Jared L. Zeff, ND
Yesterday I was on the phone with a young colleague. She had questions about how to manage a case. She was perplexed. How does one know what really works? How does one really know what to do. This question faced me two decades ago when I was just beginning practice. It is also the most fundamental question that the physician has faced since the beginning, and has been asked for several thousand years. What is reliable in medicine?
A young man called our office a few days ago whose mother was just about to undergo chemotherapy for liver cancer. He was asking me to participate in her care. She was about to receive a new treatment for this condition, chemotherapy administered through the femoral vein to go directly into the portal circulation and enter the liver without entering the general circulation. The object was to shrink the tumor. The son was worried, and asked the doctor about the risk. He was told that there was only one chance in 99 that she would be significantly harmed by the treatment, and they expected to see the tumor shrink rapidly. I spoke with the oncologist last night, to collaborate about my involvement. I would begin to treat her today. She died last night, from hepatorenal syndrome induced by the chemotherapy.
How do we apply the principle, “Do no harm”? Our definition tells us:
“Naturopathic physicians follow three precepts to avoid harming the patient:
Naturopathic physicians utilize methods and medicinal substances which minimize the risk of harmful effects, and apply the least possible force or intervention necessary to diagnose illness and restore health;
Whenever possible, the suppression of symptoms is avoided as suppression generally interferes with the healing process;
Naturopathic physicians respect and work with the vis medicatrix naturae in diagnosis, treatment and counseling, for if this self-healing process is not respected the patient may be harmed.”
The point of our philosophy is to instruct our practice, to be our reliable guide in the pursuit of our patient’s healing. In standard medicine, reliability is considered to be based upon scientific experimentation, the statistical analysis of controlled studies. I am sure that the woman who died last night from kidney failure is part of a study to evaluate the effectiveness of this new approach to liver tumors. No one purposely tried to harm her. Treatment was given to extend her life. Unfortunately, it appears that the treatment killed her. There was no other treatment to offer, at least from the standard oncological perspective. And the patient was considered a terminal case, anyway. It may be determined with sufficient study that such treatment is not particularly effective, or carries too great a risk of what happened in this case.
In naturopathic medicine we increasingly utilize controlled studies to evaluate our medicine, particularly outcomes studies. But we also rely upon the observation of the healing process through time.
And we have a set of guidelines, which in my opinion, would have directed us to use a different approach than was used in this case. It was this to which I referred my young colleague.
One of the most difficult aspects of the definition from which I quoted above is the section on suppression: “suppression interferes with the healing process”. If this is true, then it places naturopathic medicine at odds with standard medicine more than any other aspect of our philosophy. It should also cause us to continually evaluate our own practice, such as the use of periwinkle extract in the treatment of lymphoma and leukemia.
In 1981 I was preparing to re-enter medical school, this time in pursuit of an MD degree. I did not want to be an MD, but I wanted more potent tools, I thought. I wanted to be able to follow my patients into the hospital if necessary. I wanted to be able to use IV vitamin administration. I wanted to be a better naturopath. The model of practice I had learned at National College was to diagnose and treat disease: the medical model, but using “less harmful, natural medicines”. I had become frustrated because I did not know how to reliably treat people who were seriously ill. I thought that I could develop more reliable tools and training in standard medical school.
It was at that time that I met Dr. Harold Dick, an old naturopath from Spokane. He did not look impressive, but he spoke with confidence and conviction, saying that the treatment of seriously ill people was not difficult. I sent him the next serious case which came my way, a man with terminal nephritis, and watched him turn the case around much to the amazement of this fellow’s physicians at USC. Doctor Dick did this with diet, a few herbs, and hydrotherapy.
He told me that most of what I was doing was suppression. That even the vitamins I was using were suppressive, not curative. I did not understand this, and struggled for over a year to do so. I continued to observe Dr. Dick, traveling to his clinic as often as I could from my home in Oregon. Slowly, as I watched and tried to imitate him, I began to understand what he was doing. There was an order to it.
At the same time I was teaching medical history and reading medical literature from the time of the ancient Egyptians through the history of American Medicine. I was looking for the origins of medical thought which lead in the direction of our profession, as well as the development of an overall sense of medical history. One of the most significant findings I made was in volume one of Harris Coulter’s Divided Legacy.
He wrote in great detail about the theories and practices which formed the Hippocratic methods of 2400 BCE. A basic understanding of this approach was that “raw” elements occur in the patient. The body responds with “coction”, a process akin to cooking, in which these elements are transformed, and then eliminated from the body during a crisis period, resulting in restoration of the person’s health.
From this reference I went to Hippocrates, and in the treatise, “On Ancient Medicine”, I found the process described, more or less. He wrote in that treatise about the dietary origins of illness. One of the key concepts regarded fever. Fever, wrote Hippocrates, was a healing mechanism. If this were true, then I should be able to find some evidence that fever is driven by an intrinsic wisdom, rather than an exogenous pyrogenic process. I went to Guyton’s Textbook of Medical Physiology, and then to others, to read again about the physiology of fever. Was fever part of an intelligent response, under the control of a wise body? I learned that most fever is a controlled response to tissue injury or irritation, stimulated by intrinsic chemicals released by stressed cells, and that it serves a purpose in the healing process.
I looked for other writings in the historical literature about fever, from Galen through the Chinese, and through what I could find of the European writings. I discovered Avicenna’s Canon of Medicine, the fundamental piece of Arabic medial literature. I read about fever in Sydenham’s 17th century treatise “On Fever”. As is typical of research of this type, each new finding lead to other sources.
I do not want to imply by this that I am a scholar. I was on a mission of discovery. I needed to know for my own understanding, as well as the credibility of my teaching, what was out there. More particularly, I wanted to understand what to do with a person who is ill who walks into my clinic. What do I tell the mom who is concerned that her child has a fever. Dr Dick would throw a fit if a patient used an aspirin in the treatment of a fever. He would throw some of them out of his clinic. If this is a problem with aspirin, how about willow bark extract? What is the problem with this way of treating?
What I learned, both from my readings, but more realistically from watching the old doctor cure people with “incurable” disease, was that I could trust the wisdom of the body. And not only that, but this was the only way I had encountered which presented a comprehensive approach to difficult illness with some assurance of success. It was reliable.
Symptoms are an expression of this wisdom. According to Dr. Dick, suppression of symptom interferes with the process of healing, and harms the body. It violates what the body is trying to do to heal itself. I had convinced myself that he was correct. But how about the vitamins? How could they possibly be suppressive? They are nutritional elements, necessary for life.
I came to this conclusion. Anything given to relieve symptoms without removing cause is suppressive. It does not change the underlying disturbance. Vitamins are given like some kind of benign drug, which if withdrawn, does not leave the person in a state of permanently improved health. In truth, I still wrestle with this question somewhat. But I understood. Vitamins may repair a ” biochemical lesion”, or drive a process by mass action, but they do not bring about the transformation from illness to health.
What I do not wrestle with is the problem of fever suppression. A man came to see me about 10 years ago with metastatic lung cancer. He had five tumors in his lung from an excised kidney cancer of the year before. He was given a month to live. I began to work with him, and one month later he was doing better. For 8 months he continued to improve. Three of the tumors disappeared. The other two reduced to 10% of their original size. Was done with dietary changes, hydrotherapy, and homeopathy. He developed a fever. Against my advice he went to the hospital, because his medical doctors told him he had to. He might have an infection.
He was treated as if he had an infection, and given medicines to reduce his fever. I saw him a day or two later, and he looked like he had aged 10 years. I called Dr. Dick and asked what to do. He told me that there is nothing to do. The man would die in about three months. The fever was a healing reaction, produced by eight months of hydrotherapy, detoxification, and dedication. The body made the fever, returning the disturbance from a chronic suppressed state to an acute, active state. The body was in full response, and then it was poisoned. He continued to deteriorate despite my best efforts. He died 4 months later.
Consider this analogy. You have a tired old horse hitched to a large wagon filled with stones. It was really difficult to get that horse to start pulling, but you lightened the load a bit (dietary changes), coaxed and whipped it (hydrotherapy, homeopathy, acupuncture), and slowly but surely it began to pull that wagon. With the inertia overcome and now working with you, you get to moving at a pretty reasonable clip, feeling better, until you come to a hill (healing reaction-fever). Your destination is just over that hill, but you really have to coax that horse to climb that hill with those stones. It slows down some, but keeps moving up the hill. Half way up, you knock the legs out from under the horse with a two-by-four (suppression), and the horse stumbles and falls. There is just no way that horse can get up, on the slope, and begin to pull that wagon up the hill again. It just can’t do it.
This analogy is not perfect, but you see the problem. You have activated all the healing power the person has to get it to the point of healing the cancer or other chronic degeneration. In the middle of the final and most intense effort it can generate, after becoming stronger and stronger over several months, to be able to generate this final push, you poison it. That is it. There is simply no more potential in that body to heal. It is done. It can do no more.
It is in understanding the process of healing and respecting the vis medicatrix naturae that we work with our patients and see the amazing recuperative potential of the body. We see the awesome healing process occur. We see presumably incurable disease reversed. But only through working with the vis medicatrix naturae, and respecting the process of it. In doing this we fulfill the dictum, “primum non nocere”. So we choose therapies that have the least potential for suppression or harm, and we apply them in the order best utilized by the body in its healing process.
This requires an understanding of the healing process (See “The Process of Healing”, Journal of Naturopathic Medicine, vol. 7, no. 1), and the therapeutic order.
THE THERAPEUTIC ORDER
There is a natural order to therapeutic intervention. This order is determined by how the body heals. In naturopathic medicine, we refer to this as the therapeutic order, or the hierarchy of therapeutics. One begins by understanding the process of disease: health, disrupted by disturbing factorsàdisruption of functionàsymptoms of the body’s response (fever, inflammation,etc.)àdischargeàresolution. In chronic illness, the disturbing factors are being constantly encountered (wrong diet, etc.) or the healing processes are continuously impeded (suppressive treatment), so that no resolution may occur. The therapeutic order becomes obvious: identify and remove disturbing factors (modify diet and stress, etc.), stimulate the self healing mechanisms (hydrotherapy, homeopathy, acupuncture), support function (botanicals, nutritional specifics, etc.), and do not suppress the reaction or the discharge.
By this understanding, one can see that if one applies medicinal substances prior to removing disturbing causes, one should not expect permanent improvement. One can also see that one should begin therapeutic intervention with that which has the least potential for suppression or biochemical interference.
Primum Non Nocere is a rich set of instructions which dictates to us a therapeutic order as well as our therapeutic modalities. Our therapies are chosen not on the basis of being “natural”. Our therapeutic choices are the direct result of our understanding of how the body heals, and are applied to support the order of that healing process. We choose to intervene with therapies that support the vis medicatrix naturae rather than suppress it, to intervene as little as possible, and with the least force and intervention required to effect cure.
Cure is understood to be a restoration of health, upon clear and simple principles, derived from the observation of nature and the healing process, efficiently, effectively, and with the least harm to the person. This is what the naturopathic physician understands by Primum Non Nocere.