The AANP House of Delegates approved the adoption of a new Code of Ethics
for our profession in August 2012. The original Code, approved in 1990, was largely a reiteration of the principles of naturopathic medicine, and a more utilitarian and modern Code was needed. I made a presentation on ethics and the new Code at the 2012 annual convention. I described instances of egregious ethical violations that have been committed by naturopathic physicians that have led to criminal convictions, large fines and imprisonment. The AANP has asked me to provide an introductory message to accompany the announcement of the new Code to the membership. I am grateful for this opportunity to discuss this important document. I will briefly discuss the following:
Why Does the Naturopathic Profession Need a Code of Ethics?
We live in a selfish, greedy culture. There is a pervasive Machiavellian attitude about money. Rewards are not necessarily related to ethical behavior. The epitome of this is on Wall Street. We confront ethical dilemmas every day. There is no firewall from it.
Ethics are our protectors. They protect us from going astray and risking our license! They encourage self-control and honesty. They are moral guidelines that will allow us to sustain a discerning, wholesome and compassionate practice of health care, thereby protecting the public and our profession.
With a code of ethics we dedicate ourselves to these precepts because we see ourselves in each thing, in every person. We know that harming others through body, speech or mind is harming a part of ourselves: just as we as naturopathic physicians know that all parts of our body/mind are connected. This extends beyond our own identity. We are not a separate or local self, but a continuum with all else. These precepts can bring us to a sense of deep responsibility toward the greater world and responsibility for ourselves as well. They are, in essence, a way for us to take care of our global and our very local community.
Yet ethical precepts have their shadow. Like any guidelines, taken too rigidly, they can breed self-righteousness, humorlessness, and even vengeance. Justified as “helpful criticism,” they can be used as a weapon against others instead of as a tool for understanding those who are deluded or in the thrall of greed or passion.
It is often true that people hide behind ethical precepts and practice in secret the opposite of what they preach. The fact is that precepts are frequently broken. Yet it is through our failures that the muscles of truth, compassion and courage strengthen. Where we have been weak is where we find strategies for the development of our strengths. Striving for exaggerated perfection produces pretentiousness and a lack of authenticity
Ethical precepts are not truth. They usually simply point to the kindest alternative. We should let ethical precepts be our ally, not our master. We should use them as a mirror. When we are mindful, we can see that by refraining from doing this, we prevent that from happening. We arrive at our own unique insight, not something imposed on us by an outside authority.
The world’s major religions all have their version of “You shall love your neighbor as yourself” (Leviticus 19.18):
Evolution of the AANP Code of Ethics
Treat others as thou wouldst be treated by thyself – Sikhism
All things whatsoever ye would that men should do to you, do ye even so to them – Matthew 7.12
No one of you is a believer until he loves for his brother what he loves for himself – Islam
Regard your neighbor’s gain as your own gain and your neighbor’s loss as your own loss – Taoism
Never do to others what would pain thyself. - Hinduism
Do not do to others what you do not want them to do to you. – Confucianism
Hurt not others with that which pains yourself. – Buddhism
The AANP Code of Ethics adopted in 1990 did not have a clear set of ethical behaviors like most professions. The philosophical principles of naturopathic medicine included in the original Code of Ethics were not ethical precepts. The lack of any specific statement about sexual relations with patients was a major flaw. The AMA did not judge sexual misconduct as unethical either, at the time, but did rectify this the following year (1991).
At the August 2009 House of Delegates meeting Jacob Schor volunteered to chair a committee tasked with submitting an updated Code of Ethics. The committee submitted draft language that was discussed and voted on at the August 2010 and tentatively adopted pending revisions. It turned out that unknown to the committee other efforts were being made toward a similar goal.
In 2009, the Hawaii State Legislature passed a law modernizing the scope of naturopathic medicine. The law mandated clear standards of practice or guidelines be promulgated that set forth the conduct that would be allowed. From an enforcement perspective, this was important because, in the event a patient is injured or dies as a result of treatment, the Regulated Industries Complaint Office (RICO) would likely review the facts of the case in terms of the following three violations in §455-11, Hawaii Revised Statutes: (10) Professional misconduct or gross carelessness or manifest incapacity in the practice of naturopathy; (11) Conduct or practice contrary to the recognized standards of ethics of the naturopathic profession
; and (12) Utilizing medical service or treatment which is inappropriate or unnecessary. As part of proving a violation, RICO would have to compare the respondent's conduct against some generally accepted standard of practice or ethical standard.
While there are many generally accepted standards of practice available in the field of medicine, there appears to be less consensus regarding generally accepted standards of practice in the field of naturopathy
, particularly relating to parenteral therapy. In the absence of generally accepted professional standards, RICO recommended, and the legislature then mandated, that these standards be set forth in rules promulgated by the Board of Naturopathic Medicine (Board).
Upon passage of the law, the Board began drafting a Code of Ethics and Standards of Practice and Care. The Code was developed from the original AANP Code, a review of codes from other professions including medical, dental, psychology, and law;
HRS 455-11 (which stipulates the Board’s power and grounds for disciplinary action); and HRS 436B-19 (Professional and Vocational Licensing Act; grounds for disciplinary action). The Board spent nearly two years refining the draft as it went through the required process of rulemaking, which included review by the State Attorney General’s office. The Code became effective on April 13, 2012.
In November 2010, when the HOD committee became aware of the simultaneous efforts being made in Hawaii, Dr. Schor suggested that the Hawaiian bill language be substituted for the then tentative language that his committee had created. It made greater sense to have a single code for the profession rather than competing codes attempting to fill the same role. The HOD agreed, gave provisional approval to a new AANP Code in 2011, and final approval in 2012.
I will now review some essential sections of the new AANP Code of Ethics.
Honesty and Misleading Advertising, Falsifying Records, Misleading Regulatory Boards
The first element of the Code, pertaining to Honesty, states: “A naturopathic physician shall conduct himself or herself in an honest manner; shall not represent himself or herself to patients or the public in an untruthful, misleading, or deceptive manner; and shall not engage in advertising that is false or deceptive.” An example of this would be advertising breast thermography as a viable alternative to mammography.
Falsification of a medical record by a medical professional is a felony in most US jurisdictions. Covering or failure to acknowledge previous disciplinary action or criminal conviction is also forbidden in the Code.
The second section of the Code relates to improper relationship: “A naturopathic physician shall not engage in sexual relations with a patient unless that patient has been released from the naturopathic physician's care for at least one year. The termination of the physician-patient relationship shall be in writing, and the patient shall understand that the physician patient relationship has ended.”
Few events in the medical workplace have a more negative expansive ripple effect than the discovery of a physician’s sexual misconduct. Involvement includes the victim or victims and their families, the physician and his family, the affiliated institutions and staff, the profession, the state medical boards, and often the media.. Clearly, sexual boundary violations by physicians are not only devastating to the doctor perpetrator in criminal and civil legal consequences as well as loss of license to practice medicine but also cause profound and immeasurable harm to the victim as well as the medical workplace milieu. (Sealy, J. Physician Sexual Misconduct. Sexual Addiction & Compulsivity, 9:97–111, 2002) This, and the multiple nuances of the issue, is why I want to discuss it in more detail here.
Sexual contact or a romantic relationship between a physician and a current patient is always unethical
, and sexual contact or a romantic relationship between a physician and a former patient also may be unethical
. (Committee on Ethics, American College of Obstetricians and Gynecologists. Obstet Gynecol 2007 Aug;110:441-4)
Sexual misconduct can be classified into boundaries violated as well as the severity of these violations. There are 3 categories of violated boundaries. They are not mutually exclusive – a physician’s behavior can fall in 1, 2, or all 3 categories.
Boundary violations have been categorized into ethics boundaries, institutional boundaries, and professional interpersonal boundaries.
The first category is violations that occur outside of professional relationships but cross the boundaries set by the ethics and principles of the profession. An example would be the physician who trades child pornography or solicits sexual contact with a minor on his home computer. Here, assuming no patient was violated, there is still a clear violation of professional ethics that can be stated as “Above all, do no harm.”
This is a breach of trust granted every physician independent of actual patient involvement. The practice of naturopathic medicine is not a right but a privilege. I believe that the following statement should be added to the Code of Ethics: “As a member of this profession, a naturopathic physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self.”
Institutional boundary violations are exemplified by the physician who views pornography on a hospital or clinic computer. This is often discovered by hospital or clinic tracking of computer activity. The hospital or clinic may have concerns about risk to patients and dismiss the physician from staff.
Professional interpersonal boundary violations are the most common. These include crossing of sexual boundaries of patients, staff, students, residents, drug reps, etc. The AMA’s opinion: “sexual relationships between a medical trainee and supervisor, even when consensual, are not acceptable, regardless of the degree of supervision” (Benedek EP, Wahl D. S In Physician Sexual Misconduct, American Psychiatric Press, 1999).
Three levels of severity of these violations have been described. The first is sexual impropriety
, which includes inappropriate sexual comments, and constitutes 39% of reported incidents of professional sexual misconduct. Examples are: the doctor who asks inappropriate sexual questions of patients, staff, students; using sexual humor in a medical setting ignoring the discomfort of those present; criticizing a patient’s sexual orientation; and lack of respect for privacy during disrobing or draping.
constitute the second level of severity. Inappropriate touching makes up 31% of reported incidents. Examples are: the physician who does breast or genital exams when they are unrelated to the physical complaint; asking a patient for a date; and kissing in a romantic or sexual manner. Interviews of 13 female drug representative revealed that 12 reported having to deal with direct sexual advances, most of them including physical contact, by physician clients (McCague JJ. Why was that doctor naked in his office? Medical Economics, May 1999, 28-29).
The third and most severe violation is a sexual relationship with a patient, which constitutes 30% of reported incidents. Examples include touching breasts or genitals for any purpose other than appropriate exam or treatment; physician masturbating while performing an exam; grooming a patient over time with increasing sexual interaction and ultimately intercourse; and offering drugs, disability, insurance fraud, fee reduction or reports in exchange for sexual favors.
Physicians should be cautious in accepting any gifts from a patient as it can lead to a chain of subsequent boundary crossings. As boundaries are disregarded, the risk of sexual misconduct increases. Serious ethical violations often begin with what seem to be harmless boundary crossings and proceed down a slippery slope.
Crossing boundaries of a patient by a physician is always a power issue, similar to child incest by a parent, older sibling or relative. Crossings do not usually harm or exploit the patient. The danger is that the patient may feel entitled to more demonstrations of caring and assume they will granted.
Sexual exploitation of a patient, staff member, student or resident may be a form of rape. Such violations abuse the physician’s unequal power, trust, and authority implicit in their degree over the patient and focus on the physician’s gratification, not the welfare of the patient.
Sexual misconduct depends on secrecy for its survival, and a conspiracy of silence from both the physician perpetrator and the patient/victim. Profound shame compels them to make no intervention to identify the unethical behavior.
The physician may live a double life totally unknown to their spouse, friends or colleagues. The exploitive behavior is supported by cognitive distortions held by both the offending physician as well as the patient. There are 5 common distortions used by physicians:
Breach of Confidentiality/Privacy
Denial - “what’s the big deal?”
Entitlement – “I deserve some rewards”
Negotiable boundaries - “nobody knows, so who is being hurt?”
Minimization – “others do it too”
Narcissism –“I’m a very good doctor, they won’t want to lose my services, besides they liked it”
The third section of the Code relates to privacy: “A naturopathic physician shall maintain patient privacy and confidentiality; provided that if the naturopathic physician becomes aware that a patient is a danger to the public or to her or himself, the naturopathic physician shall take reasonable steps to advise appropriate public officials or agencies of the potential danger, within the guidelines of applicable laws.”
The Standards for Privacy of Individually Identifiable Health Information (“Privacy Rule”) established, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html).
The fourth section of the Code applies to performance and is straight-forward: “A naturopathic physician shall perform professional tasks and responsibilities to the best of the naturopathic physician's ability, and standards of care and refrain from engaging in any behavior that will detract from his or her ability to engage in the competent practice of naturopathic medicine.”
The Physician-Patient Relationship
The fifth section of the Code relates to Obligation: “The fundamental and primary obligation of a naturopathic physician is to the patient, and the maintenance and improvement of the patient's health and well-being.”
“A naturopathic physician shall at all times seek to employ methods of therapy that are consistent with naturopathic medical philosophy, scientific principles and evidence, and the naturopathic physician's training and experience, and shall provide patients with information about these therapies and potential alternative therapies so that the patient may give fully informed consent to the recommended treatments.”
Written informed consent should be included in the patient’s chart.
Quality, Safety, Sales of Products
“As part of the obligation to provide care, a naturopathic physician shall use his or her best efforts to facilitate a patient's access to high quality, safe and reliable medicines, medical devices, and supplements.
A naturopathic physician shall offer alternative sources for obtaining the above items in as long as those alternative sources do not compromise patient safety or clinical effectiveness.
The naturopathic physician shall refrain from recommending medicines or treatments of a secret nature and shall adequately disclose the contents of medicines or the nature and description of treatments recommended to a patient.
Furthermore, all therapies shall be monitored by the naturopathic physician in a timely manner utilizing reliable means in order to accurately assess the patient's response to employed treatments.
A naturopathic physician shall only provide or recommend services that are medically necessary or deemed to be beneficial for an individual patient.”
The sixth and final section of the Code relates to competency and is clear: “A naturopathic physician shall maintain proficiency and competence, and be diligent in the provision and administration of patient care.
A naturopathic physician shall recognize and exercise professional judgment within the limits of his or her qualifications, and collaborate with others, seek counsel, or make referrals as appropriate.
When expanding the naturopathic treatments or services provided to patients, a naturopathic physician shall pursue the appropriate advanced education and training.
A naturopathic physician shall dedicate sufficient time to each patient in order to provide (to the best of the naturopathic physician’s ability) accurate, comprehensive, and individualized patient assessment and treatment.”
In conclusion, the complete revision of the AANP Code of Ethics is a necessary and welcome iteration of ethical precepts. It should be considered as a work in progress, and will never be a final document. Amendments are welcome and can be suggested through your representative to the House of Delegates.