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Textbook of Natural Medicine

Arnold S. Relman, M.D.
January 9, 2001

This two-volume textbook, published in a second edition in 1999, is edited by two naturopaths -- one the president, and the other a member of the faculty of Bastyr University, which is the leading school of naturopathic medicine in the country. The textbook has over 1,600 pages and 57 contributors (most of whom practice and/or teach naturopathic medicine), and it purports to provide "well-documented standards of practice for natural medicine." I therefore take it to be an up-to-date summary of what is taught about the practice of naturopathic medicine and how its practitioners are expected to provide care for the patients who consult them.

Among the criteria we have adopted for deciding whether a complementary and alternative ("CAM") practice should be licensed by the State are: (a) evidence that the practice "confers measurable benefits" to those who use it (Criterion #2), and (b) evidence that the use of "some or all of the modalities within a practice that fall within the accepted standards of the practice may result in direct patient harm" (Criterion #5). A close reading of this textbook should provide some answers to these crucial questions about the potential benefit and harm of naturopathic practices as currently taught.

I borrowed a copy of the Textbook of Natural Medicine (the "Textbook") and studied it carefully over a period of several days in an attempt to answer these questions. My conclusion is that the licensing of naturopathic medical practitioners as independent providers of primary health care would endanger the health and safety of the public and would not result in health benefits commensurate with its risks. There is abundant evidence in the Textbook to support this conclusion, but I summarize below only a few of the most problematic examples of the deficiencies and dangers in naturopathic practices.

1) The textbook describes the diagnosis and treatment of only 70 "specific health problems," and they are simply listed in alphabetical order, without regard to the nature of the condition or the organ(s) involved. In comparison, standard textbooks of conventional medicine provide a much more rational and systematic presentation that includes hundreds of disease conditions and describes them in much greater depth and detail. The Textbook includes in its 70 chapters on specific diseases nothing about cancer, diseases of the blood (including leukemias and anemias), nothing about heart attacks or serious abnormal rhythms of the heart (such as atrial fibrillation), and virtually nothing about kidney diseases, chronic obstructive pulmonary disease, cirrhosis of the liver, or about many common and serious infections such as pulmonary tuberculosis, malaria, syphilis, meningitis, encephalitis or bacterial endocarditis. Lacking adequate education about these diseases, naturopathic practitioners might fail to diagnose them in a timely fashion or delay in referring patients for appropriate medical treatment,

2) Many of the treatments recommended in the Textbook for the 70 diseases are not likely to be effective, and treatments proven to be effective are often totally ignored. This could endanger the health and safety of patients with serious diseases who relied solely on care from a naturopathic practitioner. As explained in the Textbook, naturopathy objects to the use of pharmaceutical agents and depends instead an the use of herbal or "natural" remedies of unproven value. Here are some examples of common, serious diseases that are dangerously mistreated in the naturopathic Textbook:

A) The chapter on the treatment of anginal (coronary artery) heart disease does not even mention the use of nitrates, beta-blockers or calcium-channel blockers -- all of which are standard, effective, FDA-approved treatment for this condition. Failure to use one or more of these agents in the treatment of severe angina would probably be considered medical malpractice. There is no mention of "statin" drugs to lower cholesterol and prevent further progression of coronary heart disease. The use of angioplasty or bypass surgery for patients unresponsive to pharmacologic therapy is dismissed. "Chelation" -- a totally irrational and unproven form of treatment -- is discussed favorably. However, at the end of this chapter, it is stated that "patients with unstable angina pectoris . . . should be hospitalized", thus tacitly admitting that naturopathic methods may be ineffective and that serious cases may require medical or surgical treatment found only in hospitals.

B) The chapter on congestive heart failure recommends unproven nutritional supplements, but says nothing about the standard (and usually effective) treatment. with diuretics and ACE-inhibitors, which have been shown to give comfort to, and prolong, the lives of these patients, It does, however, admit that "In later stages, adjunct (prescription) drug therapy is Usually necessary", but gives no details,

C) The chapter on high blood pressure says nothing about the diagnostic work up that is often needed to rule out certain curable causes (such as certain diseases of the adrenal gland, or obstruction in the aorta or the renal arteries). It recommends diet lifestyle changes and the use of herbs but admits that severe cases unresponsive to these "natural" measures may require treatment with pharmaceuticals (presumably under the management of a conventional medical doctor). However, it ends with the dangerous advice that once control of high blood pressure has been achieved with drugs, the naturopathic physician should have the patient "taper off " the medications. For some such patients, a reduction in medication risks sudden resurgence of severe hypertension and the possibility of a stroke or heart attack. Most patients with severe hypertension need to remain on medication indefinitely, or for many years.

D) The chapter on diabetes says very little about the use of insulin, nothing about oral hypoglycemic drugs, and nothing about the diagnosis, prevention or treatment of diabetic acidosis-- except to warn that it is a medical emergency that will require hospitalization,

E) The chapter on epilepsy says nothing about the use of anti-epileptic drugs, without which many cases simply could not be adequately controlled. Uncontrolled epilepsy is dangerous.

F) The chapter on HIV infection and AIDS advocates various types of herbal and "natural" remedies but gives no information about conventional drug therapy. Although it is admitted that no clinical studies have yet demonstrated the effectiveness of naturopathic medical care in HIV infection when used alone, or even as a supplement to conventional medical treatment, the chapter nevertheless ends with this advice: "We urge physicians to apply the principles of naturopathic medicine in the care of their HIV positive patients." As if this neglect of the proven life-prolonging value of anti-viral pharmacotherapy were not shocking enough, the chapter also fails to recommend drug treatment of pregnant women with HIV infections, which is standard practice for the prevention of HIV transmission to the newborn. Neglect of such treatment would surely be considered malpractice in the medical profession.

G) The chapter on the treatment of asthma is also seriously deficient because it says nothing about the use of bronchodilator drugs, or drugs that block the allergic response in the lining of the respiratory passages, or about the short-term use of adrenal steroids for emergency cases. These are all well-established treatments for asthma; and it is difficult to imagine how serious cases could be managed without them. However, the Textbook advises naturopathic physicians to refer patients with acute asthmatic attacks to a hospital emergency room. This acknowledging that naturopathic remedies may not work and that seriously ill patients will need treatment by conventional medical methods. But this advice is also deficient in that it fails to mention that appropriate medical treatment could prevent the onset of attacks that require emergency care.

3) As already noted, naturopathic teaching (as exemplified in the Textbook) claims that "natural" herbal remedies are generally superior to pharmaceuticals in the treatment of most diseases -- despite the fact that the FDA forbids the manufacturers of herbal preparations and dietary supplements from making therapeutic claims. The textbook nevertheless devotes a large section to herbs and dietary supplements in which many such claims are made, often with little or no credible supporting evidence in the peer-reviewed scientific literature. At the same time, the Textbook omits entirely (or mentions only in passing) the use of many standard, proven pharmaceuticals that modern medicine has found useful or even essential in the treatment of serious diseases. For example:

Perhaps most disturbing of all, there is no mention of opioid drugs in the treatment of intractable pain. Morphine and its derivatives are often essential for the relief of patients in the terminal stages of cancer. It is almost incomprehensible that nowhere in the numerous discussions of the management of pain by a great variety of "natural" methods is there a reference to the use of morphine or other analgesic drugs. Obviously, as any experienced physician knows, there are alternatives to drugs that may help -- particularly when pain is mild, moderate or only intermittent. But in advanced cancer, morphine is often the only way to afford relief, and it seems remarkable that the Textbook should omit such an essential form of treatment.

Primary care practitioners whose education does not include the use of prescription drugs simply cannot be expected to provide effective and safe care for many serious conditions they are likely to encounter. While it is true that unnecessary or inappropriate use of drugs is harmful, and that even proper usage of drugs can sometimes cause serious reactions, there can be no doubt that on balance prescription drugs have been enormously beneficial, and that drugs will be even more important in the future. The anti-pharmaceutical bias of naturopathic education (as illustrated in the Textbook) therefore poses real risks for patients who rely on naturopaths for the management of their illnesses. Without prompt and appropriate drug therapy many patients with serious diseases will die.

I recognize that there are probably large variations in philosophy and medical education among naturopathic practitioners. Some may practice more prudently than others and may use conventional medical treatments more frequently and work more closely with conventional medical practitioners. But we should make public policy decisions based on the standards of practice that are being taught, not on our opinions about individual practitioners. Judging by the standards of practice presented in the Textbook, it seems clear that the risks to many sick patients seeking care from the average naturopathic practitioner would far outweigh any possible benefits.


Dr. Relman is Emeritus Professor of Medicine and of Social Medicine, Harvard Medical School; Editor-in-Chief Emeritus of The New England Journal of Medicine; and a member of the Massachusetts Board of Registration in Medicine (BORM). He prepared this report while serving as BORM's representative to the Special Legislative Commission on Complementary and Alternative Medical Practitioners, an ad hoc group formed to provide advice to the Massachusetts legislature.

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This article was revised on April 10, 2002.