The Bell Tolls for Homeopathy: Time for Change in the Training and Practice of North American Naturopathic Physicians
This is a curious article. The authors acknowledge that homeopathy is unscientific and can only work via placebo effects. However, rather than recommend that naturopaths abandon it, they feel they should continue to use it as a form of placebo therapy. They also point out that naturopathic students spend a lot of time memorizing homeopathic material covered on national board exams, rather than considering the theoretical aspects of homeopathy.
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Journal of Evidence-Based Integrative Medicine 2019 Jan-Dec;24:2515690X18823696
The Bell Tolls for Homeopathy: Time for Change in the Training and Practice of North American Naturopathic Physicians
Article first published online: January 16, 2019; Issue published: January 1, 2019
David H. Nelson (1), Jaclyn M. Perchaluk, ND (2), Alan C. Logan, ND (3), Martin A. Katzman, MD (4)
1 Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
2 Inside UHealth, Naturopathic Clinic, Woodstock, Ontario, Canada
3 inVIVO Planetary Health, Research Group of the Worldwide Universities Network (WUN), West New York, NJ, USA
4 The Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
Abstract
North American naturopathic medicine is a distinct form of practice that is woven into the larger fabric of integrative medicine; in a number of US states and Canadian provinces, naturopathic doctors enjoy a wide scope of practice, including the ability to make diagnoses, order tests, use medical technology, write prescription drugs, and perform minor surgeries. However, the basic premise of naturopathic medicine and its guiding principles—considering the whole person and supporting healthy lifestyle behaviors—is the unifying approach in clinical practice. In the 1970s, homeopathy—considered in many circles to be a hypothesis-driven, fringe form of alternative medicine—became embedded into the training and practice of North American naturopathic doctors. Since the earliest days of its theory (circa 1800), homeopathy has escaped, and continues to escape, biological plausibility; however, the persistence of this modality (and the insistence by both its consumers and practitioners that it provides benefit) speaks to the role of expectations, beliefs, values, agency, context effects, and the placebo-at-large. It is our contention that the progression of professional naturopathic medicine in the 21st century requires a major transition in how it approaches the subject of homeopathy. We propose that students should be encouraged to critically analyze the tenets of homeopathy, its lesser known history, and the idea of homeopathy as a biomedicine that simply awaits untold chemicophysical mechanisms. Furthermore, the modality of homeopathy should be incorporated into the larger context of placebo studies, narrative medicine, ethics, and psychotherapeutic techniques.
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https://journals.sagepub.com/doi/full/10.1177/2515690X18823696Excerpts:
"The transition from global health care dominated by the prevention and treatment of infectious disease—to the one that is overburdened by complex noncommunicable diseases—has necessitated a deeper discourse concerning the role of the placebo (and more broadly, patient expectations, beliefs, and therapeutic agency) in 21st-century medicine; at the same time, rapid advances in science and technology have allowed researchers to gain unprecedented knowledge concerning the ways in which the psychosocial aspects of the biopsychosocial model manifest in human physiology.6 Volumes of international studies using objective physiological markers demonstrate that levels of expectancy concerning chemical agents dressed up as biomedicine—even if those agents happen to be drops of water or pellets of sugar—possess biological underpinnings7; labeling descriptors on products, even carrots, can influence consumption,8 and there is little doubt that branding, packaging, and labeling of placebos is intertwined with psychobiological outcomes.9,10 Labeling effects are further magnified by social influences, including individuals who endorse the expectations of placebos.11
"Homeopathy—a theoretical proposal, which suggests that an imprint of a specific agent remains inside water or sugar globules even after it is diluted to the level of seas and oceans, represents a fringe form of alternative medicine; the reported benefits by users and those who prescribe such remedies are of high-level relevance to the burgeoning growth of placebo studies. Here in our commentary, we will discuss the waxing and waning of this culture-driven intervention and place it into the context of a shifting zeitgeist concerning the role of the placebo in clinical medicine. Furthermore, we discuss these changes as they relate to the growing profession of naturopathic medicine. Homeopathy permeated North American naturopathic medical education in the latter part of the 20th century at a time when it was a small group of several hundred practitioners. Today, naturopathic medicine (with some 7000 practitioners) is enjoying an expanding role in the systems of North American health care; however, the emerging research (and cultural winds) concerning homeopathy—and the placebo—forces difficult questions on how this modality should be approached."
"The notion that water has a 'memory' or enduring imprint derived from the original substance (and through the dilutions and succussion, a robust shaking at each point of dilution) has been disproven.15 In short, the theory of homeopathy is not biologically plausible (ie, it does not follow the known laws of chemistry and physics). The theory is, however, dressed up and marketed—with both on-label and associated marketing—as a form of biomedicine."
"By the mid-1800s, the accumulated evidence demonstrated that homeopathy was no better than placebo13; almost 200 years on, with untold volumes of rigorous investigation added to the scientific annals, the scientific and medical consensus remains the same—there are 'no good-quality, well-designed studies with enough participants for a meaningful result reported either that homeopathy caused greater health improvements than placebo.'18"
"While homeopathy has had its detractors since its earliest days, it has also had many who have pledged allegiance to its efficacy, including affluent, sociopolitically powerful individuals.25,26 Despite its intellectual absurdities, it has been resilient in its political durability and remains commercially lucrative..."
"However, the cultural bell appears to be tolling for homeopathy. In 2017, the United Kingdom’s National Health Service stopped funding homeopathy,28 recent consensus statements from Australia, Italy, and the European Academies Science Advisory Council concerning lack of evidence (beyond placebo) have been highly publicized,18,29,30 and federal authorities in the United States are scrutinizing its place among over-the-counter health products.31 Once soft on homeopathy, major North American media outlets are now serving up harsh op-ed material32 and celebrating professionals who take a stand against its marketing as an 'alternative' to appropriate public health and medical advice.33 Reporting on homeopathy is no longer being tempered by quotes from advocates who maintain its effects are beyond the placebo34..."
"These cultural changes are generally side-stepping whether or not homeopathy, as a placebo, has value. In Europe, many medical doctors continue to prescribe homeopathy pro re nata, quite often as a placebo; for example, about one-fourth of Swiss medical doctors prescribe homeopathy at least once in a given year... About 10% of the French population is prescribed a homeopathic remedy by a physician each year.37"
"In sum, the enduring legacy of a theory that has no biological plausibility—and little in the way of scientific support (beyond placebo)—speaks very loudly about the role of expectations, values, agency, and beliefs in the healing process. In the clinical setting, these factors may be magnified even further. Indeed, the homeopathic consultation—extended time spent with patients, provider empathy, narrative competence, and the setting itself, which contains the trappings of trust and authority—appears to be central to the clinical benefits, rather than the chosen remedy.39 In the context of chronic, complex noncommunicable diseases, the question of homeopathy is now one concerning ethics and the clinical relevancy of placebos in the 21st century. Homeopathy certainly 'works' insofar as belief systems, values, and expectations—or the placebo-at-large—permeates all aspects of clinical medicine..."
"Much like homeopathy itself, the idea of prescribing placebos—at least in academic debate—has remained contentious; however, in the real-world clinical settings, the prescribing of placebos appears to be commonplace."
"However, while the cultural bell may be tolling for homeopathy in North America, the sounds of liberty are simultaneously emerging in the form of open discourse concerning the underappreciated role of the placebo in clinical medicine."
"Dr Ofri states,
"Frequently my patients ask if a multivitamin will give them more energy. In the past I would say no, because there are no significant scientific studies to demonstrate this, and also because in the absence of a vitamin deficiency there’s not much for a basic multivitamin pill to do. Now I take a different approach. I say something along the lines of 'Many of my patients find that they have more energy when they take a multivitamin'.”
"Indeed, 2018 marked the publication of first Expert Consensus on the Implications of Placebo and Nocebo Effects for Clinical Practice52; while acknowledging that there are many outstanding research questions, the authors maintain that the area of interdisciplinary placebo studies is robust enough to allow for clear recommendations for clinical practice. Placebos can provoke clinically relevant, biological effects—genuine biopsychosocial phenomena that cannot be dismissed (as they have been by some authors) as spontaneous remission, normal symptom fluctuations, and regression to the mean.53–55 Sophisticated brain imaging studies are demonstrating that placebo responses may be predetermined by brain biology.56,57 The emerging research on open-label placebos (where the recipient is explicitly informed that the pill is inert) indicates that benefits can be realized without deception58–63; such disclosure removes the most potent ethical objection to placebo, that of trickery."
"However, the tide may be turning. Emerging research on open-label placebos, expert consensus, and high-profile media are combining to shift the perception of the placebo as something to be minimized, and toward something that might be maximized. Thus, there are 2 overlapping trends of relevance as we transition our discussion to naturopathic medicine; on one hand, homeopathy—a biologically inert placebo dressed up as a biomedicine—is increasingly viewed with hostility in academic and lay writing, and on the other hand, the placebo and its effects are increasingly embraced with clinical interest and openness."
"The Merriam-Webster dictionary defines naturopathy broadly as 'a system of treatment of disease that avoids drugs and surgery and emphasizes the use of natural agents (such as air, water, and herbs) and physical means (such as tissue manipulation and electrotherapy).'73 Such vague definitions highlight that naturopathy is difficult to categorize; by default, this definition allows for virtually any form of treatment to be considered 'naturopathic,' as long as it be deemed nonsynthetic. It also infers that naturopathy opposes drugs and/or surgery; finally, the definition asserts that naturopathy is a system of treatment as opposed to prevention."
"Unlike the inference within the Merriam-Webster definition above, North American naturopathic doctors (NDs) do not avoid drugs, indeed many have prescription drug rights on par with medical doctors, can order medical tests, use ultrasound and other devices of medical technology, and are licensed to perform minor surgeries."
"Research has demonstrated that NDs may play an important role in the health of individuals and society; for example, North American NDs (graduates of the accredited doctoral-level schools) have been shown to lower the risk of noncommunicable diseases, provide health care in a cost-effective way, and reduce employee absenteeism.75–79 It has also been demonstrated that the care offered by licensed NDs is considered culturally competent by underrepresented minority groups.80"
"Despite documented societal benefits provided by naturopathic care, there is also a concern that some North American NDs provide advice that runs counter to the principles of public health and demonstrate a lack of critical appraisal skills.83
"Students entering naturopathic medical programs can expect homogenous training for the first 2 years at each of the 8 accredited colleges and universities; during this time, there is strong academic emphasis on basic medical sciences such as anatomy, physiology, biochemistry, differential diagnosis, pathology, and so on with training hours comparable to those of medical doctors (MD) and doctor of osteopathy (DO) programs."
"As the first 2 years give way to the latter 2 years, there is an increasing academic emphasis on these and other core aspects of training; some of these modalities are far-removed from mainstream MD and DO programs—most notably, botanical medicine, acupuncture, physical medicine (techniques of massage, manipulation, hydrotherapy) and homeopathy. The latter modality can take up enormous portions of the total academic hours within the didactic curriculum—140 hours in total.84
"Interestingly, prior to enrollment in a naturopathic medical program, homeopathy (in comparison to other modalities and lifestyle prevention) is of little interest as a driving force in personal values concerning health...Less than 19% consider homeopathy to be important. However, after admission and through training, approximately 75% of the students consider homeopathy to be important.74...It might also be worth learning more about the one-fourth of students, even after enrollment, who still do not value homeopathy.
"Given the absence of evidence supporting homeopathy over placebo, the scientific implausibility of its tenets, and the lack of critical appraisal applied by its advocates (especially concerning founder Samuel Hahnemann and the origins of homeopathy86,87), we wonder to what extent that change in values through naturopathic education rests on the aforementioned enculturation. To what extent are clinical success stories of homeopathy explained to students as a yet-to-be-discovered 'bioactive' resonance with which they need not concern themselves too deeply? To what extent are the major clock hours within homeopathy devoted to a critical discourse and deeper understanding of human belief systems, expectations, placebo, mimicry of the packaging and appearance of biomedicine, therapeutic 'agency' (the sense of control over health outcomes), and context effects that describe the entire healing environment and therapeutic process in which personal disclosures take place (often within settings of comfort, institutional trappings of trust, white coats, diplomas on the wall etc)?88–90 Even more important, how much of the academic time is devoted to the ethical conundrum of prescribing an agent known to be inert? Our own experience suggests little to none.
"Indeed, ND students may be surprised to learn that Hahnemann dismissed the existence of vis medicatrix naturae in his writings.91 Moreover, he maintained that no cure had ever occurred but through homeopathy; thus as stated in the 1800s, he disparaged Tollo Causa (his words Tolle Causam) and those who sought the root environmental sources of illness.92 Not only do these homeopathic notions conflict with 2 of the basic naturopathic principles, they are at odds with the fundamentals of epidemiology—the science that should otherwise guide all 6 principles in practice."
"Interestingly, homeopathy was not always a part of naturopathic medicine in North America...Over time, however, electives in homeopathy were introduced into the curriculum of naturopathic medical programs, and by 1978, the leading North American institution required a 40-hour minimum in homeopathy.94,95 As mentioned, that curriculum commitment has ballooned to 140 hours."
"...because it was decided that naturopathic national board exams will test basic knowledge of dozens of common homeopathic remedies, instruction radiates around the nucleus of remedies as a form of biomedicine (as if on par with the differences between fluoxetine and sertraline), and encourages rote memorization. This approach also discourages the application of critical appraisal pertaining to these common remedies and homeopathy as a theoretical system..."
"As mentioned above, the available evidence suggests that it is the process of homeopathic case taking—rather than a specific remedy—which is at the heart of the therapeutic value. Homeopathic case taking is a lengthy process of trying to build a picture of the total lived experience of an individual - stressors, likes and dislikes, sources of hope and happiness, psychosocial resources, and minute details of psychological and physical symptoms.96,97 Put simply, the patient engages in a practice that is central to the human experience—storytelling; this process, and attentive listening on the part of the practitioner, is the essence of psychotherapeutic techniques, and more specifically, what is now called narrative medicine."
"Some researchers and clinicians refer to the benefits of this process as the placebo effect; however, it is probably better stated as context effects. That is, an authentic placebo such as drops of pure water or globules of sugar should, theoretically, have no biological healing effects at all. In reality, according to placebo expert Klaus Linde and colleagues, the administration of the blank remedy 'completes a complex therapeutical situation and thus conveys meaning, influences expectations and possibly triggers conditioned responses or behaviour changes.'100 This is evident because identical placebo interventions produce varying placebo effects depending on the context in which they are administered."
"Thus, the first step in the transformation of naturopathic education is to abandon any requirements to memorize lists of homeopathic remedies, and instead devote training hours and board exam questions to placebo studies, sense of agency, context effects, the process of narrative medicine, and the skills inherent in the psychotherapeutic process vis-à-vis homeopathy. The second step is to introduce mandatory disclosures to patients when a homeopathic remedy is recommended after case taking; these might be along the lines of the US Federal Trade Commission recommendations: 'There is no scientific evidence that the product works—the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts.'102...The third step is to devote training hours and board exam questions to the ethics surrounding the administration of the placebo in general, and homeopathic remedies in particular."
"In our opinion, if the North American naturopathic profession is unwilling or unable to initiate the implementations we describe, the only other viable option is to state explicitly—to prospective students and patients alike—that homeopathy is a form of commercially available metaphysical or celestial medicine."
"Much has changed since homeopathy was introduced into naturopathic education and training in the 1970s. More than a decade has passed since the editorial board of The Lancet announced the 'end of homeopathy' (2005)—that is, the end of any notion that it has benefit beyond the placebo.115 Since then, scientific consensus and research has strengthened that position. Maintaining the idea that homeopathy has yet-to-be-determined chemicophysical properties may provide cognitive comfort for the provider because it allows for a side-step around the discomfort of ethics, disclosures, and the requirement of a deeper knowledge of placebo studies. However, this notion is no longer tenable; for North American naturopathic medicine, continuing to stare at this apple on the wagon—not attending to it—will likely disturb the entire cart."
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