Naturopathic Scope of Practice

Naturopathic scope of practice varies by state, sometimes including such practices as minor surgery and sometimes excluding such things as lab tests.

On May 6, 2006 the Board of Naturopathic Examiners of Oregon State will host a day-long seminar examining legal and ethical issues in naturopathic practice. Michael H. Cohen will present on "NATUROPATHIC MEDICAL ETHICS IN THE 21st CENTURY."

The talk will:

1. Provide an overview of key legal issues facing clinicians and hospitals advising patients concerning integration of complementary and alternative medical (CAM) therapies and providers including those representing naturopathic medicine into conventional medical settings. Issues will include from among the following:

a. Licensure
b. Scope of practice
c. Malpractice
i. Standard of care
ii. Duty to refer
d. Professional discipline

2. Present a liability risk management used to guide conventional clinicians exploring the matter of counseling patients concerning inclusion of CAM therapies (including referrals to CAM providers such as ND's).

3. Discuss specific areas of concern to naturopathic medicine, including:

a. The issue of non-licensed naturopathic providers.

i. Should non-licensed practice be criminalized, or legalized?
ii. What do the CA, FL, MN, and RI statutes allow? What about Colorado and Wyoming?
iii. How should licensed ND's respond? By pointing out differences in training and skill and marketing accordingly?
iv. What if non-licensed naturopathic providers have broad authority to do just about anything (given the disclosure and other constraints), while licensed NDs have scope of practice constraints?

b. Should naturopathic practice be considered "primary" care?
i. What does it mean if the state licensing statute designates them as such?
ii. Can they advertise as such if statute and regulations are silent about "primary care" status?

c. Scope of practice boundary areas; licensure, credentialing, competence.

i. Analogize to borderland cases within medicine that are arising under disciplinary boards--EDTA chelation, intravenous hydrogen peroxide, etc. Is this a case where beneficence is most controversial, and standard of care unclear?

· What does having a license really mean? How should or will the board likely respond to a complaint about these things?
· Should ND's have less or more leeway than MD's? Is this practicing "below the standard of care" or "unethical practice?" How do you as a practitioner know whether it is or isn't?
· How do you build or create a standard of care over time? How can the community create guidelines that the board can then implement when such cases arise?

ii. Case example: Cranio-sacral therapy. Can any ND provide? How is competence to be determined when the Board does not regulate this therapy and the statute is ambiguous regarding practitioners' scope?

iii. Case example: Consider a situation where best medical practice is to treat patient with a prescription that is not within the ND formulary--for example, use of thiazide diuretics in treating hypertension; or, use of common antibiotics (other than Cipro, a strong antibiotic which many NDs are authorized to prescribe) for treating urinary tract infections. How should NDs respond to lack of clear legal authority to follow best practice, particularly in the absence of any direct guidance from the statute of board regulations?

d. What is considered standard of care:

i. Case example: Refusal to recommend antibiotics for recurrent child ear infections, based on honoring Tolle Causum (let nature heal) and avoiding symptom suppression.

ii. Case example: Refusal to prescribe antibiotics for a condition (let's say urinary tract infection) based on concern that to do so would be suppressive. Instead the ND proposes a number of 'constitutional' treatments including hydrotherapy, strict dietary regimen of steamed veggies and minimal grains, biotherapeutic drainage (a homeopathic proprietary method of treatment), and allergy testing.

Should or would the ND likely be either: (a) disciplined, or (b) subject to malpractice liability?

e. Issues arising during spiritual care.

i. Case Example: Therapeutic Touch, homeopathy, energetic medicine, whether it be Reiki or other hands on, and including homeopathy or Bach Flowers.

Can a licensed ND be 'safe' only using such modalities in Oregon when treating with these modalities? Is evidence of safety, efficacy and/or mechanism necessary to provide it? How do practitioners maintain boundaries? What about informed consent?

4. Discuss key ethical issues and their interplay (such as autonomy vs. non-maleficence) or interpretation (such as beneficence and state of the evidence); new ethical values in IOM Report. Do so in terms of the cases above.

5. Briefly explore potential future directions for the legal and regulatory structure supporting notions of integrative health care.

For more information, please contact the Oregon Board of Naturopathic Examiners.