Naturopathic Physicians of British Columbia and the College of Physicians and Surgeons of British Columbia. Upon further study, the Council altered its conclusions significantly, stating that:
... the training of naturopathic physicians is considerably less than medical practitioners, particularly in respect of clinical hours. The clinical training that naturopathic physicians receive in the four-year curriculum is insufficient for anyone to become competent in the great number of areas which the College wishes to have included in the scope of practice. (27)
Naturopaths were found unqualified to: perform cervical manipulations, administer allergy test procedures, prescribe Schedule 1 drugs (28 proposed), and be granted hospital treatment privileges. (28) Despite the council's conclusions, the province decided to grant naturopaths (in the April 9, 2009 amendment) some of the very same reserved acts (e.g., allergy testing) found in the report to be beyond the scope of the profession. (29) Since this report, the BCHPC has not published any documents that explicitly support the expansion of scope.
Ontario's Health Professions Regulatory Advisory Council (HPRAC) published a report in January 2009 recommending an expansion of naturopaths' scope of practice. The report claimed that licensed naturopaths should be permitted to prescribe a limited number of 'Schedule 1' Drugs, including amino acids, antillipemic agents, hormones, vitamins, anti-infectives (antibiotics, antivirals, antifungals), analgesics, antipyretics, non-steroidal anti-inflammatory drugs, and skin and mucous membrane agents. (30) The Council's "review of the naturopath education and training programs in drug therapies found educational content is similar to the content taught in nursing, pharmacy and medical schools." (31) HPRAC went on to speak of continuing education programs as evidence of this claim, and noted that naturopaths believe the expansion of scope necessary to "keep pace with advancing clinical knowledge [...] and trends in consumer demands." (32)
HPRAC's confidence in naturopaths' abilities was also bolstered by the claim that they have a strong safety record in jurisdictions (i.e. some American states) where they have limited prescribing rights. (33) However, we found that no studies were cited in support of this. Additionally, while the HPRAC report purports to be based on literature reviews, responses of health colleges to questionnaires, and other evidence, these sources are not disclosed. (34) Despite the lack of consensus between these provincial council reports, the expansion of scope of practice for naturopaths has been approved in both British Columbia and Ontario. We could not find any publicly available government documents that explain these actions and how the conflicting views were resolved so as to justify them. In addition, we found few references to empirical evidence. Given the recognized value of evidence in policymaking in this context--that is, in relation to a healthcare intervention--this lack of reference to any data or scientifically informed rationales seems particularly problematic. To be fair, there are recognized challenges associated with the collection of evidence in the context of some complementary and alternative practices (e.g., obtaining funds to conduct clinical trials). But, at a minimum, these challenges should have been noted, in addition to reasons as to why, in the aggregate, the expansion of scope was nonetheless justified.
There has been little discussion with regards to the expansion of naturopaths' scope of practice in the BC and Ontario legislatures. This is especially surprising in the case of Ontario, where there were amendments to legislation. In British Columbia the updated regulations were not accompanied by a legislative amendment, but they still constituted a relatively large alteration to the practices of many different types of health professionals. For the most part, discussion seems to have taken place outside of the legislative assembly. One Ontario MLA, during the second reading of Bill 179, spoke specifically of being influenced by lobbying naturopaths into altering the content of his speech mere hours before attending legislature. (35)
This is reflective of the larger lobbying effect that occurred between the first and second readings of Bill 179. Ontario Naturopaths were originally entirely excluded from scope expansion. They responded by organizing a letter-writing campaign that "described naturopaths as primary care providers, comparable to family physicians, and worthy of the right to prescribe." (36) After the second reading took place in 2009, the Standing Committee on Social Policy agreed to an alteration, and naturopaths were included alongside nurses and other health professionals as candidates for scope expansion. (37) It appears that the complementary and alternative medicine community's advocacy efforts had a direct effect on the outcome of the legislative process.
From 2005 forward--around the time that discussion of these types of amendments began--there have been only eight mentions of naturopathy in the BC and Ontario legislatures in which arguments for expansion were presented. These have all been brief, and each was handled within minutes. Four main justifications were provided.
The first was that naturopaths must be allowed to fulfill their traditional role, which requires treating the cause of disease and not merely the symptoms; expanded testing and prescribing rights were alleged to be necessary for this. (38) The second was that expansion improves patient choice, access and quality of care, and as such is beneficial to Canadians in general. (39)
The third justification related to public need, described by one MLA as "protecting our public health system for families in the future." (40) Increasing the number of services that can be provided by non-physician health care workers would conceivably allow the government to spread out the existing burden currently shouldered by physicians. The fourth justification was economic in nature. One Ontario MLA spoke of it as a recruitment effort: "We're doing it because we are in a global, competitive world that is trying to attract health human resources." (41) The idea, we presume, was that a wider scope of practice would be more attractive to naturopaths and, therefore, foreign naturopaths would move to the province, enhancing the economy and relieving health human resource shortages. (42)
Emotional appeals have also played a part in this discourse. One Ontario MLA cited his own experience of cancer, claiming that the naturopaths helped him more than traditional medicine by altering his "mental attitude" and by recommending "minerals and vitamins and omega oils and things of that nature, which are very helpful to get your immune system up." (43)
In the Manitoba legislature, where regulation of naturopaths has been proposed, there have been some appeals to public safety as a justification for licensing. One MLA said "one needs to ensure that all angles, measures of safety and security have been ensured and, most importantly, that there is uniformity within the practice of any profession." (44) This argument has been absent in the B.C. and Ontario legislatures, where regulation is already in place.
The media plays an important part in the communication of health policy issues; it both reflects and shapes attitudes about specific controversies and concerns. (45) Important health issues are contested in the media, which frames the debate and can ultimately affect policy decisions. (46) As such, we looked at how the expansion of naturopath's scope of practice was portrayed in the popular press, specifically in Canadian newspapers. (47)
In order to collect all relevant Canadian newspaper articles relating to expansion of naturopaths' scope of practice, three searches were undertaken on the Factiva media database. Searches were restricted to Canadian newspapers only (no date restriction), and the following search terms were used: [naturopath* licens*], [naturopath* licenc*], [naturopath* prescri*]. In total, 182+104+496 = 782 (respectively) search results were gathered. The results were then culled, and duplicates were removed, leaving relevant 39 articles. Although the articles contained arguments for and against expansion of naturopaths' scope of practice, we only considered justifications for expansion.
We found only a few references to the efficacy of naturopathic treatments as a justification for expansion of scope, and each of them came from one or more naturopaths. BC Naturopathic Association (BCNA) president Christoph Kind stated in 2009 that "naturopathic medicine is substantiated by voluminous research ... the scientific education and training that naturopathic physicians receive is no different than the scientific training medical doctors receive." (48) Several other accounts described naturopathic training as extensive. While such assertions do not support the efficacy of the treatment provided, they highlight the tone and focus of the public debate. For example, a BCNA representative is reported as stating that naturopaths "are already fully trained in pharmacology, much like medical doctors, and they are trained to diagnose and treat disease." (49) In these cases and in all others noted, no reference to research or documents was subsequently provided to substantiate any claim. To be fair, this is fairly common in a media report. (50) Given space limitations and the more casual tone, one cannot expect the frequent inclusion of scientific data. (As noted above, it is more worrisome that official and/or public reports also lack this referencing.)
Another claim was that a scope of practice expansion would improve patient care. Proponents contended that it would help patients by providing more choice, reducing wait times, and increasing ease of access. Patient choice was the main public justification given by the B.C. Minister of Health for granting prescription rights to naturopaths in 2009. (51) Of course, this has a human resource aspect with* regards to health care as well. One goal of the scope of practice expansion has been to "increase the number of practitioners in a system that is increasingly short of skilled professionals of every kind." (52)
The most common form of argument related to regulation of the profession was that it would allow standards to be enforced, protecting the public and preventing misrepresentation. This was sometimes combined with the point about increasing patient choice. For example, in relation to proposed regulation in Alberta, it was stated that "Albertans deserve the choice of going to a naturopathic doctor and being assured certain standards, training and disciplinary measures are in place." (53)
The fight to increase naturopaths' power has also been framed as a "turf war," whereby doctors are concerned with controlling health services and will do anything to prevent having to share this control with naturopaths. One MLA went so far as to say in the media that legislation preventing the Ontario College of Physicians and Surgeons from regulating alternative medicine was "necessary to provide 'freedom of choice for the patient, freedom of fairness, and immunity from harassment for doctors." (54) This perception of the debate was bolstered in 2006 when the American Medical Association released a subsequently leaked internal policy resolution "opposing the licensure of naturopaths to practice medicine." (55)
Examples of success in granting naturopaths limited prescribing rights in some American jurisdictions ("we have not seen any significant issues regarding the extended scope") have been cited as evidence that doing so is sale and effective. (56) Continuing education in pharmacology is required in certain instances (e.g. Oregon--however, this requirement is only five hours per year). (57)
Paradoxically, one reason presented for establishing regulation of naturopathy in unregulated provinces has been the need to shift focus away from symptom management and a related reliance on pharmaceuticals. (58) This seems, in some respects, to contradict naturopaths' recent efforts and successes in expanding prescription rights to the "allopathic" use of pharmaceuticals for treatment.
Efficacy & A Critique of Justifications Presented
We found that justifications for expanding scope of practice were rarely supported by evidence, particularly in relation to efficacy. More common were references to the nature of the training received by naturopathic practitioners. In addition, there were allusions to consultations with practitioners, but the content of these consultations--which may have contained references to evidence--is not readily available. (59) As noted, our analysis was limited to publicly available documentation. Still, given the controversial nature of the decisions, and the heated nature of the public debate, one would expect evidence to play a more prominent role. This seems particularly so given the ongoing controversies associated with the efficacy of many (if not most) naturopathic remedies. Given aforementioned provincial commitments to evidence-based decision-making, one would expect the government to demand clear evidence to counter these perceptions of naturopathic medicine. (60) We found evidence, as previously defined, to be largely absent. (61) While policymakers may have been presented with this evidence, we could not find a public record of this, nor related documentation.
The controversy associated with the science of naturopathic treatments is relevant to this discussion for several reasons. First, as noted, the naturopathic community does not have a strong tradition of using evidence-based treatments and, given the growing acceptance of an evidence-based approach to health care, this should have triggered a transparent analysis of the relevant scientific evidence. Second, this evidence arguably should be required for any treatment that might flow from an expanded scope of practice. For example, an expanded laboratory testing power may be used for diagnoses leading to the use of ineffective treatments. (62)
Third, the granting of regulated status and expanded scopes of practice has been used by the naturopathic community, in an interesting application of circular logic, as evidence of efficacy. The argument seems to go like this: grant us regulatory status because our treatments are efficacious; our treatments are efficacious as evidenced by the fact that we are a regulated profession. ("It's not magic, just good science. And this naturopathic approach has been regulated in Ontario for 85 years"). (63) Policymakers should be sensitive to this line of thinking and the potential impact it can have on policy development and public perceptions.
While a comprehensive analysis of the efficacy of the most common naturopathic treatments is beyond the scope of the paper, there are reasons to be skeptical about the existence of evidence to support claims of efficacy. There is evidence that a number of treatments favoured by naturopaths, such as acupuncture, are more effective than placebo (even here, however, the evidence is far from conclusive). (64) Yet, many of the most commonly used treatment approaches, such as homeopathy, chelation, colonic irrigation and others, remain scientifically unsupported. Systematic reviews of the research undertaken on these treatments consistently show that they have no effect beyond placebo. (65) Despite this growing consensus within the scientific community, a recent study of the websites of naturopaths in Alberta and BC found that many of the most scientifically questionable therapies remain among the most commonly advertised. (66)
As noted above, one explicit rationale for the expansion was the training provided at naturopathic colleges. We found this in both media and policy reports. But there are at least some reasons to be cautious, from an evidence-based perspective, about the relevance of this rationale. Specifically, extensive training does not necessarily mean the related treatment will be evidence-based. For example, the Textbook of Natural Medicine (used in colleges and considered an authority on the subject--the Association of Accredited Naturopathic Medical Colleges recommends reading the third edition prior even to enrollment (67)) endorses methods and treatments that lack scientific support, e.g., 'detoxification', and makes many demonstrably false claims, e.g. that "taking one's armpit temperature upon awakening is a reliable test for thyroid function." (68) In his 2001 review of the textbook, Professor Arnold Relman, editor-in-chief emeritus of the New England Journal of Medicine, stated:
Many of the treatments recommended in the Textbook for the 70 diseases are not likely to be effective, and treatments proven to be effective are often totally ignored. This could endanger the health and safety of patients with serious diseases who relied solely on care from a naturopathic practitioner. [...] Some may practice more prudently than others and may use conventional medical treatments more frequently and work more closely with conventional medical practitioners. But we should make public policy decisions based on the standards of practice that are being taught, not on our opinions about individual practitioners. Judging by the standards of practice presented in the Textbook, it seems clear that the risks to many sick patients seeking care from the average naturopathy practitioner would far outweigh any possible benefits. (69)
It is difficult to reconcile the opposing views on naturopaths' qualifications taken by the BCHCP and the HPRAC, but the concern about training content does not appear to have been met with solid refuting evidence. The BCMA concurs; it stated in its 2009 submission to Health Minister George Abbott that "Beyond the statements of their Association and College, there is no evidence that naturopaths have sufficient training to provide the proposed expanded scope of services in keeping with established safety and quality standards." (70)
Given this concern, it is difficult to accept that such an increase in patient choice and access is necessarily better for the patient. It is possible that an increase in patient choice in this instance could result in significant safety risks, due to inadequate qualifications and training. (71) More evidence needs to be presented in order to conclusively determine this point.
One may recall that economic benefit was also presented as a justification for practice expansion in legislative debate. Again, we found that no solid evidence was provided in the publicly available documentation. (72) Additionally, other commentators speculate the opposite--that costs would increase with an expanded scope of practice:
Then there is the matter of cost. Allowing naturopaths to write prescriptions will almost certainly increase the consumption of drugs in B.C. That will put pressure on the Fair Pharmacare program. But drug costs are already the most rapidly expanding area of the health budget. There is also likely to be an increase in double doctoring--where area patient asks several practitioners to treat the same complaint. Indeed the government is inviting this, with its talk about giving patients more "choices." (73)
The argument among those noted in our analysis that seems the most secure concerns regulation rather than expansion of naturopath powers--namely, that regulation ensures safety and the enforcement of standards. This argument has been opposed by the claim that regulation is misleading to the public, as it indicates government endorsement and the legitimization of a field not supported by scientific evidence. (74) Both arguments are valid, but one wonders if there may be a way to explicitly avoid official endorsement while simultaneously establishing more robust standards; these two goals are not diametrically opposed.
The articles and statements collected for this analysis comprise the public and policy-level discourses surrounding an expanded scope of practice for naturopathic medicine in Canada. In general, we found little reference to empirical evidence, and claims to evidence that were present in reports were not supported by disclosed sources. (75) Given the push toward evidence-based medicine, and given that the majority of naturopathic treatments remain scientifically unsupported, such a lack of evidence is problematic and certainly not ideal for policy making. (76)
Significant concerns exist regarding the expansion of practice of naturopaths in British Columbia and Ontario. There is very little clear evidence in the public record that explains these policy decisions. This evidence either (1) does not exist, indicating that the statutory changes may be unjustified and politically-driven, or (2) exists but has not been presented in a transparent manner, indicating inadequate communication on the part of policymakers and proponents of the expanded scope (note: opponents are also certainly guilty of this). This is an issue that affects the health of Canadians, and as such, either conclusion represents a failure in the policy-making process.
Naturopathic Regulation--Arguments and Examples
1. Improving Patient Care
Policy Reports: "Providing NDs with the tools to support them in the provision of primary health care may be one way to improve access to care for Ontarians" Legislative Debates: "British Columbians in return will get to enjoy the results of improved choice, quality and access"
Media: "B.C. Minister of Health George Abbott says the regulations are about choice."
2. Treatment Efficacy
Legislative Debates: "I'll tell you that when I had cancer seven years ago, the therapy that was the most helpful to me was that of the naturopaths."
Media: "The science behind naturopathic medicine is substantiated by voluminous research conducted by independent, third-party medical experts."
3. Scientific Education and Training
Policy Reports: "... educational content is similar to the content taught in nursing, pharmacy and medical schools"
Media: "... [naturopathic doctors] are already fully training in pharmacology, much like medical doctors, and they are trained to diagnose and treat disease."
4. Safety and Enforcement of Standards
Legislative Debates: "one needs to ensure that all angles, measure of safety and security have been ensured and, most importantly, that there is uniformity within the practice of any profession."
Media: "Albertans deserve the choice of going to a naturopathic doctor and being assured certain standards, training and disciplinary measures are in place."
5. Turf War with Medical Doctors:
Legislative Debates: "There's great resistance in the existing medical field. Let's face it: That's where the pressure comes from. Other than the medical doctors, they don't want anyone else to use the title, by and large. My reaction is, 'Get over it. '"
Media: "[the BC Medical Association] has lobbied to remove [NDs'] services from the Medical Services Plan ... It claims it's about competence, but it has the pong of protectionism. "
6. Economics and the Burden on Health Care
Policy Reports: "Providing NDs with the tools to support them in the provision of primary health care ... may assist in reducing pressures on emergency rooms by keeping care in the community."
Legislative Debates: "There is a real opportunity, I think, for Ontario to embrace what they're asking for in these times of doctor shortages, rising costs of medicine and hospital wait times."
Media: "The goal is to increase the number of practitioners in a system that is increasingly short of skilled professionals of every kind.
7. Successful Scope Expansion Elsewhere
Policy Reports: "Evidence from jurisdictions such as Oregon and Arizona that currently authorize prescribing for NDs indicates a high safety record."
Media: "the drug-prescription experience in three American states proves that naturopathic physicians in British Columbia could prescribe a range of medications safely and effectively"
(1) Nadeem Esmail, "Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitudes" (2007) 87 Public Policy Sources 1 at 20 (see Table 6). Online: Fraser America <http://www.fraseramerica.org/commerce.web/product_files/Altmedicine.pdf>.
(4) Timothy Caulfield, Allan Becker, Susan Elliot, Susan Waserman and Judah Denburg, "To endorse naturopathy is to reject science; The issues between medical doctors and naturopaths go beyond a turf war" Vancouver Sun (26 February 2009) A15; Jason Lam, "Naturopathy: Complementary or Rudimentary Medicine?" (2002) 80 University of Toronto Medical Journal 63; Aijing Shang, Karin Huwiler-Muntener, Linda Nartey, Peter Juni, Stephan Dorig, Jonathan Sterne, Daniel Pewsner & Mattias Egger, "Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy" (2005) 366 Lancet 726; E. Ernst, "A systematic review of systematic reviews of homeopathy (2002) 54 Br J Clin Pharmaco 577; Ranit Mishori, Aye Otub & Aminah Alleyne Jones, "The dangers of colon cleansing" (2011) 60 The Journal of Family Practice 454. See also other sources cited throughout this paper.
(5) As will be further expounded, in Ontario and B.C. naturopaths are regulated and have been granted prescribing and other nontraditional rights. Regulation is also present in Saskatchewan, Manitoba and Nova Scotia. The other provinces do not regulate naturopathy, but some (like Alberta) await the approval of bills that would do so. As will become clear further on in our analysis, the general rationales for the regulation of health professionals include, inter alia, patient safety and the establishment of complaint frameworks and disciplinary systems. See CAND, Questions: Education and Regulation, online: Canadian Association of Naturopathic Doctors <http://www.cand.ca/index.php?40>.
(6) ScottGavura, "Naturopathy a prescription for quackery" National Post (November 24, 2009), at paras 16-18. Online: NP <http://network.nationalpost.com/np/ blogs/fullcomment/archive/2009/11/24/scott-gavura-naturopathy-a-prescription- for-quackery.aspx>; See also footnote 32 in its context.
(7) Ontario, Ministry of Health, Regulation of a New Health Profession under the Related Health Professions Act (RHPA), 1991 (Ontario, Health Professions Regulatory Advisory Council, 2011) at 15 (Appendix A).
(8) College of Physicians and Surgeons of British Columbia, "Practice Guidelines and Protocols" CPSBC, at para 1. Online: < https://www.cpsbc.ca/node/480>; College of Physicians and Surgeons of Ontario, "2008 Practice Guide" CPSO (2008), at 10. Online: <http://www.cpso.on.ca/uploadedfiles/policies/guides/ PracticeGuideExtract_08.pdf?terms=scientific+evidence>; Ministry of Health Services (BC), "2009/10 Annual Service Plan Report" BC Ministry of Health, at 10. Online: <http://www.bcbudget.gov.bc.ca/Annual_Reports/2009_2010/hs/ hs.pdf>; Ontario Ministry of Health and Long-Term Care, "Excellent Care for All" Ontario Ministry of Health, at para 1. Online: http://www.health.gov.on.ca/ en/ms/ecfa/pro/ecfa_ebc.aspx>.
(9) Dieter Hauschke & Iris Pigeot, "Establishing Efficacy of a New Experimental Treatment in the 'Gold Standard' Design" (2005) 47 Biometrical Journal 782 at 782. The three arms of the gold standard design are placebo, active control and new treatment. These evidentiary standards have evolved from branches of logic and statistics that have been developed and proven over centuries. That being said, it should be noted that there is an active discussion about the value of and challenges with evidence-based medicine, especially concerning its applicability to alternative procedures that may take a more individualized approach. See, for example, ID Coulter, "Evidence Based Complementary and Alternative Medicine: Promises and Problems" (2007) 14 Forsch Komplementarmed 102.
(10) Canadian Association of Naturopathic Doctors, "What is Naturopathic Medicine?" at para 1. Online: CAND < http://www.cand.ca/index.php?78&L=0>.
(11) Canadian Association of Naturopathic Doctors, "Questions: Naturopathic Treatments" at para 3. Online: CAND <http://www.cand.ca/Naturopathic_ Treatments.37.0.html?&L=0>. Regulatory definitions of naturopath and their practice can be inadequate and self-referential. For example, Ontario's Naturopathy Act, 2007, SO 2007, cl0, Sch P defines naturopaths' scope of practice as "the assessment of diseases, disorders and dysfunctions and the naturopathic diagnosis and treatment of diseases, disorders and dysfunctions using naturopathic techniques to promote, maintain or restore health" without defining 'naturopathic' in the definitions section.
(12) Meghan Walker & Tara Gignac, "The power of natural medicine" National Post (27 November 2009) A19 at para 8.
(13) Canadian Association of Naturopathic Doctors, "Natural Therapies". Online: CAND <http://www.cand.ca/Naturopathic_Treatments.37.0.html?&L=0>.
(14) Health Professions Act Naturopathic Physicians Regulation, BC Reg 282/2008, sl.
(15) British Columbia Medical Association, Submission, "The BCMA Submission to Minister George Abbott on Proposed Amendments to the Naturopathic Physicians Regulation" (19 February 2009), at para 7. Online: BCMA <https://www. bcma.org/files/BCMA_Submission NP Regulation.pd[>; British Columbia, Ministerial Order No. M130, Regulation of the Minister of Health Services (April 9, 2009), at 5-11. Online: BC Health < http://www.health.gov.bc.ca/ professional-regulation/pdfs/BC_Reg_156_2009.pdf#redirect_notice_ display_301>. A full list of excluded Schedule 1 drugs is noted in the ministerial order--some examples include codeine, diazepam and morphine. Al] other Schedule 1 and Schedule 2 drugs can be prescribed by Naturopaths--including many antibiotics and antipsychotics. See full list at College of Pharmacists of British Columbia, "Drug Schedules Regulation to the Pharmacy Operations and Drug Scheduling Act of British Columbia" (November 2011), at 2-16. Online: CoPoBC < http://library.bcpharmacists.org/D-Legislation_Standards/D-4_Drug_ Distribution/5012-Drug_Schedules_Regulation.pdf>.
(16) Laura Eggertson, "Naturopathic doctors gaining new powers" (2010) 182(1) CMAJ E29 at para 9. Online: CMAJ <http://www.ecmaj.ca/content/182/1/E29.full>.
(17) Wendy Stueck, "BCMA chief expresses worry over expanded role for naturopaths" The Globe and Mail (28 January 2009), S1.
(18) British Columbia Medical Association, "Submission to Minister George Abbott", supra at para 7.
(19) See Caulfield, at A15; Letter from Arthur Dodek to the Honourable George Abbott (24 Feb 2009), College of Physicians and Surgeons of British Columbia. Online: <https://www.cpsbc.ca/files/u6/MoHS_Naturopaths_090224_Dodek. pdf>; Doug Ward, "B.C. naturopath cites U.S. experience; He says those in three states allowed to prescribe medications" Vancouver Sun (3 March 2009) A5 at para. 5; Randall White, "More powers for naturopaths" Vancouver Sun (18 February 2009) Al0; Calgary Herald, "Seeking the right prescription on naturopaths" Calgary Herald (18 February 2009) Al2; Peter McKnight, "Naturopathy's main article of faith cannot be validated; Reliance on vital forces leaves its practices based on beliefs without scientific backing" Vancouver Sun (7 March 2009) C5.
(20) Katherine Dedyna, "Licence to prescribe still rankles B.C.'s MDs; Naturopathic doctors don't have the training to make medical diagnosis, BCMA president says" Vancouver Sun (7 March 2011), D3.
(21) Ibid. We are not saying that these opinions about safety are definitive--indeed, one could argue that concerns about safety can be intentionally overblown in order to justify rejecting naturopaths" requests [Christoph Kind, "Endorsing naturopathic medicine accepts science over spin" Vancouver Sun (3 March 2009) A7 at para. 4]. Rather, we note these safety concerns to highlight that they were part of the public debate and, as such, one might expect evidence to be used to refute them. To a large degree, as we will see, those involved in the public debate failed to raise said evidence.
(22) Ontario Medical Association, Submission, "Submission to the Standing Committee on Social Policy on Bill 179: 'An Act to Amend Regulated Health Professions Statutes'" (September 2009), at 15. Online: OMA <https://www.oma.org/Resources/Documents/Bill179Sept2009.pdf>.
(23) Anna Sharratt, "Naturopaths' prescribing rights expanded; After extensive lobbying efforts, naturopaths across Canada are getting governmental green lights for greater prescribing rights" CBC News Health (9 November 2009), online: CBCNews <http://www.cbc.ca/news/health/story/2009/10/22/ f-naturopaths-get-prescribing-rights.html>.
(24) A health profession regulatory council generally advise the province's Minister of Health on "whether unregulated health professions should be regulated, whether regulated professions should no longer be regulated, amendments to the Regulated Health Professions Act, a health profession act or a regulation under those acts, quality assurance and patient relations programs of [the province's] health regulatory Colleges, and on other matters referred to it by the Minister." (Ontario's HPRAC website statement, <http://www.hprac.org/>).
(25) British Columbia, Ministry of Health, Naturopathic Physicians Scope of Practice Preliminary Report, (British Columbia, Health Professions Council, 1998) at para. 27 of executive summary. Online: BC Health <http://www.health.gov.bc.ca/ professional-regulation/hpc/review/part-i/scope.naturopath.html>.
(27) British Columbia, Ministry of Health, Post-Hearing Update of Preliminary Report: Naturopathic Physicians (British Columbia, Health Professions Council, 2001). Online: BC Health <http://www.health.gov.bc.ca/professional-regulation/hpc/ review/part-i/update-naturopath.html#>.
(28) British Columbia, Ministry of Health, Post-Hearing Update, supra.
(29) BC, Ministerial Order No. M130, supra at 3-4.
(30) Ontario, Ministry of Health, Critical Links--Transforming and Supporting Patient Care; Analysis with regards to the prescribing and use of drugs in the profession of naturopathy (Ontario, Health Professions Regulatory Advisory Council, January 2009) at 266-268.
(31) Ibid at 262. The HPRAC tempered this statement, however: "On balance, HPRAC is satisfied that there is sufficient evidence in the current drug education of naturopathic doctors to recommend prescribing authority for traditional naturopathic remedies that have been rescheduled. However, there may be additional re-education requirements for practitioners who graduated before 1994, when the NPLEX examinations." (Ibid) All this being said, they still recommended granting the right to prescribe antibiotics, which were never traditional naturopathic remedies. (Ibid., at 267.)
(32) Ontario, Critical Links, supra at 263.
(33) Ontario, Critical Links, supra at 263-264.
(34) HPRAC, supra at 15-16.
(35) Ontario, Legislative Assembly, Debates (Hansard), 39th Parliament, Session 1 (24 September 2009) at 1300 (Mr. Michael Prue). "I had planned on speaking about something else, but I was so impressed, over the last hour, with the men and women who were there advocating on behalf of their cause that I thought I would change what I was going to say today, and I have."
(36) Gavura, supra at para 18.
(37) Ibid at para 19.
(38) British Columbia, Legislative Assembly, Official Report of Debates of the Legislative Assembly, Volume 26, Number 2 (13 February 2008) at 1705 (M. Polak).
(39) British Columbia, Legislative Assembly, Official Report of Debates of the Legislative Assembly, Volume 26, Number 2, (13 February 2008) at 1555 (J. McIntyre).
(40) British Columbia, Legislative Assembly, Official Report of Debates of the Legislative Assembly, Volume 26, Number 2, (13 February 2008) at 1555 (J. McIntyre).
(41) Ontario, Legislative Assembly, Debates (Hansard), 38th Parliament, Session 2 (26 March 2007) at 2120 (Mr. Fonseca).
(42) While this is an intriguing idea, our searches did not turn up evidence to support the suggestion that complementary and alternative practitioners will relocate to jurisdictions that grant them the most rights.
(43) Ontario, Legislative Assembly, Debates (Hansard), 38th Parliament, Session 2 (28 May 2007) at 1730 (Mr. Parten).
(44) Manitoba, Legislative Assembly, Debates (Hansard), 39th Parliament, Session 4 (13 May 2010) at 1120 (Ms. Sharon Blady).
(45) Elizabeth A Shanahan, Mark McBeth, Paul Hathaway & Ruth Arnell, "Conduit or contributor? The role of media in policy change theory" (2008) 41 Policy Sciences 115; Jon Silverman, "Addicted to distortion: the media and UK drugs policy" (2010) 9 Safer Communities 26; Jason Barabas & Jennifer Jerit, "Estimating the Causal Effects of Media Coverage on Policy-Specific Knowledge" (2009) 53 American Journal of Political Science 73. See generally, T A Ten Eyck, "The Media and Public Opinion on Genetics and Biotechnology: Mirrors, Windows or Walls?" (2005) 14 Public Understanding of Science 305.
(46) See generally, A Peterson, "Biofantasies: Genetics and medicine in the Print News Media" (2001) 52 Social Science and Medicine 1255; S. Hornig Priest, "Public Discourse and Scientific Controversy: A Spiral-of-Silence Analysis of Biotechnology Opinion in the United States" (2006) 28 Science Communication 195.
(47) It is of course important to note that other forms of media are important contributors to the framework of debate. However, for the purpose of methodological simplicity we limited our search to Canadian newspapers.
(48) McKnight, supra at para 6.
(49) Amy O'Brian, "Naturopaths to be allowed to prescribe medication; B.C. Medical Association opposes move on grounds that personal safety could be at risk" Vancouver Sun (16 February 2009) A4.
(50) This lack of evidence was noted in other media reports. See, for example: Clara Byrne, "Naturopaths wary of boy's vegetable diet treatment; 'If we practiced like that ... we would lose our licence,' doctor says of cancer therapy" Ottawa Citizen (27 July 2007) F7 at para.8, where one naturopath likened the idea that naturopathic treatments, training and methodology are questionable to a myth: "'We're looking for evidence-based research. It's not like we throw on our cauldron.'"
(51) "Seeking the right prescription on naturopaths" Calgary Herald (18 February 2009) Al2.
(52) Vaughn Palmer, "Health care reforms look to be ambitious, not to say controversial" Vancouver Sun (21 March 2008) A3.
(53) Seeking, supra.
(54) Richard Mackie, "Alternative medicine gets a break; Ontario medical college says patients should have access to non-traditional treatments" The Globe and Mail (2 September 1997) A6.
(55) Erik Goldman, "Healthcare Practitioner Marketing: AMA to Oppose ND Licensure" Nutraceuticals World (1 October 2006). Online: Nutraceuticals World <http://nutraceuticalsworld.com/contents/view/13643>.
(56) Ward, supra at paras 1, 8. The HPRAC Critical Links policy report also supports this argument, but fails to cite any studies in support of it (HPRAC, supra at 263-264).
(57) Ward, supra at para 11.
(58) Walker & Gignac, supra at para 8.
(59) HPRAC, supra at 15-16. The Ontario report refers to consultations, studies and other evidence as the foundation of its conclusions, but never lists the actual sources.
(60) Ministry of Health Services (BC), "2009/10 Annual Service Plan Report," supra at 10; Ontario Ministry of Health and Long-Term Care, "Excellent Care for All" supra at para 1. If these decisions are not, at least partly, based on a belief in efficacy, then this should also be made clear. In other words, if the government decision is that the concept of evidence-based practice does not or should not apply to naturopaths, this approach should be made public.
(61) Ontario, Ministry of Health, Regulation of a New Health Profession, supra at 15 (Appendix A).
(62) BC Ministerial Order No MI30, supra at 3. The HPRAC report also notes that naturopaths wish to be able to prescribe conventional drugs in cases where laboratory testing indicates infection (HPRAC, supra at 257.
(63) Walker & Gignac, supra at para 4; Kind, supra; O'Brian, supra at para 6.
(64) See, for example, Suarez-Almazor, Maria E., et al. "A Randomized Controlled Trial of Acupuncture for Osteoarthritis of the Knee: Effects of Patient-Provider Communication." (2010) 62(9) Arthritis Care & Research 1229.
(65) See Umut Altunc, Max Pittler & Edzard Ernst, "Homeopathy for Childhood and Adolescence Ailments: Systematic Review of Randomized Clinical Trials" (2007) 82(1) Mayo Clinic Proceedings 69; Shang et al, supra; Dugald Seely, Ping Wu & Edward Mills, "EDTA chelation therapy for cardiovascular disease: a systematic review" (2005) 5 BMC Cardiovascular Disorders 32; UK, House of Commons Science and Technology Committee, Evidence Check 2: Homeopathy (London: The Stationery Office Limited, 2010), online: <http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/ 45.pdf>; American Cancer Society, "Chelation Therapy" (1 November 2008), online: <http://www.cancer.org/Treatment/TreatmentsandSideEffects/Complementary andComplementaryandAlt/PharmacologicalandBiologicalTreatmentchelation- therapy>; E Ernst, "A systematic review", supra.
(66) Timothy Caulfield & Christen Rachul, "Supported by Science?: What Canadian Naturopaths Advertise to the Public" (2011) 7 Allergy, Asthma & Clinical Immunology 14. In this study it was found that, for example, in Alberta, "homeopathy was the most common treatment advertised on the websites (94% of websites note this treatment) and the third most common in BC (79%)." (at 18)
(67) Association of Accredited Naturopathic Medical Colleges, Naturopathic Medicine FAQ, online: AANMC <http://www.aanmc.org/naturopathic-medicine/naturopathic-medicine-faq. php>.
(68) Stephen Barrett, "A Close Look at Naturopathy" (23 Dec 2003), at paras. 38-39. Online: Quackwatch <http://www.quackwatch.com/01QuackeryRelatedTopics/Naturopathy/naturopathy. html>.
(69) Arnold Relman, "Textook of Natural Medicine [Review]" (9 Jan 2001), at paras 5, 17. Online: Quackwatch <http://www.quackwatch.com/01QuackeryRelatedTopics/Naturopathy/relman1. html>.
(70) British Columbia Medical Association, "Submission to Minister George Abbott", supra at para 11. On the other hand, these opposing viewpoints would have benefited from the inclusion of evidence describing how naturopaths are in fact unqualified to perform the expanded services.
(71) Letter from H.M. Oetter to Daryl Beckett (20 Jan 2009), College of Physicians and Surgeons of British Columbia, at 3. Online: <https://www.cpsbc.ca/files/u6/MoHS_Naturopaths_090120.pdf>. The possibility of additional pharmacological training for prescribing naturopaths would help to remedy this concern about qualification.
(72) Walker & Gignac, supra at para 19; Valerie Farina, "More powers for naturopaths" Vancouver Sun (18 Feb 2009) A 10, at para 4; British Columbia, Debates (13 February 2008), supra at 1555 (J. McIntyre).
(73) Times Colonist, "Time to clarify health priorities" Times Colonist (6 March 2011), online: <http://www2.canada.com/victoriatimescolonist/news/comment/story.html?id= 06d66de4-73da-4469-9e17-3e613e64fe68>.
(74) Caulfield, Becker, Elliot, Waserman & Denburg, supra at para. 15; Massachusetts, Minority Report of the Special Commission on Complementary and Alternative Medical Practitioners, A Report to the Legislature (Massachusetts: SCCAMP, January 2002) at 4, 31.
(75) HPRAC, supra at 15-16.
(76) Ministry of Health Services (BC), "2009110 Annual Service Plan Report," supra at 10; Ontario Ministry of Health and Long-Term Care, "Excellent Care for All" supra at para 1; McKnight, supra. It should be noted that such issues of accountability in public policy making are not unique to issues in complementary and alternative medicine; however, this lack of uniqueness does not trivialize a relevant critique.
Blake Murdoch *, Robyn Hyde-Lay ** and Timothy Caulfield ***
* Blake Murdoch, Research Associate at the University of Alberta Health Law & Science Policy Group and JD/MBA Candidate.
** Robyn Hyde-Lay, Research Associate at the University of Alberta Law & Science Policy Group.
*** Timothy Caulfield, Canada Research Chair in Health Law and Policy; Professor, Faculty of Law and School of Public Health; Research Director, Health Law and Science Policy Group, University of Alberta. Thanks to Nola Ries, Susan Elliott and Heather Boon for her tremendously valuable input. This research was funded by The Allergy, Genes and Environment Network (AllerGen) NCE and SafetyNET: An Academic and Professional Partnership Building a Culture of Safety for Spinal Manipulation Therapy. We would also like to thank the reviewers for the helpful suggestions.
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|Author:||Murdoch, Blake; Hyde-Lay, Robyn; Caulfield, Timothy|
|Publication:||Health Law Journal|
|Date:||Jan 1, 2011|
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