1. My references do not come from reputable sources, do not reflect what NDs really do, or are out of date.

As stated in the article, I was careful to include only references that any reasonable person would consider representative of the highest levels of “naturopathic medicine”: the Textbook of Natural Medicine — “the most comprehensive summary available of the actual practices and recommendations of naturopaths,” according to its own back cover[1] — the Position Papers and other articles offered on the Web site of the American Association of Naturopathic Physicians (AANP), the course catalogs and other information from the Web sites of “approved” naturopathic schools, especially Bastyr, and other articles or quotations only if they were written by faculty members or other prominent members of the field. The vast majority of these references were either published or posted within the last 5 years. All of this is a matter of fact, discoverable by any reader.

Thomas Shepherd,[2] the president of Bastyr University, claims that I “[used] a 1968 HEW report to argue that naturopathic physicians (NDs) do not practice science-based medicine.” My reason for citing the 1968 report, as I made clear, was to demonstrate the paradox of Medicare having once made that determination, and then failing to check its currency for the purposes of its recent appointments to the Medicare Coverage Advisory Committee. Throughout the article I did what Medicare should have done: I provided ample, current evidence that NDs still do not practice science-based medicine. I concluded that nothing in naturopathy, other than the superficial trappings of respectability, has changed since 1968. Neither President Shepherd nor any other correspondent, in referring to those superficial trappings, has refuted that charge. Dr. Robbins's letter leaves little doubt about how the naturopathic hierarchy responds to legitimate criticism.[3]

If, as Mr. Gagnier[4] also suggests, my citations “lag far behind the current data,” then NDs have their work cut out for them. To paraphrase what I have written elsewhere, “To be credible, any assertion that naturopaths [no longer hold these beliefs] would require a formal change in the AANP position paper[s] and a dramatic shift in the literature emanating from the field. Unless that happens, any such assertion should be considered a dishonest attempt to [misrepresent the field].”[5] To that I add that the “dramatic shift” must include formal, public repudiations of all pseudoscientific claims and of pseudoscience itself. Is this, perhaps, what presidents Boggs and Mittman[6] have in mind for their “companion article?” If so, I would be the first to applaud.

The references in my article encompass a large amount of material that clearly characterizes the tenets of the field. I didn't make any of it up; I let naturopaths speak for themselves. I can assure readers that I could have written 10 more, similarly critical articles, without want for additional citations. If these practices truly don't reflect what NDs do, why are they so abundant in naturopathic literature? If NDs don't really do these things, what do they do instead? If they are merely involved in straightforward, dietary and lifestyle counseling, what do they offer that's special, and why should we consider them “doctors”? If what they really do are the same things that MDs do, why should society grant them “primary care physician” status without residency training?

The answers to these questions are clear and inescapable. For further evidence, I invite readers to examine the continuing education course listings of the Oregon Board of Naturopathic Examiners.[7] If readers aren't familiar with “cranial adjusting,” “Nambudripad's allergy elimination techniques,” “anthroposophical medicine,” homeopathy, applied kinesiology, the ACAM (the major organization advocating EDTA “chelation therapy” for atherosclerosis), “the sanctity of blood” (a code for opposition to vaccinations) and the rest, they can find explanations at Quackwatch.org. The endorsement of such practices by a state naturopathic licensing board also demonstrates that licensing NDs doesn't protect the public. Rather, it shields quackery from the scrutiny of the law.

2. The validity of naturopathic medicine is demonstrated by its support in government (including accreditation of its schools and NIH-funded research), on medical school Web sites, and in other parts of the public domain. It is also shown by its burgeoning popularity and by its lasting power. It has existed for more than 2000 years, having begun with Hippocrates (nevertheless, now it is suddenly an “emerging profession”[6]). The millions of people who believe in complementary and alternative medicine can't all be stupid. It's great that CAM is being taught in medical schools.

It should not be necessary to state that the validity of any health claim is determined by science and reason, rather than by political institutions, popularity, history, catch phrases (“emerging profession”), or other irrelevant means.

Governmental accreditation of schools, it may surprise the readership to learn, has little to do with the validity of what they teach. In the case of naturopathic schools, accreditation is based on “record-keeping, physical assets, financial status, makeup of the governing body, catalog characteristics, nondiscrimination policy, and self-evaluation system.”[8] For those who still doubt that accreditation is distinct from validity, consider that astrology also boasts an accredited school.[9]

Support of naturopathy by the NIH means support by the National Center for Complementary and Alternative Medicine (NCCAM). This has nothing to do with the validity, or even the potential validity, of naturopathic methods. It has everything to do with the history and formal language that created the NCCAM, as I have discussed at length elsewhere.[10] The NCCAM funds unethical and wasteful research at Bastyr,[10] some examples of which I will discuss below.

Naturopathy is not synonymous with “CAM” in general, and is not comparable even in popularity alone. To suggest otherwise is a “bait and switch” tactic. Naturopathy's popularity may be burgeoning, but one would be hard-pressed to prove it. In the United States, there are around 2500 naturopaths who are graduates of the schools approved by the AANP (by comparison, there are about 30,000 physicians in Massachusetts alone. This should give pause to those correspondents who charged that I must “feel threatened” for economic reasons. I don't). Two of the recent, major national surveys of the public's use of “unconventional medicine” did not mention naturopathy at all[11,12]; the third assigned it 0.7% of the total, without distinguishing between NDs and “traditional naturopaths.”[13] Not that this matters, of course, because validity is not determined by popularity.

Here are a few examples of popular beliefs and practices that have “stood the test of time”: astrology, voodoo, racism, sexism, anti-Semitism, slavery, torture, oppression of women, persecution of homosexuals, female genital mutilation, and religious wars. It should be clear from this list that popularity and persistence are fallacious tests of scientific or ethical validity. These tests are, in fact, the logical fallacies known as the “appeal to the masses” and the “appeal to tradition,” respectively.

The observation that many people believe in implausible health practices does not mean that those practices are thereby exempt from rational scrutiny, as the president of Bastyr suggests.[2] Nor does it imply, as he seems think I have concluded, that the people who believe in them are stupid. There are myriad ordinary reasons why intelligent patients and practitioners can be enticed to believe all manner of implausible claims: the natural history of most diseases (the vast majority are self-limited or cyclical), the post hoc fallacy, the will to believe, confirmation bias, selection bias, social biases, demand characteristics (including the “norm of reciprocity”), incorrect diagnoses, inadequate follow-up, the placebo effect (even if its definition and reality are in question), ideomotor action, poor science education in schools, and many more.[14-16]

These are the sorts of judgmental errors that have convinced followers of every ineffective healing claim throughout history. When these ordinary effects are weighed against the extraordinary nature of those healing claims, it becomes clear which are more likely to be real. Thus, we needn't invoke fantastic theories such as “water memory” (in violation of the second law of thermodynamics), “toxin” cleansing programs, Qi, meridians, psychokinesis, “applied kinesiology,” “craniosacral rhythms,” “unruffling the human energy field,” or “align[ing] the individual's body in a more true balance”[17] to explain why a patient feels better, when mundane explanations will do. To ignore this sort of analysis is to ignore one of the fundamental truths of patient care.

Some, but not all, of these sources of error can be eliminated by randomized, controlled trials (RCTs). But RCTs are subject to additional errors, including confounding biases, cuing and other subtle, unconscious biases, post-hoc analyses, multiple testing artifacts, noncomparable study and control groups, other statistical errors, erroneous conclusions, fraud, and more. That is why it is a fool's errand for advocates to perform clinical trials of highly implausible claims. This has been discussed elsewhere, but in summary such research inevitably results in equivocal, rather than merely negative, conclusions. “Further research” is invariably called for, with no end in sight.[18-23]

Mr. Gagnier's understanding of biological plausibility is almost incoherent. He writes, “many therapies used in medicine today were discovered through serendipitous findings in unrelated research.”[4] This is true, but unrelated to the issue of plausibility. Then he writes, “therefore, efficacy of an intervention may be shown irrespective of a known biological mechanism,” which does not follow from the first sentence, even if it is true; and it also has nothing to do with plausibility. We might all agree that aspirin is an example of a medicine whose efficacy was shown irrespective of a known biological mechanism. But a “known biological mechanism” is not the same thing as biological plausibility. Aspirin was perfectly plausible at the time of its introduction in the late 19th century, because it was a chemical that could interact with biochemical processes. That those exact processes were not known for many decades did not make aspirin any less plausible. Compare this with the myriad naturopathic claims that I've already cited. Many of them are known to be absurd (oxygen traversing skin, wet compresses aborting strokes, water “memory,” the iris manifesting a homunculus, “transfer of neural energy” [ie, psychokinesis], etc.); others are highly implausible and easily explained by ordinary mechanisms (applied kinesiology by ideomotor action, colonic “cleansing” by the norm of reciprocity, etc.); and still others are barely plausible but highly unlikely and dangerous and, unlike aspirin, are without any empirical support (eg, St. John's wort as an anti-HIV drug).

None of these claims should be studied in human trials. Only St. John's wort meets the minimum plausibility standard, but it would first need to be studied in laboratory and animal settings before it could be ethically offered to humans for that purpose, and it has already been demonstrated to cause subtherapeutic HAART levels.[24] Given the scarcity of resources, the danger, and the low likelihood of success, it would be wasteful to pursue St. John's wort as an anti-HIV drug. Nevertheless, that is exactly what is being done at Bastyr under a grant — funded by taxpayers — from the NCCAM.[25] The description of the study falsely suggests that St. John's wort has “yet to be systematically evaluated for…interactions with highly active antiretroviral therapy (HAART).”[25]

Two other taxpayer-funded studies at Bastyr are “transfer of neural energy,”[26] which ignores more than 100 years of futile research in parapsychology, and “Distant Healing Therapy in HIV/AIDS,”[27] which is justified by a fraudulent pilot study.[28,29] Mr. Gagnier[4] writes that “to establish causation requires a review of all principles of causation, not just biological plausibility.” Naturopaths would seem to include supernatural forces among their “principles of causation.”

There are now CAM courses at many medical schools, but these are, overwhelmingly, uncritical and promotional.[30,31] The preceding few paragraphs, for example, reveal more truth about CAM than the entire curricula at most medical schools. This isn't surprising, because there is plenty of money for CAM departments, all donated by advocates: Fetzer, Osher, Templeton, American Specialty Health, Medtronics, NCCAM, etc. There is no funding specifically earmarked for critical thinking about CAM, as far as I know. The seeds of CAM-friendly dollars are also falling on the fertile field of irrational postmodernism, which has infected medical schools more than most realize.[32,33]

3. Naturopathic medicine offers effective treatments that have eluded modern medicine. There are thousands of citations to support this.

If naturopathic treatments are so well founded, why haven't naturopaths offered evidence for some of their most basic claims? An obvious one is the current AANP Position Paper on “Treatment of Strep Pharyngitis,” written in 1992.[34] It would have been a simple and inexpensive matter, over the years, for naturopaths to compile case series of their treatments and outcomes, but they have done no such thing. That is why I used it as an example of naturopaths not studying their methods because they are already certain that they work.

A couple of correspondents took me to task for citing that position paper. They accused me of bias for having selectively quoted from it, leaving out this section:

The use of antibiotics should be reserved for those patients who are unresponsive to naturopathic modalities and are not making significant improvement in a timely manner (ie, no response after one week of naturopathic therapy).[34]

The correspondents argued that this shows that naturopaths know when to initiate real (as opposed to “natural”) antibiotic therapy. Actually, it shows the opposite. Most cases of streptococcal pharyngitis will resolve, with no treatment at all, in 3–5 days.[35] The rationale for antibiotic treatment is not to cure the sore throat, but to prevent rheumatic fever and, to a lesser extent, suppurative complications. Thus, it's a self-fulfilling prophecy that most patients on “naturopathic modalities” will make “a significant improvement in a timely manner.” It is also a self-fulfilling prophecy that some of them will develop acute rheumatic fever 2–4 weeks later.

Moreover, the demonstration that rheumatic fever is a delayed sequela of streptococcal pharyngitis was not made until the early 1930s.[36] How, in 1992, could naturopaths have known that they “have been successfully treating Strep pharyngitis with very low incidence of poststreptococcal sequelae…for close to one hundred years”?[34] All of this is what is meant by pseudoscience.

It is likely that practitioners who have been taught that their methods are nearly infallible and who have little experience with subtle, uncommon diseases will miss the diagnosis of rheumatic fever. Are these the practitioners that Drs. Katz[37] and Jacobson[38] would have take care of their children? If not, why would it be acceptable for naturopaths to take care of other people's children?

I am still awaiting the studies and systematic reviews that purportedly support naturopathic methods. The Textbook of Natural Medicine [1] claims that its assertions are supported by “10,000 citations to peer-reviewed literature providing standards of practice for natural medicine. Based on a solid combination of theory and clinical studies [etc.].” I have examined many of these citations and found that, overwhelmingly, they are either irrelevant to the claims made, are preliminary and inconclusive, are based only on animal or in vitro studies, or are mere restatements of similar opinions. I have discussed these findings elsewhere, as has at least one other author.[10,39,40] I will give more examples below.

The citations offered by the authors of the letters here are, with one exception, references to methods well known to all in healthcare and written, typically, by medical doctors. They don't refer to naturopathy per se, but to practices that are either vaguely embraced by “CAM” proponents in general, or that aren't “CAM” at all. To claim that the DASH diet or the low-fat diet advocated by Dean Ornish, for example, constitutes support for naturopathy[2] is quite a stretch. The only partial exception to nonnaturopathic authorship among these citations is the recent trial of Echinacea in children, but it refutes, rather than supports, a longstanding naturopathic claim.[41] Nevertheless, the very naturopaths involved in the study are already resisting its obvious conclusion.[42]

Dr. Katz[37] writes that “naturopathic physicians recognized the importance of omega-3 fatty acids to health long before their conventional counterparts.” Where is the evidence for this assertion? For Dr. Katz, as for naturopaths, a little knowledge can mean trouble. The history of interest in omega-3 fatty acids can be traced to the 1970s, when Danish researchers were intrigued by the high-fat diet, but low mortality rate from coronary disease, of the Inuit in Greenland.[43] Numerous articles in mainstream medical journals followed, as a perusal of PubMed can quickly confirm. Naturopaths are nowhere to be found among the authors.

The Textbook of Natural Medicine promotes omega-3 fatty acids.[44] None of the citations that the Textbook offers for support are from naturopathic literature; all are from medical or nutritional literature. Its recommendations for omega-3 fatty acids, like so many other recommendations in naturopathic literature, are exaggerated, premature at best, and offered as a near panacea. The Textbook claims that these molecules can prevent or significantly alter the course of asthma, atherosclerosis, atopic dermatitis, Crohn's disease, depression, diabetes, hypertension, multiple sclerosis, psoriasis, and rheumatoid arthritis. Regarding the asthma claim, the Textbook states, “studies [sic] have shown that children who eat fish more than once a week have one-third the risk for asthma of children who do not eat fish regularly.”[45] The lone citation is to a questionnaire survey that did not investigate omega-3 fatty acids per se, and whose own authors admitted was limited in its ability to generate firm conclusions.[46]

The hypertension chapter in the Textbook states, “over 60 [sic] double-blind studies have demonstrated that either fish oil or flaxseed oil are very effective in lowering blood pressure.”[47] Four citations are offered to support this claim. One is a study that did not look at dietary or medicinal intervention at all, but at existing adipose composition in adult male subjects. It found that the linolenic acid content of adipose tissue, but not the linoleic acid content, was inversely correlated with blood pressure.[48] Another citation reviewed the different lipid and blood pressure effects of linolenic acid compared with long-chain n-3 fatty acids. It cited 2 hypertension studies, one of which showed a lowering of systolic blood pressure (no number was given) with either type of fatty acid, and the other of which did not.[49] While interesting, neither of these references supports the assertion in the Textbook.

The other 2 Textbook citations are to relevant reviews. One is a 1994 review of omega-3 PUFA in cardiovascular disease in general. It cites 7 positive and 3 negative studies of omega-3 PUFA in hypertension. It concludes: “Systolic pressure has typically been reduced by 3 to 6 mm Hg and diastolic pressure by 2 to 4 mm Hg.” Its overall conclusion is this: “Clinical studies investigating the effects of dietary omega-3 PUFA in the prevention and treatment of cardiovascular disease (CVD) are beginning to emerge. The results have offered some promise, but further studies are needed to define the role of these agents in CVD.”[50]

The second review is a meta-analysis of fish oils in hypertension. Most of the studies that it reviews are the same as those cited by the review in the previous paragraph. Most were not double-blinded. The review finds that of “the six [sic] studies that enrolled untreated hypertensives (n = 291), significant reductions of SBP (systolic blood pressure) and DBP (diastolic blood pressure) were present in two and four trials, respectively. Weighted, pooled estimates of SBP and DBP change (mm Hg) with 95% confidence intervals were…-5.5 (-8.1 to -2.9) and -3.5 (-5.0 to -2.1) in the trials of untreated hypertensives…Side effects, most commonly eructation and a fishy taste, occurred more frequently in omega-3 PUFA participants than in control participants (28% vs 13%, P < .001).”[51]

Thus, fish oils could hardly have been considered as “very effective in lowering blood pressure,” and there was evidence that patients might not warm to the treatment. The Textbook's erroneous claim of “60” studies was perhaps a typographical error, but it persists in my copy, which is the second reprint. It accompanies the equally erroneous “double-blind” statement.

More important is that after several more years of study, the blood pressure effect of omega-3 fatty acids turns out to be considerably less than early trials had suggested. A recent meta-analysis of 36 trials reported an average systolic BP drop of 2.1 mm Hg and a diastolic drop of 1.6 mm Hg.[52] The effects were even smaller in the 22 trials that were double-blinded. The gradual disconfirmation of a hypothesis for which there was considerable early enthusiasm is common in medicine and in science in general, and is a good reason to be circumspect when faced with exuberant initial claims.

Dr. Katz would seem to disagree. He also writes, regarding omega-3 acids, “we have only recently begun to catch up,”[37] citing a prolific author who just happens to be a medical doctor. Does he mean we should have promoted these substances before adequate study, as naturopaths did? Is what passes for evidence in the Textbook of Natural Medicine the sort that Dr. Katz, the self-proclaimed author of a textbook of evidence-based medicine, finds compelling?

The modest changes in blood pressure reported above are even less than typical minute-to-minute fluctuations in anyone's blood pressure, offering those wedded to “natural” remedies the perfect opportunity to ignore unwelcome data when treating patients. Thus, the assertions in the Textbook of Natural Medicine could easily have resulted in morbidity from untreated hypertension over the past few years. There is no way to know the extent to which this may have happened, because naturopaths don't look.

4. The basic sciences taught in naturopathic schools are the same as those taught in “conventional” medical schools. They are taught by PhDs, so they must be comparable. The NPLEX examination, moreover, proves that NDs are grounded in science.

Dr. Robbins's letter[3] speaks volumes about what really happens at naturopathic schools. I need only observe that regardless of what basic sciences are taught or who teaches them, the students are also taught that homeopathy is valid, that dissolved oxygen can be absorbed through the skin in appreciable quantities, that sugar in the diet translates to sugar in the ear, that Goldenseal cures streptococcal pharyngitis, that wet compresses can abort an evolving stroke, that swallowed whole enzymes traverse the gut and home in on arthritic joints, that the iris contains a homunculus that is the key to diagnosis of disorders throughout the body, that “craniosacral rhythms” exist, and all the rest. The poor students will need an enormous amount of maturity, perseverance, and prior knowledge of basic science and critical thinking to avoid being thoroughly duped. Regular medical students can't be expected to have those capacities at that stage in their lives, and the accompanying letters suggest that it's no different for naturopathic students.

The NPLEX examination remains a mystery. Its contents are not available on its Web site, contrary to President Shepherd's assertion.[2] Only a table of contents, of sorts, is to be found there. It includes homeopathy, a field that is refuted by science.[19] When I served on the Massachusetts Special Commission, I asked the President of the Massachusetts Association of Naturopathic Physicians, as it was then called, to bring a copy of an old NPLEX exam to a meeting. She said that she would, but did not. I imagined then, and still do, that naturopaths would rather that those who are capable of critiquing the exam not be given the opportunity.

5. I have, obviously, never met a real ND. If only I would travel to a naturopathic school or clinic and observe NDs in action, I would be convinced that they are loving and caring, and can function as primary care physicians.

I have met several real NDs, although I haven't spent time at a school or clinic. I spent a year and a half as a member of the Massachusetts Special Commission on Complementary and Alternative Health Care Practitioners. The commission, in spite of its more general name, was charged to consider naturopathic medicine exclusively. The several NDs that frequented the commission meetings (most were either Bastyr or NCNM grads) were well meaning and sincere. Unfortunately, sincerity alone does not a primary care physician make. How much sincerity would compensate a mother whose asthmatic child had suffocated while languishing in a bath containing hydrogen peroxide, or whose infant had died of overwhelming sepsis? How much “caring” would compensate for even a single unnecessary case of rheumatic heart disease? Would a loving approach justify a relapse of AIDS in a patient convinced to take St. John's wort or garlic because of what he reads on the Bastyr Research Web site?[10] How many debilitating strokes could have been aborted if not for delays caused by treating patients with wet compresses?

Caring also doesn't necessarily translate to good counseling or psychosocial skills. Consider this advice from an instructor at Bastyr who is also coauthor of the AANP Position Paper on Homeopathy:

So, what can I do to lower my risk of getting breast cancer? Keep your breasts happy and healthy. Love them and yourself. We often develop illnesses because of our own unresolved feelings and lack of love for ourselves…Deal with any unresolved maternal, nurturing, and relationship issues so they're not lurking in your breasts.[53]

There isn't the slightest evidence, of course, that unresolved feelings lurk in one's breasts or have anything to do with the genesis of breast cancer. To tell these things to a patient amounts to emotional blackmail. Real caring is another thing altogether: it means caring enough to learn as much as possible about human biology and modern medicine, which is hard work. It also means knowing one's limitations, and that begins by acknowledging that what you or your patients just feel is right ain't necessarily so.

I am sorry to report that sincerity also does not predict honesty. In an interview last summer with the Greenfield (MA) Recorder, I quoted the same naturopathic treatise on asthma, taken from the AANP Web site, that I later cited in the MedGenMed article.[54] The President of the Massachusetts Association of Naturopathic Doctors subsequently denied, in an October 15, 2003 Recorder article, that he had ever heard of this treatise and also denied that it had come from the AANP Web site. It would seem, for purposes of advancing the ND political agenda, that sincerity gives way to deception.

6. MDs, say some, should consider naturopaths to be their colleagues.[6,37,38,55]

It seems that Drs. Jacobson and Katz know little of what naturopaths do or stand for. One assumes that Dr. Jacobson, in particular, would be shocked to discover the extent to which naturopaths oppose childhood vaccinations.[5] Does she know the origins or the rationale for homeopathy, a universal naturopathic method? Does she support “colon cleansing”? I, too, am dismayed by what is not taught in medical schools, but that would begin with what Carl Sagan called “the fine art of baloney detection.”[56]

Is it possible that Drs. Jacobson and Katz are embarrassed by my article because they know a few naturopaths and find them to be very nice people? I don't doubt that many NDs are nice people, nor do I doubt that they believe that they are committed to good medicine. These points are irrelevant to the greater issue, however: the field of naturopathic medicine, as a whole and at its highest levels, promotes fanciful, pseudoscientific, dangerous, and unethical practices. It holds its graduates out to society as “primary care physicians” when their training is undeniably inadequate. The evidence for all of this is overwhelming. Shooting the messenger won't make it go away.

Dr. Katz may be ignorant of naturopathic literature, but his letter suggests that he has another axe to grind. He complains that my article was “flagrantly biased,” “misleading and objectionable”[37] — without citing even one example of an inaccurate statement in it. He makes irrelevant forays into the failures of medicine and the definition of the word “critical.” The man doth protest too much, methinks. His receipt of $1 million of public funds to study “CAM,” together with his postmodernist language distortions and his directorship of an “integrative” medicine center, identify him as an advocate.[10]

The argument that the best way for MDs to deal with pseudoscientific practitioners is to collaborate with them, and thus coax them to become more responsible, has been made before.[57] It is blind to the history of medicine and to the nature of pseudoscience. It is likely to do far more harm than good, because it is perceived as an endorsement of pseudoscientific practices and of the practitioners who perform them. Members of the public who are scientifically naive can't be faulted for concluding, after hearing opinions such as those of Drs. Katz and Jacobson, that naturopathic claims are every bit as valid as anything in medicine proper. Members of the public who are scientifically sophisticated are left scratching their heads, wondering why medicine has suddenly squandered its hard-won scientific and ethical underpinnings. Either way, these dalliances undermine good medicine and public health.

For those reasons, such collaboration is a direct violation of at least 2 formal, modern statements of medical ethics. The recently published Medical Professionalism in the New Millennium: A Physician Charter requires a:

Commitment to scientific knowledge. Much of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use.[58]

The American Medical Association Code of Medical Ethics is even more explicit:

E-3.01 Nonscientific Practitioners.

It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care.

E-3.04 Referral of Patients.

A physician should not so refer a patient unless the physician is confident that the services provided on referral will be performed competently and in accordance with accepted scientific standards…

E-8.20 Invalid Medical Treatment.

(1) Treatments which have no medical indication and offer no possible benefit to the patient should not be used (Opinion 2.035).

(2) Treatments which have been determined scientifically to be invalid should not be used (Opinion 3.01).

E-9.132 Health Care Fraud and Abuse.

The following guidelines encourage physicians to play a key role in identifying and preventing fraud:

(1) Physicians must renew their commitment to Section II of the AMA's Principles of Medical Ethics which states that “a physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character, competence, or who engage in fraud or deception.”

V. A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.[59]

Physicians who consider naturopaths to be their colleagues thus find themselves in opposition to one of the fundamental ethical precepts of modern medicine. If naturopaths aren't to be judged “nonscientific practitioners,” the term has no useful meaning. An article by a physician exposing quackery, moreover, does not identify its author as “biased,” but simply as fulfilling one of his ethical obligations as a physician.

The best way for MDs to deal with pseudoscientific health practices, in a free society, is to be informed, honest, and forthright about them. MDs should learn enough about nonstandard practices to make a reasonable determination of their validity or potential validity, based on science and critical thinking. If it is clear that certain practices and the practitioners who perform them are pseudoscientific, MDs should state as much whenever asked by patients, legislators, or anyone else. Such statements help to marginalize the practices and the practitioners in question, which is the goal. It is part of our ethical covenant to society as physicians. Unambiguous exposés of quackery will inevitably appear rude to some people[60] and hurt some feelings. This is a fact of adult life.

7. “Allopathic” medicine doesn't have all the answers, gives short shrift to patients, and is dangerous. Only 15% of its claims are evidence-based.

This was probably the most common complaint, but I've saved it for last because it has little to do with the article. Whatever the failures of modern medicine may be, they are irrelevant to the case against naturopathy. To invoke them is formally recognized in debate as the tu quoque (“you too”) fallacy, in which one participant tries to deflect criticism by pointing to the failings of the other(s). But such deflection has nothing to do with the legitimacy of the criticism itself, which stands or falls on its own merit.

Those who thought that the article pitted medicine against naturopathy might be reminded that naturopaths, not I, introduced the issue by portraying themselves as “primary care physicians.” Such a claim requires scrutiny. Would anyone with an interest in healthcare think otherwise? Every physician that I know who has trained in primary care, me included, feels strongly that medical school was only the starting point. The residency was, by far, the real training ground. To think that any of us was prepared, immediately upon obtaining the MD degree, to hang a shingle as a primary care practitioner, is ludicrous and scary. This would be tantamount to thinking that a new grad of a driver's ed course, having just received his license, is now qualified to race in the Indianapolis 500.

It is obviously, and trivially, true that standard training in primary care medicine is not a guarantee of quality.[61] It is just as obvious, however, that a formal 3- or 4-year residency with intense exposure to a wide variety of patients and diseases produces a vastly more qualified practitioner than does the lack of such a residency, all other things being equal. The president of Bastyr admits as much, even as he suggests otherwise in the same letter.[2] He can't have it both ways.

The naturopaths' primary care claim is also refuted by the content of their training, which is replete with fanciful, antiscientific nonsense. That is why any residency program worth its salt should continue to refuse admission to graduates of naturopathic schools. Thus, while the bulk of my article did not pit naturopathy against modern medicine per se, it did pit naturopathy against science and reason. That is my “bias,” and for that I offer no apology. Nor do I offer an apology for using clear, exact, critical language.

I will allow myself to be deflected by the tu quoque fallacy only to the extent that some misconceptions about medicine and its history make a dialogue such as this an almost impossible task. To wit:

• There is no such thing as “allopathic” medicine, a pejorative term coined by the founder of homeopathy, Samuel Hahnemann. Those who use it to describe modern medicine only betray their ignorance. Ironically, one place in North America that still gives a favorable nod to what Hahnemann meant by “allopathic medicine” — the prescientific, highly toxic practices of bloodletting, purging, scalding, etc., based on the “four humours” — is Bastyr University. Look it up: Bastyr doesn't teach it merely for historical interest, but “in the light of its twentieth century revolutionary reformation and resynthesis, with brief history of its competitive existence, stature and staying power.”[62]
• Modern medicine is “Western” only in the trivial sense that, for the most part, it evolved in the West. It is now the medicine of most of the world and is widely known to be effective where traditional practices were not. It is universal because it deals with universal facts of anatomy, physiology, pathophysiology, and all the rest. It is universal also because its methods can be tested by anyone in the world who cares to do so. This distinguishes it from craniosacral rhythms, the “human energy field,” meridians, Qi, and doshas, for example, which are undetectable, unmeasurable, and therefore unfalsifiable. To label modern medicine as Western in the postmodern “group narrative” sense — witness Dr. Katz's use of the terms “native preferences” and “allopathic philosophy”[37] — is akin to calling what Einstein did “Jewish physics.”
• Of course medicine doesn't have all the answers. It took at least tens of thousands of years, once humans had evolved enough intelligence to be capable of doing so, to figure out some of the most important causes of disease and to discover some therapies and preventive measures that actually work. The current pace is breathtaking compared to that, but science still takes time. To think that while we are waiting we should resort to fantasy is a nonsequitur. Patients are free to choose, of course, but physicians who urge them toward unlikely solutions are dishonest or incompetent. We already know the most likely reasons that some people with chronic diseases are comforted by whimsical methods, and they are not specific to those methods. If among those methods are some that actually show promise for being useful, I'm all in favor of studying them, but not in advocating them prior to study; and there is nothing specific to naturopathic literature that suggests any real promise.
• Short shrift, which medical doctors universally deplore, is an onerous fact of third-party payment schemes. To think that it somehow justifies quackery is another nonsequitur.
• That complex disease interventions are inherently risky is unsurprising, but they are justified as long as the potential benefits outweigh the potential risks. The same cannot be said for interventions such as homeopathy or colonic “cleansing,” which lack even the potential for benefit. Jet planes also have inherent risks, and very scary ones at that, but it doesn't follow that we should prefer flying carpets.
• The dangers of modern healthcare are known to the public only because medicine investigates its practices and publishes its findings even when they are not flattering. Medicine is now in the very public process of designing systematic measures to reduce errors and increase safety, much as the airlines and other inherently risky, but now quite safe, enterprises have done.
• The “15%” claim, regarding the evidence basis for modern medicine, has achieved “urban legend” status but, as at least one correspondent grants,[4] has been soundly debunked.[63] Even more important is that all serious proposals in medicine are based on biologically plausible criteria even before clinical trials take place. The right heart catheter, for example, was not a “native preference.”[37] It was an innovation based on physiology and anatomy that had already proved its value in the laboratory. Investigators subsequently found evidence that in the clinical setting it may be more harmful than helpful (remember the tendency for disconfirming evidence to mount over time?). This did not “sully” medicine at all, however. Rather, it illustrated medicine's broad, if incomplete, commitment to self-scrutiny and improvement by objective testing, even in the face of a widespread impression that a method is valid. Does Dr. Katz really believe that this is analogous to the naturopathic position paper on Strep pharyngitis?

Recent Bastyr grads Bongiorno and LoGiudice[64] offer examples of “bona fide medical breakthroughs [that] initially came under intense fire,” as though these somehow impugn medicine. But this assertion merely exemplifies the points made above: that medicine improves itself cumulatively through science, while naturopathy rebuffs science. By failing to give its students the intellectual tools to discern these facts, Bastyr has abdicated its pedagogical responsibility, as I will now explain. The initial “intense fire” is nothing other than necessary scientific skepticism, without which it is impossible to separate the valid from the bogus. Since the era of modern, scientific medicine began in the second half of the 19th century, no true breakthrough has been rejected, but all have been required to prove themselves before being generally accepted. Elsewhere, I have described the history of this process for Helicobacter pylori and peptic ulcer disease, and have shown that the time course for its acceptance was entirely appropriate.[65]

Bongiorno and LoGiudice seem unaware that the core claims of osteopathy and chiropractic are not “bona fide medical breakthroughs” at all, but are implausible, unproven, and largely incoherent.[66,67] In practice, manual spinal therapy is accepted only for the treatment of back pain, and even for that it isn't particularly effective.[68] Osteopathy has, for the most part, repudiated its pseudoscientific beginnings and joined the world of rational healthcare. That is why graduates of its schools, but not those of chiropractic or naturopathy, can train as residents and legitimately identify themselves as primary care physicians or specialists.