A Skeptic North Response to the Naturopaths’ Rebuttal

Last week, a Skeptic North article was adapted and printed in the National Post. Highly critical of a proposal to grant naturopaths the right to prescribe, it generated a heated response both at the Post and here at Skeptic North. Advocates demanded the Post allow opportunity to post a rebuttal, and the editors obliged. Their response was disappointing. Rather than refuting the arguments put forward against naturopath prescribing, it was a textbook example of the typical circular reasoning and self-defeating logic that naturopaths use to justify their particular belief system.

The naturopathic industry in Ontario has had it relatively easy for the past 85 years, operating on the margins of the health care system, and facing little scrutiny or questions about its practices. Now that naturopaths seem to believe that they are capable of being a primary care alternative to medical doctors, questions about capabilities are being raised. And with the Post’s article last week, naturopaths have been called upon to justify the lack of scientific evidence underlying their practices.

Picture of CAND booth taken at the 2009 Toronto Whole Life Expo. The expo featured dubious treatments such as homeopathy and ear candling (which is banned from sale in Canada).

The rebuttal was written by two naturopaths. Despite the friendly and professional tone (in contrast to some of the comments seen on the original post or on the National Post website), the rebuttal clearly demonstrated that naturopaths are not science-based medical practitioners, and that they lack the training, understanding of science, and qualification to prescribe.

Below we will address some portions of their response.

Naturopathic medicine is based on the scientific assertion that the body, when given the appropriate support, has the potential to heal itself. This isn’t a magical and transcendent anomaly of physics. It’s how the body works and we’ve known it for centuries. Each time you heal from a cut, a cold or a broken bone, you’re seeing vis mediatrix naturae, or “the healing power of nature” at work. It’s not magic, just good science. And this naturopathic approach has been regulated in Ontario for 85 years.

The authors here are unknowingly referring to the immune system. Medical doctors (read: people with medical degrees) are aware that people have an immune system and are capable of self healing. The immune system is very complex and is not fully understood, but scientists have a good grasp as to how it works. Instead of trying to understand the immune system as a complex piece of biology, naturopaths turn to pre-scientific views of healing such as “medicatrix naturae“. Medicatrix naturae (misspelled by the authors as “mediatrix naturae” in their rebuttal) is a term used to refer to Hippocrates’ outdated and pre-scientific notion that the body is constantly trying to remain in “balance”. For example, fever is mechanism to “restore balance”. This philosophy was the basis of western medicine for centuries, which included treatments such as blood-letting, until modern science-based medicine thankfully replaced it with concepts like the germ theory of disease and the knowledge of the immune system.

While it is true that naturopathy has been regulated for 85 years, that does not mean that it is a scientific practice or beyond criticism.

Of course, healing a broken bone is not much help if you keep breaking it. As naturopathic doctors (NDs), our focus is on finding and treating the cause of a chronic problem, not just managing the symptoms.

It is true that chronic diseases are a problem for many Ontarians. Medical scientists continue to make progress by finding treatments and cures for many illnesses, but qualified medical doctors do not claim to be able to heal every illness.

It would be great if there was someone out there that could help sufferers of chronic illnesses when they have exhausted all avenues of legitimate treatment, but there is no evidence to show that naturopaths can fill that gap. And clearly, our doctors are doing a great job looking after our health – we have the longest lifespan in history in major part due to their care.

Some patients first come to NDs because they are looking for options to conventional medications or are interested in a more natural approach to health. Others want to be able to take better charge of their health and focus on prevention, or want help managing the side effects from medications or intensive medical therapies. As well, many patients have not had success with conventional options to address chronic or unresolved conditions.

This passage is important, as it touches on a few areas.

Firstly, it shows that naturopaths want to be able to provide conventional (in other words: effective and proven) treatments. But if a patient is seeking conventional treatments, they should seek out a medical doctor who is trained in such methods. The government provides doctors with the right to prescribe because they have received the requisite level of education and real world experience to make the right choices for patients. Naturopaths claim that they should be able to offer conventional treatments, but then what would separate them from acting as your primary doctor? Does it make sense to allow someone who only has four years of education after receiving a bachelors degree to act as a doctor? This would completely undermine the entire medical and integrated education systems that we have in place to protect patients. When did it become ok to practice medicine without a medical license?

Secondly is the issue of the entire underlying fallacious philosophy of naturopathy. Naturopaths claim to be more interested in a “natural approach” to medicine. This reflects little more than a naturalist preoccupation. Natural does not mean effective or safe. The presence in nature of dangers such as snake venom, poison ivy, hemlock, arsenic, asbestos, etc. shows testament to the fact that “nature” is indifferent to our health. Only objective investigation, such as medical science research can reliably determine what substances are safe and effective. While a naturopath may recommend that a patient with a headache consume white willow bark, it might contain contaminants and a specific dosage of bark is likely to contain a varying amount of active ingredient. On the other hand, a medical doctor would instead recommend a specific dosage of Aspirin (which was originally derived from white willow bark) and be confident that it is not contaminated and contains a reliable, purified, and consistent dosage.
Naturopaths claim to fill a niche that is being missed by medical doctors – that of prevention. Medical doctors indeed care a great deal about prevention. That is why one of their many recommendations is, for example, vaccination to prevent disease. It’s worth pointing out that naturopaths regularly oppose life-saving vaccines, which are one of the best ways to prevent a patient from becoming sick.

Naturopathic doctors are likely to undertake additional diagnostic testing to understand what else might be going on, and take the time to talk to patients about lifestyle and environmental factors, all in the interest of identifying the potential underlying causes of a patient’s complaints. Most referrals to NDs come from other patients who have been helped, and from practitioners who understand for themselves how NDs practice.

The authors imply that they are specialists when it comes to identifying the “underlying causes” of illnesses, as opposed to focusing on symptoms. This implies that physicians do not adequately address the cause of illness. However, this is a misrepresentation of the medical profession that reflects a poor understanding of science-based medicine. For example, if a patient reports shortness of breath (a symptom) to their doctor, the doctor will run a series of diagnostic tests to determine the cause. Not to do so could result in prescribing the wrong treatment, as many things could cause shortness of breath.

In contrast, naturopaths often use homeopathy, a placebo treatment that is based on the out-dated symptom-based philosophy that “like cures like” – in other words, prescribe a diluted agent that supposedly causes shortness of breath to treat shortness of breath. However, there is insufficient evidence that such a treatment would safe or effective. This patient may then avoid seeking science-based medical care for a real problem, believing they will be cured by the homeopathic treatment. In this case, asthaa, heart problems, blood circulation problems, etc. – which may require medication or surgery to treat safely.

This complementary system is vital when we are living in a society that is increasingly focused on symptom management. It may be that with all the pressures in the health-care system, conventional medicine is no longer fully considering the unique circumstances of each patient. This may be one reason for an increasing reliance on pharmaceuticals. There may be good evidence for how a drug may treat a symptom. But that may not be enough to achieve good health. In fact, over-reliance on pharmaceuticals may be making us sicker by masking the opportunity to diagnose or remediate the true cause of the disorder.

This statement reflects a misunderstanding of basic pharmacology. With the exception of things like pain killers and anti-inflammatories, few drugs are designed to treat “symptoms”.  It is also interesting to note here that the authors are downplaying the usefulness of drugs and emphasizing their dangers, they wish to have the right to prescribe the same pharmaceuticals! These are mutually exclusive views.

Most importantly, what patients want is to not be sick in the first place. The American Institute for Cancer Research determined that one-third of all cancers could be prevented through exercise, diet and weight management. Naturopathic doctors have the clinical skills and training to help patients integrate these preventative strategies.

This is presented as though naturopaths have a monopoly on knowledge that exercise and good diet is beneficial. Any doctor, dietician, or other health care provider will tell you about the importance of a healthy active lifestyle. The American Institute for Cancer Research also makes no mention of naturopathic alternatives, so it’s a wonder why the authors mentioned this at all.

Ontario’s naturopathic doctors have training that compares with other primary care providers. Licensed naturopathic doctors have a pre-medical university degree followed by four years of intensive medical training at an accredited Naturopathic College and regulatory examinations.

The Academic pre-requisites to get into the Canadian College of Naturopathic Medicine (CCNM) state that an applicant must have a four-year bachelor’s degree. Neither a specific health- or science-related degree, nor science prerequisites, are required. For example, a lit-crit grad is just as qualified for entry into the CCNM as a bio-chem grad, even without extra science courses. The authors do not address that naturopaths have no required residency training with other medical fields. Other health care workers such as doctors and nurses require significant amounts of supervised training treating patients in a science-based environment.

Four years of specialized education is also meaningless if the subject is meaningless. A masters degree in unicorn breeding from an unaffiliated college does not mean that unicorns exist. Similarly, four years learning about the details of homeopathy is of no use if homeopathy does not work.

With this training and education, the scope of naturopathic care extends to the treatment of serious conditions, usually in collaboration with other health-care practitioners. Every review of our record has recognized the safety of the more natural approach of naturopathic care.

There is no evidence that any treatments offered by naturopaths, but rejected by medicine, have any effect on disease. If a treatment had evidence of effectiveness, it would be medicine. If not, it might remain “naturopathic”.

The treatment of disease should be based on expected benefits and known risks. When there is no plausible benefit, then any amount of risk is unacceptable. And given that there is no evidence of effectiveness underlying many of naturopathy’s treatments, are they ethical to offer to patients?

Also, if a patient is dying from a terminal illness, does it matter if the best treatment is “natural” or not?

In fact, contrary to what Mr. Gavura has suggested, research has shown that in jurisdictions such as Utah and Arizona, where NDs and pharmacists have been awarded prescribing authority similar in scope to that of a medical doctor, malpractice insurance (a reflection of the risk associated with prescribing rights) for naturopathic doctors remains one-third that of a regular family physician.

Malpractice insurance is more complex than merely reflecting the risk associated with prescribing rights. This is merely cherry picking. They conveniently ignore the deaths attributed to naturopathic care in Washington and Oregon.

And although there are unfortunately deaths associated with so-called “traditional” medicine, the deaths in the US (particular one in Oregon that was directly as a result to illegal prescribing and misdiagnosis by a naturopath who was merely fined $5000 plus $250 per illegal prescription) reflect what is at stake when the door is opened for undertrained professions to start prescribing medicine with insufficient oversight and a poor understanding of science-based medicine.

Meanwhile, the limits of randomized control trials favoured by the pharmaceutical industry are being increasingly recognized. Randomized control trials tend to test a single treatment approach to the eradication of a symptom. This approach works against individualized care, and tends to be biased toward over-treatment rather than prevention. Clinical studies are critical to advancing knowledge, but in themselves they are not the solutions to health problems.

The authors demonstrate a misunderstanding of the nature and importance of clinical trials. Clinical trials were first used to discover the importance of vitamins. It was a clinical trial that first determined that citrus (which contains vitamin C) prevents scurvy. This was discovered by a doctor, not a naturopath. In this case, a clinical trial was definitely the “solution to a health problem”.

A red flag for unscientific medical practitioners is hostility to, or the downplaying of, scientific evidence such as clinical trials. We know that some treatments are more effective than placebos thanks to clinical trials. Homeopathy (which is taught extensively at the CCNM) is one of these placebo treatments. It is due to their ineffectiveness that doctors don’t prescribe homeopathic remedies. Naturopaths, in an attempt to excuse their recommendation of homeopathy, instill unjustified doubt in the necessity of clinical trials. But clinical trials are the best and most reliable method for separating treatments that work from treatments that don’t work. Clinical trials rescued our culture from such notorious, yet ancient and natural, treatments as blood-letting and trepanation. Clinical trials did so by filtering out bias, the placebo effect, and other confounding  factors that make it nearly impossible to determine efficacy by mere anecdote alone.

All of these factors were carefully considered by the Ontario government and their advisory panel, the Health Professions Regulatory Advisory Council (HPRAC), as part of the decision in October to award prescribing authority to naturopathic doctors. The need for NDs to have prescribing authority was accepted by every other regulated health profession.

This is also incorrect. After the Ontario legislature shut out the HPRAC’s recommendations for naturopathic prescription rights after the first and second readings, the naturopath community launched a write-in campaign, which sent the bill to the Standing Committee on Social Policy, which in turn worked the naturopaths back into the bill. This was not because of medical or scientific reasons, but because of populism and disingenuous appeals to freedom. As for the “need” being accepted by every other regulated health profession, this is also misleading because the various professions were approving of the amendments to the parts of the bill that dealt with their own profession (nursing for nurses, pharmacy for pharmacists etc.), not because they all suddenly decided that naturopathy was a legitimate, science-based practice.

HPRAC also recommended that Ontario’s NDs, similar to NDs in almost every other regulated jurisdiction, have the capability to take on a larger role in primary care with access to basic primary care pharmaceuticals such as antibiotics. What NDs will be able to prescribe will be determined through an extensive process to establish new rules for the profession, which should take about three years.

This approximately three-year process will have oversight not from the medical or academic communities, but from the naturopathic community. In other words, subject to the approval of the Minister, the list of drugs that naturopaths will have the right to prescribe will be made by the naturopaths themselves.

In our developing model of integrative medicine, Naturopathic Doctors are not costing the system more money. Instead, they are decreasing the costs of care for patients with chronic illness while providing better access to primary care for patients preferring a more natural approach.

With 23,000 registered physicians in Ontario, and fewer than 1000 naturopaths, the argument that this amendment will lower the burden on health care is a bit silly. Furthermore, naturopaths are not primary care providers, and yet-again, “natural” does not mean safe or effective. Further still, there is no evidence that this will decrease cost for patients or the Ontario government.

We will continue to build relationships with practitioners knowledgeable enough to seek our partnership in the management of their patients. To those practitioners we have one message; we look forward to working with you.

The Naturopathic community has not had a good relationship with the medical community. For decades they have derided science-based medicine as being blinded by a materialist paradigm that blinds doctors to the “healing power of nature”. They denigrate mainstream doctors and the medical industry as being profit driven while the alternative medicine industry hypocritically earns billions of dollars a year. The authors seem to want it both ways: Science is bad for being reductionist, and yet, naturopathy is a totally legitimate science! The cognitive dissonance must be as loud as a jet engine.

The naturopaths’ response was very telling. At heart of the op-ed was that naturopathy is an unscientific practice of medicine. Therefore, it’s no surprise that in their response the common theme was that naturopathy is a scientific practice. The author raised the issue in his article that by prescribing treatments such as homeopathy and colonics, naturopaths do not respect science. The naturopaths did not adequetly address this issue. Instead of showing that they respect science, they instead play word games with the definition of the immune system and downplay the importance of clinical trials.

We call on the Ontario government to put the health and safety of Ontarians first: Immediately amend Bill 179 by removing plans to allow naturopaths to prescribe drugs. It’s time to take a stand for medical care based on science.

Co-written by Jonathan Abrams and Steve Thoms

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  • Jonathan Abrams

    Jonathan Abrams is the latest founder and president of the Ottawa Skeptics. He organizes local events, makes media appearances as the token skeptic, and is one of the website maintainers. He is the host of the skepticism podcast The Reality Check. When he’s not thinking about science and skepticism, he’s working as a computer engineer, playing pinball, or doing the dishes.