Defining our Medicine: A Long and Winding, Necessary Road, or Where Education Meets the State
David Schleich, PhD
There is an inevitable need to achieve “social closure” for our medicine, achievable in our time if the necessary conditions can be systematically met. Those include: a permanent naturopathic medical education foundation within higher education (accredited schools); a regulatory and public policy-based framework for medical practice (state and provincial licensing); and a commitment to the ongoing, demarcated codification of the key knowledge of the profession (e.g., The Foundations of Naturopathic Medicine Project). In this regard, Hans Baer reminds us that we have long pursued “some form of state-mandated recognition and/or accreditation, even one internal to the occupational group” (2006). Certainly, those efforts as early as 1978 to establish a “CNME”-type accrediting body, and the landmark accomplishment of defining the profession at Rippling River in 1989, were essential mileposts on that long, winding and utterly necessary road.
We still need to be vigilant about having right at hand the clearest and most evocative definition possible for our medicine, as issues swarm menacingly (such as the regulation of practitioners, definitions of scope of practice or regulations covering the variances in pharmacopoeias and formularies). Educational arrangements notwithstanding, how we formally define and brand ourselves underpins our credibility and sustainable effectiveness. There are some definitions and descriptions which, because of their source and currency, are not only broader and more objective than others, but also provide a more stable, clearer launch pad for us as we all support efforts to expand the licensing reach of the profession, geographically and scope-wise.
Defining the Profession
Baer explains how the naturopathic profession is very much caught up in the state’s (generically speaking) often slow response to statutory registration and concomitant, authorized self-regulation. He notes: “The state may engage in several forms of patronage with respect to complementary health occupations” (2006, p. 1776).
A beginning point for any of these interventions, however, is a clear sense of who we are, defined unequivocally. In this connection, I have found that the analytical tools and definitions of naturopathic medicine from Dower, Hough and O’Neil, in their Arkay Foundation report, Profiling the Professions: A Model for Evaluating Emerging Health Professions (September 2001), out of the University of California’s Center for the Health Professions to be particularly useful in their breadth, inclusiveness and utility. The categories of definition encompassed in that work take into account the major aspects of institutional development that concern us here. For example, the categories include, at the very least, government regulation and private sector recognition, the education and training of naturopaths, and a model for evaluation (Dower et al., 2001). Moreover, the comprehensive nature of the descriptions and definitions considers all those practitioners, regulated and otherwise, who find value in naturopathic modalities and therapies. The resulting breadth and objectivity are most helpful in sorting out the conflicting claims of philosophical, medical and even political positions taken by competing groups within the CAM community. As well, the inclusive nature of the Arkay Foundation work is particularly relevant to the circumstances that led to the creation of naturopathic colleges or programs in Oregon, Washington, Arizona, Ontario, British Columbia, Connecticut and Illinois.
In any case, beginning to paddle through these variegated waters, we learn – as Stephen Myers pointed out at the AANP Convention in Salt Lake City in 2002 – that there is a constellation of practices that form naturopathic medicine today in Europe, Australia and North America. In his seminar, Dr. Myers concluded that its roots are in the “nature cure movement of the 18th- and 19th-century Europe.” This is an important element of any defining statement from a CAM group professing to be “naturopathic,” in that rivals all insist on this least common denominator of origin, the “nature-cure movement.” In addition, there is another denominator in this debate. For example, there are those groups (such as the Thomsonians, early and modern chiropractors, acupuncturists and early eclectics) who assert, to iterate Dr. Myers, the “belief that the physician merely supports the active self-recuperative powers of the human body” and that this principle and related understanding are “applied by modern naturopathy within the framework of modern scientific knowledge” (AANP, 2002).
Defining NDs, Naturopaths, Others
The University of California report is recognized for its impartial and inclusive research design. The document provides a good starting point in that it constitutes an excellent framework for distinguishing among naturopaths, naturopathic doctors, naturopathic physicians and mainstream licensed primary care practitioners who select one of the naturopathic modalities for inclusion in their traditional scope (Dower et al., 2001). Dower et al. explain that, overall, three groups “have interests in sustaining naturopathic methods of practice” (p. 1). The authors specifically identify naturopathic physicians as those who have completed a formal curriculum of four years of study in schools recognized by our accrediting body, the CNME, a non-government agency. The focus of naturopathic physicians (also called naturopathic doctors) is on “standardized entry to the profession as they define it, improving evidence-based research, and seeking formal recognition by state [and provincial] authorities” (p. 2). The second group they call naturopaths. They differ from naturopathic physicians or doctors in that the group “maintains the strictest definition of natural healing and does not incorporate surgical, non-natural pharmaceutical or obstetrical care into their practice” (p. 2). Theirs is a “much more varied set of pathways for entry into practice, and training ranges from self-instruction and apprenticeship to formal courses of study” (p. 2). The third group identified in the Arkay study consists of licensed practitioners such as medical doctors, dentists or nurses who have added a naturopathic modality to their existing, regulated practice.
Meanwhile, parallel to the Arkay definitional scaffolding and critical to erecting early in this thesis an awareness of the complex and shifting ground of CAM providers, there are many related descriptions of what naturopathic medicine is, and of what naturopathy is. Individual scholars such as Newman Turner (2000), for example, suggest that “naturopathy is based on the recognition that the body possesses not only a natural ability to resist disease but inherent mechanisms of recovery and self-regulation,” forming the basis for “nearly all the techniques in complementary medicine” (p. 110). The U.S. Department of Labor, on the other hand, defines naturopaths in its Dictionary of Occupational Titles less philosophically and with more focus on what the practitioner actually does. The naturopath, in the view of the Department: “… diagnoses, treats and cares for patients using a system of practice that bases treatment of physiological function and abnormal conditions on natural laws governing the human body. Utilizes physiological, phytotherapy, food and herbs therapy, psychotherapy, electrotherapy, physiotherapy, minor and orificial therapy, mechanotherapy, naturopathic corrections and manipulations, and natural methods or modalities together with natural medicines, natural processed food and herbs and natural remedies. Excludes major surgery, therapeutic use of x-ray and radium and the use of drugs, except those assimilable substances containing elements or compounds which are components of body tissues and physiologically compatible to body processes for the maintenance of life.” (U.S. Department of Labor, 1991)
This U.S. government definition seems to emphasize modalities rather than philosophy. In contrast, the AANP commissioned in 1986 two naturopathic physicians, Pamela Snider and Jared Zeff, to “create a unifying definition” based on a blend of philosophy and modalities. By November 1989 at Rippling River, Ore., the following definition, arising out of wide consultation and consensus, was confirmed: “Naturopathic medicine is a distinct system of primary healthcare: an art, science, philosophy and practice of diagnosis, treatment and prevention of illness. Naturopathic medicine is distinguished by the principles which underlie and determine its practice. These principles are based upon the objective observation of the nature of health and disease, and are continually re-examined in the light of scientific advances. Methods used are consistent with these principles and are chosen upon the basis of patient individuality. Naturopathic physicians are primary healthcare practitioners, whose diverse techniques include modern and traditional, scientific and empirical methods.” See the accompanying story for more definitions of naturopathic medicine that were borne from the AANP commission.
Next month we’ll examine the Canadian path to a definition of naturopathic medicine, a road equally long and winding in many ways.
State Patronage of Complementary Health Occupations
- Subsidization of training programs in either private or public tertiary institutions
- Statutory registration of practitioners
- The granting of research funds
- The incorporation of complementary practitioners into the public health insurance system.
Source: Baer: Social Sciences & Medicine, 63:1771-1783, 1776, 2006.
AANP Definition of Naturopathic Medicine
The statement defining naturopathic medicine that was borne at the 1989 AANP convention in Rippling River, Ore., included the well-known set of principles that are the foundation for the practice of naturopathic medicine.
- The healing power of nature (vis medicatrix naturae)
- Identify and treat the cause (tolle causam)
- First do no harm (primum non nocere)
- Doctor as teacher (docere)
- Treat the whole person (tolle totem)
Naturopathic methods: “Naturopathic medicine is defined primarily by its fundamental principles. Methods and modalities are selected and applied based upon these principles in the relationship to the individual needs of each patient. Diagnostic and therapeutic methods are selected from various sources and systems and will continue to evolve with the progress of knowledge.”
Naturopathic practice: “Naturopathic practice includes the following diagnostic and treatment modalities: utilization of all methods of clinical and laboratory diagnostic testing including diagnostic radiology and other imaging techniques; nutritional medicine, dietetics and therapeutic fasting; medicines of mineral, animal and botanical origin; hygiene and public health measures; naturopathic physical medicine including naturopathic manipulative therapies; the use of water, heat, cold, light, electricity, air, earth, electromagnetic and mechanical devices, ultrasound and therapeutic exercise; homeopathy; acupuncture; psychotherapy and counseling; minor surgery and naturopathic obstetrics (natural childbirth). Naturopathic practice excludes major surgery and the use of most synthetic drugs.”
Source: AANP definition of naturopathic medicine. Prepared for the Special Committee on the Definition of Naturopathic Medicine, Dr. Pamela Snider and Dr. Jared Zeff, Co-chairs. Adopted 1 November 1989, Rippling River, Ore., Convention of the AANP.
David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Other previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd) and the University of Toronto (PhD).
Baer HA: The drive for legitimation in Australian naturopathy: Successes and dilemmas, Social Science & Medicine 63:1771-1783, 2006.
Dower et al: Profiling the Professions: A Model for Evaluating Emerging Health Professions, San Francisco, 2001, Center for the Health Professions. University of California.
Myers S: Author’s notes from a meeting at the AANP Convention, Salt Lake City, Utah, August 2002.
U.S. Department of Labor: Dictionary of Occupational Titles. Washington, D.C., 1991, U.S. Dept. of Labor.
Newman TR: A proposal for classifying complementary therapies, Complementary Ther Med 8:82-7, 2000.