The Naturopathic Physician and his professional practice: the Deontology of Naturopathic Medicine
Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
Session II in the I interdisciplinary seminar on Naturopathic medicine, academic medicine: reflections for an approach.
School of Medicine, University of Salamanca
Salamanca, May 17-18, 1991
The Code of Ethics and Medical Deontology
Professional relationships between naturopathic physicians and academic physicians
The obligation to validate, by means of research, naturopathic practices
I would like to begin by thanking Prof. Antonio Carreras for inviting me to take part in this seminar. On the one hand, being invited to Salamanca is always an honor for a university student, since being here for a few hours is a gift. In addition, the topic he offered me has forced me to review a problem that is not often reflected upon.
In my considerations this afternoon, I start from the idea, stated in the degree scroll of this seminar, that, on the one hand, between Academic Medicine and Naturopathic Medicine there are some important differences in the way of understanding the disease and the role that the doctor should play in its treatment and prevention. And that, on the other hand, there is a common core between them, which includes such decisive elements as the Hippocratic-Galenic genealogy of both Medicines, the basic Education obtained in the same Schools, or the membership in the heart of the same professional corporation.
This last feature, the integration of all naturopathic doctors in the Collegiate Medical Organization, could lead us to the immediate and valid conclusion that the problem whose discussion has been entrusted to me does not exist: there is not and can not be a specific Deontology of naturopathic medicine, because, for the Collegiate Medical Organization, there is only one medical ethics, universal and unique. "The duties imposed by this Code - says article 2.1 of the current Code of Ethics and Medical Deontology - are binding on all physicians, whatever the modality in which they practice". The naturist modality is one of them. There is no reason why there should be a peculiar deontology for academic medicine and another, different one, for naturopathic medicine. If both are legitimate modalities of professional practice, both should be guided and inspired by the common precepts of the Code.
However, in the internship there are not only specific and real problems that affect more directly or more frequently one or the other modality of professional practice. There are also deontological documents that are aimed at shedding light on these problems and that, in our case, constitute an important reference letter to describe the Deontology of Naturopathic Medicine. It should be noted in parenthesis that, in reality, there are no specific documents on Naturopathic Medicine, but on Alternative, Complementary or Non-Conventional Medicine. I understand that, for many of you, it is not legitimate to place Naturopathy among the Medicines of these denominations. For those who think so, I say again that the problem whose discussion has been entrusted to me does not exist.
However, if it is legitimate to distinguish between the two types of medicine, it seems to me that it would be useful to start by taking knowledge of the above-mentioned ethical documents. These are some articles of the Code of Ethics and Medical Deontology and a Declaration of the Central Commission of Deontology. Let us begin with the latter.
In February 1985, at the repeated request of Doctors Palafox and Peral, the Central Commission of Deontology offered the General committee of Medical Associations a package of measures related to the practice of Alternative Medicine, among which was the publication of a graduate institutional document "Declaration and Recommendations on Alternative and Complementary Medicine". The General committee , for reasons unknown to me, did not make the document public. I believe that it is worthwhile to know what was the opinion of the Central Committee at that time. The essence of that project Declaration read as follows:
"From different instances it has been order (...to the Commission...) an opinion about the deontological aspects of the so called Alternative Medicines.... The Commission wishes to submit to the consideration of the General committee the following principles in case it considers interesting their knowledge dissemination among physicians and the public....:
1. All true medicine must have a strong scientific commitment, both in its orthodox mainstream, which bases its causes, mechanisms and remedies of disease on the natural-scientific method research , and in its alternative forms, which base their pathogenic theories and therapeutic practices on various intuitions. Medicine must maintain a constant and acute critical awareness and constantly review the efficacy of its procedures and doctrines. Physicians practising Alternative Medicine are especially obliged to this critical and revisionist attitude.
2. One and the other Medicine - orthodox and alternative - are obliged to respond to the needs of the sick and to protect them from unreasonable damages and risks. This obligation of benefit to the patient and of quality control of medical care has been developed in traditional Medicine according to very precise scientific criteria by means of clinical research (diagnostic, pharmacological, surgical, etc.), whereas, in Alternative Medicines, there has not been a parallel development of these criteria.
3. Consequently, doctors who follow unorthodox lines are obliged to be extremely competent in the diagnostic function and in the correct indication and application of therapeutic measures; and also to keep a properly annotated file of their patients, which allows them to record goal their observations and makes possible a rigorous assessment of the efficacy of their methods. Like orthodox doctors, they are bound by the rules of the Code of Medical Ethics, and in particular by the precept to keep themselves fully trained and up to date in their scientific training (articles 5 and 29); by the rule to share with their colleagues, without any professional reservation , the new scientific knowledge they possess (article 18), and by the mandate to refrain from practices that are unfounded or inspired by charlatanism (article 32); if, on the one hand, they enjoy freedom of prescription (article 13), they are, on the other hand, particularly obliged not to recommend or apply dangerous examinations or treatments (article 30), and must always submit to the rules on advertising set out in Chapter IX of the Code.
4. A truly competent internship in Medicine can only be carried out thanks to the intellectual training and character provided by the programs of study, culture and ethics proper to the medical profession. The entry into the field of medicine of persons who do not have the degree scroll of a physician must therefore be qualified as intrusive. No one who is not a doctor can call himself or herself a medical professional or practise medicine, whether orthodox or alternative. In the service of the public, a clear distinction must be made between doctors and non-doctors. It is a professional misconduct, as stated in article 32 of the Code, to association or co-operate in such a way as to mislead, as it would be tantamount to covering up for anyone who, without holding the degree scroll medical degree, is in any way practising the profession or in fact equating himself or herself with doctors.
5. The Commission wishes to propose to committee General that, following the corresponding report of the advisory service Juridical , it request the following actions from the public authorities:
a) The creation, in the Schools of Medicine, of Professional Schools for promote the training and the research in those modalities of Alternative Medicines that offer greater prospects of efficacy.
b) Recognition of the Associations of doctors practising the different modalities of alternative medicine, if their purpose is to promote the training of their members and the research and assessment of their techniques, provided that they respect the rules of the Code of Ethics.
c) The concession, in order to fill in the fractional legislation in force, of legal recognition to those modalities of Alternative Medicine that do not yet have it, taking into account that these are medical activities, whose practice by those who do not have the degree scroll of Doctor should be considered as intrusive.
d) Vigorous action against intrusion."
This is the text of the Declaration approved by the Central Ethics Commission at its meeting of February 23, 1985. The references to articles and chapters of the Code of Ethics correspond to the 1979 Code, not to the current 1990 Code, in which these rules and precepts are still in force.
The Code of Ethics and Medical Deontology
To fill in the set of deontological texts applicable to naturopathic medicine, and as a fundamental element of this set, it is necessary to reference letter to some articles of the current Code of Ethics and Medical Deontology.
First of all, in Chapter V, dedicated to Quality of Medical Care, there are three articles that are more immediately applicable. They reiterate part of the doctrine contained in the Declaration. But I will take the opportunity to quote them and comment on them in some detail.
article 24.1 states that "As long as non-conventional medicines have not achieved an acceptable scientific basis, the physicians who apply them are obliged to objectively record their observations in order to make it possible to assessment the efficacy of their methods".
This article defines the corporate attitude towards alternative medicines, an attitude that is marked by a confident acceptance, free of doctrinal prejudices, but conditioned to the objective verification of their results, of their efficacy. It is, it must be recognized, a very temperate and serene attitude for these times, in which Medicine is involved in a field of conflicting social, cultural, economic and political tensions.
It would have been very easy today, when we are witnessing unprecedented scientific progress in medicine and in the name of that progress, to fall into a rigid demand for orthodoxy, into an intemperate condemnation of unofficial medicine. Because medical progress does not only consist in conquering new knowledge and procedures, but also, and especially, in refuting false ideas, in discarding harmful, futile or illusory remedies, lacking in foundation and measurable effects. And precisely because it is not easy to get rid of deeply rooted ideas, criteria or habits when they are shown to have become obsolete, the promoters of progress can easily fall into excessive zeal.
And today it would have been very easy to fall into this condemnatory attitude, or, on the contrary, to adopt an irresponsibly tolerant posture. The temptation to tolerate is very strong today. For years now, medical unemployment has been a high-risk status , both professional and deontological, in which not a few physicians are forced to accept employment opportunities of little dignity. In addition, there is a growing issue of physicians who see in the internship of exotic medicines a way to satisfy certain social fashions and to obtain a secure economic return, since a considerable part of the public does not hide its resentment against academic medicine and is inclined towards a gentler, more natural and less aggressive medicine than orthodox medicine. We do not know how far this movement, which translates the broader social phenomenon of the rejection of technological-industrialism and the return to nature and environmentalism, will go in the field of medicine. It has even been said that academic medicine is a residual product of the naively scientistic medicine of the 19th century, while holistic medicine is the modern and "progressive". The unrestricted authorization of all variants of alternative medicine may even enjoy official protection. The Ministries of Health do not take a dim view of the rise of these practices and their social acceptance, since they remove quite a few patients from the national health systems, with the consequent economic relief for the battered ministerial Economics . As a result, fewer and fewer governments are interested in closely monitoring the internship of sectarian medicine and are turning a blind eye to the legal prohibition of quackery. The issue of countries that tolerate, under the complacent gaze of the World Health Organization, the internship of alternative forms of healing is growing.
I think that the ethical attitude that defines the Code and informs the Declaration is temperate and serene, because it is born from a healthy historical perspective. The vision of the past sample us how relative are the limits that separate orthodox Medicine from itself and from other Medicines. True Medicine is, by essence, open to progress. Academic Medicine will always contain in its bosom pathogenetic or therapeutic ideas that are transitory, outdated, destined in a more or less near future to be discarded and replaced by other more valid ones. It will always be the case that what is accepted as respectable and even advanced by "official" medicine at any given moment will later be rejected and even derided, just as many procedures that enjoyed respectability in the past are nowadays. But not everything is relative in this field. There is a moral obligation to treat according to the medical art of the moment. It will never be ethical to use irrational therapies, based on distortions of science, or esoteric remedies, whose composition is kept secret, which cannot be subjected to assessment.
Moreover, I do not know whether it is a temporary or permanent defect, academic medicine, or rather a large majority of orthodox physicians, are unable to offer a remedy to a considerable issue of patients presenting with "undifferentiated diseases", with chronic and troublesome disorders, for which neither objective pathophysiological instructions nor effective treatments have been discovered. Unfortunately, these physicians do not usually show much interest in these difficult patients, nor do they devote the time necessary to help them cope with their symptoms. It is precisely these patients, resentful of official medicine, who turn to alternative medicines, in which, it seems, they find the relief and comfort that scientific medicine was unable to give them. This is a status that orthodox medicine has to accept with humility.
Furthermore, both the Declaration and article 21.1 insist that it is an ethical requirement to give a scientific basis to the internship of all medicine, including that of non-conventional medicine. From this derives the obligation of all physicians, including those who follow non-conventional systems, to critically review their way of acting, in order to adapt or maintain it in accordance with the scientific criteria of the moment. It is important to insist that when the physician, by virtue of his therapeutic freedom, incorporates into his internship some system of diagnosis or treatment not validated by official medicine - whether degree scroll a simple addition to an otherwise orthodox medical internship , or in exclusive dedication to one of the variants of alternative medicine - deontological tolerance is obtained in exchange for not abdicating two fundamental obligations: that of offering the patient a professionally acceptable treatment, so as not to fall into the deontological fault of inadequate care; and that of clearly distinguishing between the procedure evaluated and already received in the lex artis and the experimental procedure , not yet critically evaluated, and for the application of which the ethical rules governing biomedical experimentation must be followed.
In any case, the Code and Declaration state that it is a fundamental requirement that physicians record their observations honestly and objectively. For only in this way is it possible to critically analyze the clinical protocols of the patients they have treated and to determine whether these unorthodox practices have any efficacy and to what approximate Degree Orthodox medicine demands the same of every new diagnostic and therapeutic procedure that wants to make its way into official internship . If the physician who follows some form of non-orthodox medicine were to neglect this obligation (Articles 15.1 and 15.4), it would be very difficult for him to demonstrate that his behavior is that of a true physician, since all genuine therapeutics are characterized by having passed the requirement to demonstrate that they possess verifiable quality and efficacy. This is a fundamental and irrevocable feature, which distinguishes the practice of medicine from the practices of quacks and sorcerers.
Precisely to mark the boundary that separates the deontological practice of medicine from its corruption, the following two articles have been included in the Code: 24.2 and 24.3. The first reads as follows: "Practices inspired by charlatanism, those lacking a scientific basis or those that promise the sick or their relatives impossible cures, illusory or insufficiently proven procedures, the application of simulated treatments or fictitious surgical interventions or the practice of medicine through consultations exclusively by letter, telephone, radio or press are unethical". Not all of its content, I hope, is relevant to the naturopathic doctor, but some parts of it are. The condemnation, in the first place, of the different forms of quackery, which have as a common feature to induce in the patient the conviction that the quack doctor is somehow superior to his other colleagues, so that, somehow, his medical care is also superior and more advantageous. The temptation of charlatanism can fall victim to physicians who feel endowed with special diagnostic or therapeutic abilities or who believe themselves to be in possession of unassailable theories or intuitions. It is possible to incur in the deontological fault of charlatanism both by making use of any form of advertising and by speaking directly to a single patient. This article condemns the internship of promising cures or to achieve certain results thanks to the treatment applied (even committing, if the treatment is not to the patient's liking and satisfaction, to refund the money). Such conduct constitutes a radical adulteration of Medicine, which consists of applying means and rendering services, not guaranteeing results. Both charlatanism and the promise of results may fall under the prohibition of the recent Law 3/1991 on unfair skill . The ethical indignity of deceiving the good faith of patients by offering them remedies of unknown efficacy or toxicity, or by applying magical, fictitious or illusory procedures is obvious.
Finally, article 24.3 warns that "It is not deontological to facilitate the use of the office, or to cover up in any way, to whoever, without possessing the degree scroll of physician, engages in the illegal practice of the profession". It is logical that the Code prohibits, apart from the criminal legislation on intrusion, the association or cooperation of physicians with non-physicians. The Code reiterates what is stated in the General Statutes of the Spanish Medical Association in article 44 article paragraphs d) and g), which prohibit physicians from "lending their names to appear as medical director or advisor of medical centers that do not comply with the laws in force and the Code of Ethics".
The association, for the purpose of attending patients, between physicians and non-physicians, including among the latter those who hold diplomas of no legal value, lends itself to misleading the public, since many would be led to believe that the care offered by a group which a registered physician is a member has the ethical and professional guarantee of the Medical Association.
This is what, in essence, the Code of Ethics and Medical Deontology tells us about alternative medicines. I would like to comment on two issues that seem to me to be of interest: the deontology of professional relationships between naturopathic doctors and academic doctors, and the ethical obligation to validate, through research, naturopathic practices.
Professional relationships between naturopathic physicians and academic physicians
Chapter VII of the Code, which deals with the relations of physicians among themselves, imposes the ethical obligation of professional fraternity, a duty that is classified as primordial, and over which only the rights of the patient take precedence. It states that mutual attention among physicians should be marked by deference, respect and loyalty; it prohibits derogatory criticism of the actions of colleagues; it establishes that the appropriate venue for resolving disagreements on scientific, professional or ethical issues is not public controversy, but discussion in private or in appropriate sessions, and that the arbitration of the Colleges should be used to settle these conflicts. And he reminds that the duty of fraternity cannot inhibit the obligation to denounce, objectively and discreetly, the infractions to the deontological rules or the lack of skill of the colleagues.
Relations between academics and naturists are not always cordial. There are variable Degrees mutual incomprehension and contempt, and a permanent war of ideas. It is to some extent logical that physicians are passionate in defending the doctrines in which they firmly believe, in the intuitions they see confirmed by observable results. And it is almost inevitable that their love of truth will lead them to regard with disdain or as positively heretical ideas that are beyond the margin of what they profess, to attribute to diagnostic or observational errors the achievements of the antagonists, to exaggerate their failures. In a word, there is a tendency to take polarized sides. The opposing modality receives an unqualified, Manichean condemnation.
The mutual incomprehension is maintained and reinforced by the patients' partnership . The patient who, disappointed by the other system, rants about the attention received there, is not restrained. On the contrary, he is allowed to let off steam at ease. Sometimes, the physician joins in the contemptuous criticism of his colleague, circumventing the deontological mandate which forbids such criticism in the presence of the patient, his relatives or third parties. In particular, it is always particularly painful for the physician when one of his patients "flees" to the other system.
The academician can be inflamed with a debelling zeal against the importation of exotic ideas or the application of empirical remedies; against the symbolic-irrational interpretation of the symptomatology or the cunning exploitation of the hypochondriac personality; against the medicalization of the innocuous ailment or the abuse of the physician as a placebo. The cultivator of naturo-holistic medicine has many of his academic colleagues as agents of a soulless and heartless medicine, unsympathetic, victims of techno-addiction, forgetful of the sick man and his need for comfort, concerned only with molecules, cells and mechanisms, uninterested in prevention, capable of spending enormous amounts of money for very little benefit to very few sick people.
The solution to this interprofessional conflict cannot be achieved by insult or schism, but through respectful relations. Fanaticism should be cured by a little self-criticism. It is necessary to recognize the common elements: the Hippocratic heritage, the unity of professional ethics, respect for the patient, the deontology of medical indication. Everyone has to recognize that medical technology can be used wisely or abused superstitiously. But all must also accept that wise abstention or criminal disregard of that same technology is also possible. All will have to agree that many situations cannot be solved except by resorting to old wisdom that does not forget the somato-psychic-spiritual unity of man, but they must also accept that there are disorders in which that wisdom can be a hindrance, since they only need some technical repairs.
In interprofessional relations, the obligation to have recourse to a competent colleague should always be present, whenever the best interest of the patient so advises. This is a traditional rule of medical ethics, which appears in all the Codes, ancient and modern. The London International Code of Medical Ethics states it in these words: "The physician owes his patient all his loyalty and the resources of his science. Whenever an examination or treatment is beyond the physician's ability, he should call in another qualified colleague in the subject". Telling the patient to seek the financial aid of another colleague can sometimes be very costly, because the physician feels that it may damage his prestige in the eyes of the patient and his relatives, or that it is tantamount to acknowledging his own limitations to them. But the physician must sacrifice his staff pride and his school prejudices and, for the good of the patient, advise the enquiry with a competent colleague in the subject.
The obligation to validate, by means of research, naturopathic practices
I believe that better mutual knowledge and the duty to be good colleagues can contribute greatly to peace between academics and non-conventionalists in the field of professional practice. However, integration into a solid unity cannot come as long as non-conventional practices are not validated through scientific research . This full integration is not possible as long as the incommunication that comes from using two different languages persists: that of experimental science and that of intuitions; the scientific language of the molecules that mediate pathophysiological processes - from which neither the healing of diseases nor the repair of injuries are excluded - and the intuitive language of the natural vital force; the scientific language of homeostatic holism - that of the well-characterized neuroendocrine pathways and of the messengers that connect some cells with others, some organs with others, some functions with others - and the language of intuitive holism that speaks of unidentified, unmeasurable energies that actualize the mysterious wisdom of the body.
It is necessary to overcome, as article 24.1 points out with optimism ("As long as the so-called Non-Conventional Medicines have not managed to acquire an acceptable scientific basis"), the present unsatisfactory status . These doctrines and their practices must be put through the sieve of scientific validation, in order to discard the invalid and keep the effective. In my opinion, the investigative validation of naturopathic medicine must be achieved at two levels.
First of all, it is necessary to clarify, by means of a rigorous characterization of the indications and therapeutic results, what is the real clinical efficacy of the different trends and techniques of non-conventional medicines. It is necessary to determine what their strengths are and where their limits are located. Once the wheat has been separated from the chaff, we must proceed to develop the fundamental pharmacology of these methods, translating their properties into a language of demonstrable and reproducible modes and mechanisms of action. These are not easy undertakings.
The first should be addressed immediately. It is required by the Code, as we saw a moment ago. It is also demanded by patients. article 4.3 of the Code proclaims that "The physician's primary loyalty is to his patient, and the patient's health must take precedence over any other convenience". It is irrelevant whether, a priori, the patient's health is obtained through academic medicine or by means of this or that alternative or complementary technique. What matters most, always and in any case, is the quality of Medicine, its healing efficiency. This is the field in which academic Medicine and other Medicines have to compete. They all have to submit to this unique test , to this control, to this validation. And the results of this test must be expressed in real numbers: of human beings, of nosological pictures, of symptoms, cured, prevented, alleviated. The demanding methodology of clinical Pharmacology or, better still, clinical Epidemiology, enriched by a Clinimetry that pays attention and quantifies with statistical validity the responses of patients to treatments, including the subjective responses, already have instruments to make the comparison of one and other Medicines in terms of real efficacy. The rules of the game must be agreed upon, but they must be the same for all the contenders, since it is necessary to play fair.
The second business, that of clarifying the demonstrable mechanisms of action through which therapeutic regimens operate or on which pathogenetic theories or explanations are based, is more difficult, but just as necessary. It demands a conscientious work of honest design , of rigorous research , of critically founded deductions. It is also an obligation common to both academic and naturopathic medicine. Some treatments of academic medicine are too aggressive and life-threatening: it is never licit to use them by pure intuition, by inductive reasoning, by the whim of trying to see what happens. It is necessary to know how they act and what their effects are. One might think that the means used by Naturopathic Medicine are much more innocuous, and that as long as they do not deprive the patient of a truly effective therapy, nothing is lost by applying them. But that is a falsification of Medicine, because it is equivalent to using fictitious, illusory remedies, of indeterminate action.
It is an ethical imperative to apply a single rule of quality for professional practice. There cannot be first- and class physicians, nor first- and class patients. It is necessary to validate with research the potential risks and net benefits of any medical intervention. In the face of this common rule , both medicines must be confronted. Academic medicine has already gone a long way down this road. It will be necessary to clear the path to be followed by alternative medicine. It is necessary to design, in successive steps, a common language in which we can all understand each other, in which it is possible to determine when and how the physician's placebo function average , and how the patient's desire to be cured is expressed physiopathologically, what is the mechanism by which his faith in his physician acts, how the subject or the energy that, through the word, the homeopathic dose, the stimulation that is applied, intervenes, and in which sectors of the sickness. Only if an objective, reproducible, validable research is done, complementary medicine can, in imitation of academic medicine, attain full citizenship rights in doctors' offices and hospitals. The scarce and debatable fundamental research in the area of Complementary Medicine makes it vulnerable to the irrational pretensions of people who, with or without a medical degree scroll , continue to offer the gullible a picturesque variety of these illusory or insufficiently proven treatments, prohibited by article 24.1.
It is certain that new research models are needed to achieve the integration of Complementary Medicine into Academic Medicine. I firmly believe that it is worth making this effort, which can benefit many patients and be a formidable relief in the medical expense of modern societies. I am glad that in the bosom of a School of Medicine this meeting of approximation between academics and naturopaths has been held. Deontology sample us that the way forward is through respect for the patient, through mutual collegial respect and through respect for the natural-scientific essence of Medicine.
Thank you very much.