Via the magic of “legislative alchemy,” state legislatures transform implausible and unproven diagnostic methods and treatments into perfectly legal health care practices.[1] Without the benefit of legislative alchemy, chiropractors, naturopaths, homeopaths, acupuncturists and other assorted putative healers would be vulnerable to charges of practicing medicine without a license and consumer fraud. Thus, they must seek either their own licensing system or exemption from licensing altogether.

Licensing bestows an undeserved air of legitimacy on “alternative” practitioners. Because a state’s authority to regulate health care lies in its inherent power to protect the public health, safety and welfare, the public understandably assumes licensing actually accomplishes this purpose. In fact, the opposite occurs. Any attempt to impose a science-based standard of health care becomes impossible when vitalism and similarly debunked notions of human functioning are enshrined into law.

Initial licensing is just a beginning. Once the beach head is established other benefits can follow, such as expansion of the scope of practice. If not granted in the initial legislation, “alternative” practitioners can return, seeking more goodies like self-regulation and mandatory insurance coverage.

Each year brings a fresh round of eager petitioners to the state house doors hoping to transform their base ideas into licensing gold through legislative alchemy. In this post, we look at how the naturopaths are faring. We’ll leave chiropractors, acupuncturists and the rest to a later post.

Naturopathy 101

Three years ago, Dr. Kimball Atwood wrote an excellent series of SBM posts on naturopathy, including efforts to license naturopaths in several states (In four parts: 1, 2, 3, 4)[2] Since then, naturopathy has fairly regularly appeared on SBM, its pseudoscientific practices and threats to public health offering plenty of grist (gluten-free or not) for the scientific mill in posts by Drs. Gorski (also this one), Lipson, and Kroll.

All posts are highly recommended, but if you’re pressed for time, here’s Dr. Gorski’s description of naturopathy:

…a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to ‘pick one from column A and one from column B’ when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine.

As well, according to a recent article in Maternal and Child Health Journal “published reports suggest that only a minority of naturopathic physicians actively support full vaccination.”[3] This should surprise no one, as it fully accords with naturopathy’s long standing opposition to vaccination (see also QuackWatch).

A review of Washington state insurance records reported in the article showed that children were significantly less likely to receive each of four recommended vaccinations (measles/mumps/rubella, chickenpox, diphtheria/tetanus/pertussis, and H. influenzae type B) if they saw a naturopathic physician. It would naturally follow then that pediatric use of naturopathy was associated with significantly more diagnoses of vaccine-preventable disease.

The Scorecard

In the first half of 2011 alone, bills to license naturopaths were pending before ten state legislatures. To date, only one has been successful, in North Dakota. Licensing bills failed in four states because they never made it out of committee. They remain pending in committee in five states.

Of the 15 states already licensing naturopaths, bills to expand the scope of practice (including expansion via self-regulation) were introduced in seven. These bills remain pending in two states, passed in two states, and failed in three states, again because they never made it out of committee. (A bill to expand naturopathic scope of practice is also pending in Washington, D.C.) Legislation mandating public and/or private health insurance coverage for naturopathic services is pending in one state, and failed to make it out of committee in two.

Licensing happens

In July, 2008, Dr. Atwood began the first of his four-part series, “Another State Promotes the Pseudoscientific Cult that is ‘Naturopathic Medicine,’” with the observation that Minnesota had just become the 15th state to license naturopaths. In July, 2011, North Dakota became the 16th state.[4]

North Dakota departs from those states giving naturopaths their own governing authority by establishing a State Board of Integrative Health Care. “Integrative health care,” that ever shape-shifting term, is not defined in the statute, but the Board appears to be a place to park things the state otherwise doesn’t know exactly what to do with. For starters, the Board will license and regulate both naturopaths and music therapists, but the barn door is left open for other “integrative” health care practitioners to apply for regulation.

The new Board must have at least five members, including one member of each profession (such as they are) regulated. One member must be an M.D. or D.O., although if no medical or osteopathic doctor is willing to serve the governor can appoint an advanced practice registered nurse (APRN) instead. Perhaps this indicates the level of enthusiasm for board service the legislature anticipates. The governor must also appoint a pharmacist, an APRN and a layperson, although no provision is made if none of them want to do this either.

The new law contains the typical boilerplate found in other naturopath licensing bills (discussed further below) although this one is unusually short on details and leaves it to the State Board of Integrative Health Care to sort out the specifics. The law does say that NDs cannot prescribe or administer drugs or ionizing radioactive substances or perform surgery. And even though the statute describes naturopathy as “a system of primary health care … for the prevention, diagnosis, and treatment of human health conditions, injury, and disease” a licensed naturopath “may not hold out to the public that the naturopath is a primary care provider.”

The law has two laudable provisions. First, naturopaths are prohibited from “the making of false or misleading statements about the licensee’s skill or the efficacy of any medicine, treatment, or remedy.” (Emphasis mine.) That last phrase is going to make it pretty quiet around the N.D. office. After all, if you can’t misrepresent the efficacy of, for example, homeopathic preparations or herbal supplements it’s going to be hard to come up with an explanation of exactly why you’re prescribing (or selling) them.

Second, another provision prohibits “the representation to a patient that a manifestly incurable condition, sickness, disease, or injury can be cured.” Too late for Hulda Clark, but at least the legislature had the good sense to take care that end on the bell curve of charlatanism.

Pending licensing legislation

Naturopathic licensing bills are now before the legislatures of Massachusetts (House Bill 2367, Senate Bill 1158), North Carolina (House Bill 847, Senate Bill 467) Illinois (House Bill 3350), Pennsylvania (House Bill 1717), and New York (Assembly Bills 1937 and 3057, Senate Bill 1803).

As with all naturopathic licensing legislation, these bills are based on three unproven notions: that the general public wants access to naturopaths, that naturopathic licensing protects the public from substandard health care practices, and that “educated” naturopaths are the answer to quality of care issues.

And as is true of other bills pending in 2011, both successful and not, these proposals to license naturopaths buy into the same false premise set forth in Massachusetts House Bill No. 02367:

Naturopathic health care [is] a system of health care practices for the prevention, diagnosis, evaluation and treatment of illnesses, injuries and conditions of the human body through the use of education, nutrition, natural medicines and therapies and other modalities which are designed to support, stimulate or supplement the human body’s own natural self-healing processes.

Yes, it’s those famous “self-healing processes,” which, if we can only hit them with the right plant, or animal part, or mineral, or electric current, or needle, or pressure, or thrust, or energy field, they will spring forth and do their job. They’re just being stubborn, you see, lurking there in the body, refusing to heal. Like little gods, they must be appeased with food and other amusements. And they like theirs natural.

Pennsylvania in particular wants to go after the body’s self-healing processes full bore. Its proposed licensing act would allow naturopaths to practice “behavioral medicine,” including cognitive therapy. As well, they could employ “naturopathic musculokeletal therapy” on, among other things, scar tissue and visceral organs, and “reposition … displaced body tissues and organs.” Then there’s electromagnetic energy, colon hydrotherapy, electrotherapy, magnetic therapy, low-level laser light, neural therapy, diathermy, dietary supplements and “bio-identical” hormones.

And what naturopathy licensing act would be complete without homeopathy, now with a new, improved statutory definition in Pennsylvania: “a system of employing substances of animal, vegetable or mineral origin which are given in microdosage in the prevention and treatment of disease.” “Microdosage”? How about “nonexistentdosage”?

One means of poking the body’s “self-healing processes” not available under any state’s proposed legislation is acupuncture. It is specifically prohibited except under one version of New York’s licensing bill, where it is not mentioned either as part of the permissible scope of practice or as a prohibition.

A Learner’s Permit to Practice Medicine?

One version of a New York Assembly licensing bill (A01937) and a Senate bill would prohibit the practice of naturopathy except under the supervision of a physician. (Assembly bill A03057 does not include this prohibition, and further allows “naturopathic childbirth.”)

Neither North Carolina’s Senate or House bill require actual physician supervision, but applicants for licensure must provide the North Carolina Naturopathic Doctors Licensing Board with a list of physicians from at least four specialty areas who have “agreed to work with … and accept referrals from the applicant.” The Senate bill would create an “Advisory Council” to “foster coordination and collaboration” between N.D.s, M.D.s and other health professionals “for the purpose of providing appropriate care for patients.” Naturopaths could not prescribe drugs in N.C.

In Pennsylvania, naturopaths would be regulated by the Board of Medicine. A “Naturopathic Formulary Committee” must include two physicians, a pharmacist, and someone with an advanced degree in pharmacology or pharmacognosy. Massachusetts establishes a naturopathic board which includes physicians and a pharmacologist. It does not give naturopaths prescribing privileges.

On the other hand, in Illinois, naturopaths would have their own board, which has no M.D. or D.O. physician members. However, both physicians and pharmacists must be on the “Naturopathic Formulary Council,” which would establish a formulary that can include prescription drugs.

The Illinois House licensing bill establishes a “Naturopathic Childbirth Attendance Advisory Committee” (which must include an M.D. obstetrician and a certified nurse midwife) to look into naturopathic education and training, then make recommendations regarding naturopathic childbirth attendance, which the Department of Financial and Professional Regulation must adopt as rules. The N.D. must pass the North American Registry of Midwives examination to practice “naturopathic childbirth attendance.”

All of these proposals indicate to me that the state legislatures don’t quite trust naturopaths. Naturopathy, as defined by naturopaths, is a free-standing health care philosophy (if you will) perfectly capable of operating without supervision from “mainstream” medicine. But the states aren’t buying it. While they are willing to consider licensing, it’s clear the state legislatures are not willing to unleash naturopaths on the public without some version of physician oversight. This is especially obvious regarding childbirth and prescription drugs. After all, for example, if one believes naturopaths are “real doctors” then why do they need to pass a midwifery exam to deliver babies?

This is an unfortunate half-baked approach. If the states don’t believe the education and training of naturopaths is up to par, then they shouldn’t license them at all. Instead naturopaths are given learner’s permits to practice medicine – they can be doctors, but only with adult supervision.

And now, for the good news

Naturopathic licensing bills failed in four states in 2011: Maryland, Virginia, Colorado, and Iowa. In Colorado it failed for the eighth time, largely due to the indefatigable Linda Rosa, RN, Larry Sarner and Mark Johnson, MD. In the past, the Colorado Medical Society has failed science-based medicine by supporting naturopathic licensing. This time around, according to Ms. Rosa, the Colorado Medical Society leadership stuck to their deal with the naturopaths to allow registration in exchange for naturopaths not using the term “physician” and limiting some of their scope of practice.

You can’t always get what you want…

But you can always go back and ask again, which is what’s happening in states already licensing naturopaths.

New laws in Washington and Arizona expand the scope of naturopathic practice. Arizona now allows IV administration of “nutrients.” The Arizona Naturopathic Medical Association requested “parenteral” administration authority but that word was changed to “intravenous” in committee.

In Washington, naturopaths will now be governed by their very own Board of Naturopathy, free of the meddling influence of M.D.s, D.O.s or pharmacists – the Board is composed of five N.D.s and two public members. In addition, naturopaths may now give orders to respiratory therapists and prescribe contraceptive drugs. A limitation on the use of “physical modalities” to those that are “non-invasive” was lifted.

Other bills failed to make it out of committee before the legislatures adjourned:

Alaska: would create a Naturopathic Medical Board for purpose of expanding allowed practices and procedures, including limited prescriptive authority.

Idaho: attempt to establish something called a “registered naturopathic practitioner,” which required no formal education if one had “practiced as a doctor of naturopathy” for 20 years.

Kansas: would expand the scope of naturopathic prescribing authority to include intramuscular, subcutaneous or intravenous administration of vitamins, minerals and homeopathic preparations, as well as prescription and administration of, among other things, whole gland thyroid. (If I may be permitted a comment: EEWWWW!)

Hawaii: would allow naturopaths to prescribe controlled substances.

New Hampshire and Oregon: would mandate insurance coverage of naturopathic services.

Still pending are bills in California to expand drug prescribing authority and in Hawaii to mandate insurance coverage for naturopathic services.

Hawaii law, very sensibly, requires the state auditor to submit a report assessing “both the social and financial effects of proposed mandated coverage.” In what I personally consider a new low in legislative drafting sleaziness, the Hawaii Senate’s concurrent resolution requesting the auditor’s study states:

WHEREAS, according to the American Cancer Society, naturopathy is ‘a complete alternative care system that uses a wide range of approaches such as nutrition, herbs, manipulation of the body, exercise, stress, and acupuncture … .’

Here’s a more, um, holistic view of the American Cancer Society’s statements on naturopathy for the state auditor’s consideration:

Available scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease, since virtually no studies on naturopathy as a whole have been published.

Available scientific evidence does not support claims that naturopathic medicine is effective for most health problems. Most of the claims of effectiveness are based on individual cases, medical records, and summaries of practitioners’ clinical experiences.

Excessive fasting, dietary restrictions, or use of enemas, which are sometimes components of naturopathic treatment, may be dangerous. Naturopathic treatment may involve taking unregulated herbs, some of which may have harmful effects.

As if that weren’t enough, the Hawaii Senate’s resolution adds:

WHEREAS, naturopathic medicine has become recognized as a therapy that is comparable in its effectiveness to more traditional medical and surgical practices for many types of illnesses…

Gosh, I looked and looked on PubMed and couldn’t find a single thing to support that statement. Maybe the state auditor’s research will turn up something.

By the way…

It would cost a whole lot of money – I don’t know how much, but a whole lot for sure – to draft and introduce licensing legislation and shepherd it through the legislative process in any one state. To do this in ten states in one year must cost an astronomical amount, especially in states the size of New York, Pennsylvania and Illinois. Who’s paying for this?

Conclusion

No person should be subjected to scientifically implausible diagnostic methods and treatments. States should be working to eliminate such practices, not giving out licenses to perpetuate them.

Passage of naturopathic licensing bills in the five states where legislation is pending would substantially increase the population subject to this conglomeration of pseudoscientific practices. But even one more licensing law in one state is one too many. Supporters of science-based medicine should actively oppose the “legislative alchemy” that is naturopathic licensing and, where licensing is already entrenched, oppose expansion of scope of practice and insurance mandates.

In fact, it is possible to eliminate existing licensing of naturopaths altogether, as Florida has done.

Notes

1. See, Bellamy J., Legislative Alchemy: the US state chiropractic practice acts, Focus on Complementary and Alternative Therapies (2010)15(3): 214–222.
2. For an excellent primer on naturopathy, see also, Atwood K., Naturopathy: A Critical Appraisal, Medscape, General Medicine. (2003);5(4). http://www.medscape.com/viewarticle/465994
3. Downey L, et al, Pediatric Vaccination and Vaccine-Preventable Disease Acquisition: Associations with Care by Complementary and Alternative Medicine Providers, Matern Child Health J (2010) 14: 922-930.
4. N.D. Cent. Code Ch. 43-58 (2011).

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