Jared L. Zeff, ND
Naturopathic medicine is a defined discipline, a system of medicine. It is not the accumulation of various natural therapies. It is not a vague alternative medicine, complementary medicine, or holistic medicine. It is a “separate and distinct branch of the healing arts.” It is different from the standard medicine of the American Medical Association, Osteopathy and Chiropractic.
Prior to 1989, naturopathic medicine was usually defined by its treatments. There were several extant definitions, the most widespread being the US Department of Labor, Dictionary of Occupational Titles, which, prior to 1991 defined the practice in terms of a list of limited therapeutic modalities.
In 1986, the American Association of Naturopathic Physicians (AANP), the newly revived professional association, under the presidency of Dr. Cathy Rogers, commissioned Dr. Pamela Snider and myself to create a unifying definition. This project took somewhat over three years and was distinguished by an inclusive process, which sought and received input from the entire profession and its various agencies. The committee found a single element of agreement among the naturopathic profession upon which it built its process. This element was that: the profession was unified by a philosophy, not by therapeutic modalities. The committee sifted through input from the profession and catalogued six principles. These were circulated throughout the profession for comment, criticism and revision for two years. These six principles, along with a preface and statement of practice, were placed before the House of Delegates of the AANP at its annual conference in September of 1989 at Rippling River, Oregon, which unanimously approved them as the unifying definition of naturopathic medicine. We pledged to continually reexamine these statements in the light of further experience and scientific advancement.
The Six Principles Are These:
- Vis Medicatrix Naturae: The Healing Power of Nature
- Tolle Causam: Remove the Cause
- Primum Non Nocere: First, Do No Harm
- Docere: The Doctor as Teacher
- Treat the Whole Person
These principles are guides for the practitioner of naturopathic medicine. As guides, they may be interpreted in different ways by different doctors. Thus, our medicine has richness and spontaneity, which allows for great diversity yet, at the same time, unites us. Our clinical theory develops through the application of these principles in practice. Though the principles and the practice are ancient, we are a young profession. Our profession has experienced a renaissance over the past 25 years. As a result, the number of naturopathic physicians in clinical practice has greatly increased from about 150 to 200 practitioners in 1975 to approximately 2,000 today. I would estimate about 80% of our practicing doctors have not been in the field for more than ten years. Many of these doctors have been trained in an eclectic and empirical fashion, with little reference to theory. We are still very much developing how to do this work and articulate it.
THE PURPOSE OF PHILOSOPHY
All medicine comes down to a question of validity: what works and what doesn’t. Some of our most outstanding doctors would say that validity is not found in philosophy or principles, rather in verified research, and that valid practice comes from the accumulation of research approaches to specific applications. In the Summer issue of the Quarterly Review of Natural Medicine on page 137, Steve Austin, N.D., addresses this question. He writes, “ Some devotees of natural medicine are so enamored of the philosophy that the presence or absence of hard evidence seems to bore them.” He makes an important point, one, which asks the question, “Of what use is all of this philosophy?”
Philosophy is an abstraction. If the observations on which it is based are honest and without bias, and if the philosophy can be expressed in such a way as to maintain honesty and integrity with nature, then it can truly serve a purpose. The purpose of medical philosophy and the theories which arise from it, is to guide us in clinical application. Philosophy is a reference point for organization of clinical data and the plethoras of researched material (the “hard evidence”) to which we are increasingly exposed.
My intention in this column and in the several that follow, is to explore in depth what these principles really say, allowing us to reexamine them in the light of the ten years of experience we have had with them. I invite comment and criticism. I apologize to my colleagues in advance for attempting to do what others likely could do better.
VIS MEDICATRIX NATURAE
Our first guiding principle is Vis Medcatrix Naturae, “ The Healing Power of Nature,” the observation that the body is a wise internal organization and self-healing in nature. This principle is stated: “The healing power of nature is the inherent self-organizing and healing process of living systems which establishes, maintains and restores health. Naturopathic medicine recognizes this healing process to be ordered and intelligent. It is the naturopathic physician’s role to support, facilitate and augment this process by identifying and removing obstacles to health and removing obstacles to health and recovery, and by supporting the creation of a healthy internal and external environment.” We are saying in this statement that the nature of the body is to heal itself, and the physician’s role is to assist this process. The guidance is internal, the “ordered and intelligent” aspect of the living being. It is not the physician’s role to make healing happen or to supersede the intelligence, which directs the process of healing.
This is vastly different from standard medicine. In the western medical system, the doctor’s knowledge and wisdom are intended to supersede the disease process. The naturopathic physician does not do battle with a disease entity. Instead, we rely upon the healing wisdom, vital energies and intelligence of the organism to restore normal and healthy function. The task of the doctor becomes simply to identify and remove causes, to nourish and support normal structure and function, and to stimulate the vis medicatrix naturae. Health will occur where the conditions for health exist even as disease is the product of conditions allowing it to occur. As necessary, we stimulate the process of restoration through a hierarchy of therapeutic interventions rationally applied. Remember it is the nature of the body to heal; the physician, at best, can assist this process.
“Illness does not occur without cause. Causes originate on many levels. Underlying causes of disease must be removed before patients can completely recover from illness. Symptoms are not the disease but the result of factors, which disturb the normal physiological processes, and are an expression of the body’s attempt to heal itself. The naturopathic physician seeks to treat the causes of disease, rather than to merely eliminate or suppress symptoms.”
SCIENCE, TRUTH, AND MEDICINE
What is true in medicine? How do we know something is true: In mathematics, truth is provable in absolute terms: 1 + 1 = 2. This is easy to demonstrate and is always the case. Mathematics is called the language of science. The more one can reduce one’s premise, process or proofs to mathematical terms, the more one can claim truth for that premise or theory. In medicine, this is typically done by applying statistical analysis to experimental situations and studies. The body, however, is not reducible to mathematical models. It is complex. In addition, any specific patient is an individual, a person, and not a statistic.
How do we determine what is true or what is reliable? Truth in medicine is generally determined by outcome. Did the patient get well or not? Theory is a means to this end, a guide through a maze of the complex process of illness, but it is useful only if it is reliable. The current foundation of reliability is the scientific method. This is often confused, however, with the double blind, placebo controlled, and crossover study (DBPCCS) is not “science” per se; rather, it is a method useful for some purposes of specific inquiry. Using the DBPCCS, however, we can miss the larger picture, because it is designed especially to focus on details. One of the great challenges in testing the validity and reliability of naturopathic medicine is that we treat people in all their complexity, not diseases. As soon as we begin to lump patients into disease categories for scientific studies or develop protocols to treat disease, we step back a bit from naturopathic theory and enter the realm of standard American medicine with its assumptions and methods.
THE PERSON, NOT THE DISEASE
Currently, at least a quarter of my work is with women with breast cancer. I continually have to question whether I am treating breast cancer or a whole person who has breast cancer. To what extent can I rely upon statistics of standard medical treatment of breast cancer? To what extent can I allow myself the freedom to treat the person and not the disease? This is a challenging dichotomy. Are we the doctors who treat disease with “natural medicine” or are we naturopathic physicians, those who work with the self-healing processes of the body? In the process of healing we must first seek, then remove the cause. As the cause of illness is removed, the natural tendency of the body is to improve function. The human being is not simply a physical entity. We have minds, we think. We have emotions, we feel and we translate these feelings into meaning. We are spiritual beings. Most of the early naturopathic writers, such as Lindlhar, Lust and Hahnemann, believed that illness began in the spiritual aspect of the person. I share this belief. Most of our education and therapeutic focus is on the physical aspect of the human being. It is crucial, in my opinion, that we direct more attention to the spiritual aspect. I believe we will see much more attention given to this area by our profession over the next few years.
DETERMINANTS OF HEALTH
Naturopathic medicine is not simply the diagnosis and treatment of disease with natural agents. It is a practice based upon the restoration of health. But, what is health? Although health is the natural state of the being, it is caused by the interaction of that being with the existing environment, both internal and external. Health is a product of many conditions, all of which help create the healthy state. Health has specific determinants, which can be studied and perceived in our patients.
The determinants of health include genetics, intrauterine influences, nutrition, patterns of exercise and rest, past illness and medical interventions, physical and emotional traumas, stresses and exposures (including exposure to microbiological agents). These are the areas in which we do most of our work. These are things which can be addressed and modified (usually) to enhance health. It is in these areas where we find the causes of disease. Causes of disease manifest in for groups or levels: spiritual, mental, emotional, and physical.
Of these four aspects, the spirit is the center; the next layer is the mental aspect of the person, then the emotions, and the outermost layer is the physical. If there is a distortion on the spiritual level, it will create distortion throughout the system, like ripples from a stone thrown into a pond.
The knowledge of this spiritual aspect of reality is not well developed in our culture. We have no common language to discuss it. As a profession we acknowledge the existence of a spiritual aspect of the person, but do not teach a methodology to work with it. I believe that this is a peculiar phenomenon in our American culture, with our freedom of religion (or freedom from religion). Our profession must develop a language with which to discuss the spiritual aspect of healing without reference to religion.
For now, it is incumbent upon us as naturopathic physicians to acknowledge and to work in our own ways to recognize and pursue healing in this aspect of our patients’ lives. We can discuss with the patients the presence of peace and trust in their lives, their spiritual practice, or absence of it, and our perceptions of their health or happiness in these regards. This requires that we pursue our own personal spiritual development.
When a person refuses, or is unable to take those steps, which can lead, to healing from a crippling or terminal illness, this may be primarily a spiritual issue. The extent to which we can successfully address this, and to which the person can accept change on a spiritual level, will determine whether healing can occur. Illness is a great teacher. Death is not defeat. It is neither our responsibility nor prerogative to prevent death or heal illness. It is our privilege and responsibility to work with the vis medicatrix and assist our patients in their healing process.
If the location of illness is predominantly in the mind, we may not be able to rationally communicate with the person. This significantly limits our ability to work with that person, especially in the absence of a naturopathic in-patient facility. We can recognize health or illness on this level in our patients by their ability to rationally communicate, their mental clarity, memory and other functions of the mind. We can approach these problems like any chronic illness.
The first signs of improvement in treating chronic illness are often enhanced mental clarity and memory along with an increase in energy. We have specific tools to work in this sphere. Beginning with improvement of diet and digestion and stress modification, we can generate initial changes in and set the stage for other improvements to follow. In addition, there are a variety of medicines, which target the mental function. We are rich in therapies, which applied in the order which healing dictates can produce marvelous results.
The emotional body of the patient is a transient expression of the more constant spiritual center. Laughter, sadness, anger, depression and other emotional states, which come and go in appropriate response to the variety of life, are not illness. There may be causative elements of illness in the extreme or prolonged emotional states, which usually accompany emotional trauma, such as divorce or childhood abuse. This may be a gateway to spiritual damage, or simply a transient, though dysfunctional state. It has been well demonstrated that depression, for example, can negatively affect the immune function. We recognize that the cause of illness may center in this area. We look for it and work with our patients to correct it.
Of the physical causes of disease, the generally most significant and most important to address initially is diet and digestion. This is the largest and most constant physical input into the organic system, and the one upon which the maintenance and continuation of the organism depends. If digestion is disordered, illness will result. If illness exists, digestion and diet must be optimized for any other correction to have its best effect. If diet is improper therapy will work as well or as permanently as it could otherwise. Therapeutic nutrition is the common denominator among naturopathic physicians. We all use it, although approaches may be different.
“Toxemia” deserves special mention here. This is an old naturopathic concept involving the fundamental disease-causing effects of toxins generated from dysbiotic processes in the gut and fed by improper diet and digestion. Toxins are absorbed into the bloodstream and become the basis of chronic irritation and inflammation in the body. This may be, for example, a basic cause of arthritis or other chronic, inflammatory disease.
The maldigestion, which creates the toxemia generally, has two causes. The first is diet. This includes everything from food selection and methods of preparation to the environment in which the person consumes their meals.
Stress, or perhaps we should say dys-stress, both physical and psycho-emotional, is the second major cause of acute and chronic illness. Stress negatively affects digestion. Digestion is a parasympathetic event. When under stress, the sympathetic nervous system becomes dominant is stimulated. Stress increases the cortisol and epinephrine levels in the blood. Cortisol and epinephrine cause a decrease in blood flow to the digestive apparatus via vaso-constriction while increasing blood flow to the brain and muscles. Digestion requires significant blood flow to operate effectively. Without it, the juices and enzymes necessary for adequate function cannot be produced. This results in toxemia, and a progressive weakening of digestive function. The reduction of toxemia is fundamental to healing. This can not be over emphasized. It is also an historic basis of naturopathic medicine.
Stress and diet rank at the top of our list of physical causes of disturbed health (especially in chronic disease) as well as of susceptibility to acute diseases. Other causes of disease also need to be understood, evaluated, and dealt with.
Without doubt, there are microbial causes of disease. Which is more important, microbial pathogenicity or host resistance? Both play a role. There are some pathogens, which are extremely virulent. Most, however, require “fertile soil” in which to grow. It is rare and unusual that the best treatment of an infectious illness is antibiotic therapy. This can be understood from an analogy of flies and garbage.
If one continually throws garbage out the kitchen window, there will eventually be flies to contend with. One can deal with the flies by spraying poison on them, and even spray the garbage pile itself. This is like using antibiotics. Or, one can clean up the garbage. Not only will the flies go away, but also the kitchen will smell better. This is the naturopathic approach. Clean up the garbage. If you do, the flies won’t come back when the “poison” wears off. And the flies won’t build up a resistance to the poison either.
“The naturopathic physician seeks to treat the causes of disease, rather than to merely eliminate or suppress symptoms.” Remember, fever, inflammation, and even infection are not the disease; they are the result of disturbances in the system which can be corrected. This is the art and science of naturopathic medicine. Correcting these disturbances by understanding what determines health is the first step in restoring health and eliminating the basis of disease. Failure to do so reduces the efficiency of any attempt to cure by other methods.
Also, remember the order of the healing process and the appropriate therapeutic order. First identify and remove causes of illness, then re-establish healthy conditions, stimulate the self-healing mechanisms, supplement or support the affected systems of the body, and lastly, correct the structural integrity. If we proceed in this order, it is my experience that we enhance our results significantly.
It is a fallacy to assume that this takes longer than what is often thought of as more direct action against disease such as antibiotic therapy. One can see significant results within hours of beginning such work. Naturopathic medicine does not take longer than conventional medicine. It is not only more efficient, but generally acts faster and more permanently, and is health generating and sustaining as well.
I have attempted to discuss the meaning of our first two principles. In the next issue of the journal, I will address the third of our defining principles. I invite comment and criticism and continued dialogue.