1. Legal, Professional, and Ethical Issues in Complementary and Alternative Medicine Linda Diane Feldt RPP, NCTMB Herbalist and Holistic Health Practitioner

2. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Understanding Regulatory Terms and Levels Licensure Licensure Practice acts Practice acts Title registration Title registration Certification Certification Governmental “state certified” Governmental “state certified” Private certification (no inherent legal status) Private certification (no inherent legal status) Certification by Reference (govt. accepts private standards) Certification by Reference (govt. accepts private standards) Approval of Certifying Agencies Approval of Certifying Agencies The National Council of Certifying Agencies The National Council of Certifying Agencies The National Commission for Health Certifying Agencies The National Commission for Health Certifying Agencies Registration Registration Frequently used only to allow for use of a title or to identify members of a professional group Frequently used only to allow for use of a title or to identify members of a professional group Frequently has the most flexible standards Frequently has the most flexible standards Can be done privately (by associations, schools, etc.) or by states Can be done privately (by associations, schools, etc.) or by states

3. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Levels of Regulation and Authorization Licensing Licensing local or state level government local or state level government Certification Certification by state by state standards may be developed by the profession and referenced by the state standards may be developed by the profession and referenced by the state by certifying agency (“big C”) by certifying agency (“big C”) commonly include eligibility, exam, CE, recertification commonly include eligibility, exam, CE, recertification by professional association (grey area) by professional association (grey area) may include standards, ethics, CE, may include standards, ethics, CE, may include permission to use trademarked title or name may include permission to use trademarked title or name by individual school or modality (“small c”) by individual school or modality (“small c”) most often a certificate of completion most often a certificate of completion may include permission to use trademarked title or name may include permission to use trademarked title or name Registration Registration Members of a group or profession must register with state or local agency to use title Members of a group or profession must register with state or local agency to use title

4. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Current Examples of groups using a National Certification Program American Herbalist Guild American Herbalist Guild Midwives Association of North America Midwives Association of North America American Organization for Bodywork Therapies of Asia American Organization for Bodywork Therapies of Asia The National Certification Board for Therapeutic Massage and Bodywork The National Certification Board for Therapeutic Massage and Bodywork

5. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Components of a Profession Standards for Practice Standards for Practice Standards for Education (training) Standards for Education (training) Ethics Ethics Scope of Practice Scope of Practice Continuing Education Continuing Education Membership in a Professional Association Membership in a Professional Association Complaint process Complaint process

6. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Professional Associations While the exact activities of each association will vary, they may: Sets standards for education Sets standards for education Set standards for practitioners Set standards for practitioners Create and enforce ethics guidelines Create and enforce ethics guidelines Determine scope of practice Determine scope of practice May own and defend trademark May own and defend trademark Provide initial and/or Provide initial and/or continuing education (continued next slide)

7. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Professional Associations (cont.) Be proactive in safeguarding the right to practice for members Offer professional liability insurance Encourage research Provide a professional journal or newsletter Provide a practitioner locator service Provide PR and practice development support Network with other professional associations

8. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Professional Associations a few of the challenges related to regulation Many members have entered the professions part time, or as an adjunct to another type of practice Many members have entered the professions part time, or as an adjunct to another type of practice Members may not be willing or able to pay high membership fees, especially if membership is not required to practice in their locale Members may not be willing or able to pay high membership fees, especially if membership is not required to practice in their locale Significant resources are being used to protect the right to practice Significant resources are being used to protect the right to practice Many of these associations are 501 (c ) (3) IRS designated educational organizations and are restricted in the resources they can use to affect legislation, and therefore regulation. Many of these associations are 501 (c ) (3) IRS designated educational organizations and are restricted in the resources they can use to affect legislation, and therefore regulation.

9. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Regulation Options and Realities Initiated to address public safety concerns? Initiated to address public safety concerns? Enacted at the local, state, or national level? Enacted at the local, state, or national level? Driven by economic opportunity or goals? Driven by economic opportunity or goals? Self defined by members of the profession? Self defined by members of the profession? Defined by other professions? Defined by other professions? Exclusion Exclusion Umbrella provisions Umbrella provisions Response to scope of practice/right to practice concerns Response to scope of practice/right to practice concerns

10. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Innovative Routes to Regulation The Federation of Therapeutic Massage, Bodywork and Somatic Practice Organizations has produced a consensus document on developing legislation.This document can be downloaded from www.federationmbs.org www.federationmbs.org Consumers and Practitioners are promoting legislation to ensure access to alternative therapies through “Health Freedom” bills. www.nynaturalhealthproject.org www.californiahealthfreedom.org www.naturalhealth.org www.nynaturalhealthproject.org www.californiahealthfreedom.orgwww.naturalhealth.orgwww.nynaturalhealthproject.org www.californiahealthfreedom.orgwww.naturalhealth.org The World Health Organization is involved in integrating traditional and conventional medicine www.polity.org.za/html/govdocs/ reports/who/wtms_ch3.pdf

11. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Larger Challenges There are many challenges to regulation of CAM therapies. These include: There is no one profession, but hundreds There is no one profession, but hundreds More than 200 “hands-on” therapies exist More than 200 “hands-on” therapies exist Unlike most other health care professions, many of the modalities are trademarked Unlike most other health care professions, many of the modalities are trademarked Consumer right to access to CAM therapies must be safeguarded Consumer right to access to CAM therapies must be safeguarded CAM practices often attract renegades CAM practices often attract renegades There are exploding opportunities for commercial exploitation There are exploding opportunities for commercial exploitation Few professions have been subject to such demand and commercialization before becoming established as professions Few professions have been subject to such demand and commercialization before becoming established as professions

12. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Additional Challenges Some CAM therapies have a religious or spiritual component, which is not appropriate for regulation Some CAM therapies have a religious or spiritual component, which is not appropriate for regulation Traditional therapies may have cultural or religious aspects not easily understood or appropriate for legislation or even the formality of a professional association Traditional therapies may have cultural or religious aspects not easily understood or appropriate for legislation or even the formality of a professional association There is still significant lack of information and misunderstanding about many CAM therapies There is still significant lack of information and misunderstanding about many CAM therapies As a “fringe” profession that has become more mainstream, we still have within our ranks those practitioners who may lead the next paradigm shift As a “fringe” profession that has become more mainstream, we still have within our ranks those practitioners who may lead the next paradigm shift

13. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Ethics - just the beginning As alternative therapies move from “fringe” to “mainstream” the ethics of how we practice must also be reviewed and more widely adopted. As alternative therapies move from “fringe” to “mainstream” the ethics of how we practice must also be reviewed and more widely adopted. There are conflicting ethical standards between professions, and many CAM practitioners practice a variety of work. There are conflicting ethical standards between professions, and many CAM practitioners practice a variety of work. The widespread use of multi level marketing for alternative therapies is an additional ethical challenge. The widespread use of multi level marketing for alternative therapies is an additional ethical challenge. The growing use of trademarked movements, therapies, terms, and teachings has an effect on alternative therapies and who can do and teach what. The growing use of trademarked movements, therapies, terms, and teachings has an effect on alternative therapies and who can do and teach what. Much of the consumer information on CAM is obtained from ads, popular press articles, the internet, and other non-professional sources. Ethical considerations will usually not be included in and promoted by those sources. Much of the consumer information on CAM is obtained from ads, popular press articles, the internet, and other non-professional sources. Ethical considerations will usually not be included in and promoted by those sources. Some of the ways that CAM is practiced would naturally challenge conventional ethical boundaries. Some of the ways that CAM is practiced would naturally challenge conventional ethical boundaries.

14. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources http://www.nccaom.org/ http://www.nccaom.org/ has chart of certification and state regulation for asian therapies http://www.nccaom.org/ http://www.americanherbalistsguild.com/ http://www.americanherbalistsguild.com/ links to AHG Certification and Legislative Issues http://www.americanherbalistsguild.com/ http://www.somatic.com/ccsp/certchrt.pdfchart of training requirements for many modalities http://www.somatic.com/ccsp/certchrt.pdf chart of training requirements for many modalities http://www.somatic.com/ccsp/certchrt.pdf http://www.federationmbs.org Legislative Packet http://www.federationmbs.org Legislative Packet http://www.federationmbs.org http://www.ncbtmb.com National Certification Board for Therapeutic Massage and Bodywork http://www.ncbtmb.com National Certification Board for Therapeutic Massage and Bodywork http://www.ncbtmb.com National Certification Board for Therapeutic Massage and Bodywork Ethics http://www.ncbtmb.com/handbook/code_of_ethics.htm National Certification Board for Therapeutic Massage and Bodywork Ethics http://www.ncbtmb.com/handbook/code_of_ethics.htm http://www.noca.org/National Organization of Certifying Agencies http://www.noca.org/ National Organization of Certifying Agencies http://www.noca.org/ http://www.noca.org/ncca/accreditation.htmNational Organization of Certifying Agencies Accreditation Information http://www.noca.org/ncca/accreditation.htm National Organization of Certifying Agencies Accreditation Information http://www.noca.org/ncca/accreditation.htm http://www.mana.org/ Midwives Association of North America http://www.mana.org/ Midwives Association of North America http://www.mana.org/ http://narm.org/ North American Registry of Midwives http://narm.org/ North American Registry of Midwives http://narm.org/ http://www.holisticwisdom.org/aaordinance Information opposing Ann Arbor’s proposed regulation of massage and bodywork http://www.holisticwisdom.org/aaordinance Information opposing Ann Arbor’s proposed regulation of massage and bodywork http://www.holisticwisdom.org/aaordinance

15. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources NCCA's Mission The NCCA helps to ensure the health, welfare, and safety of the public through the accreditation of a variety of certification programs/organizations that assess professional competency. The NCCA uses a peer review process to: Establish accreditation standards; Evaluate compliance with the standards; Recognize organizations/programs which demonstrate compliance; and Serve as a resource on quality certification. NCCA's Vision The NCCA will be an administratively independent resource recognized as the authority on accreditation standards for professional certification organizations/programs. Based on sound principles, NCCA standards will be optimal and comprehensive criteria for organizational process and performance. They will be broadly recognized, objective, and current benchmarks for certifying bodies to achieve and by which they operate.

16. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources Pages 40-41 of Essentials of Complementary and Alternative Medicine for chart of licensing status of CAM professions by states Coursepack: Advising Patients Who Seek Alternative Medical Therapies, Eisenberg -- list of associations, journals, and more at the end of this article.

17. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources (NCCAOM) NATIONAL CERTIFICATION COMMISSION FOR ACUPUNCTURE AND ORIENTAL MEDICINE Code of Ethics (Revised May 2001) All practitioners certified by the National Certification Commission for Acupuncture and Oriental Medicine must be committed to responsible and ethical practice, to the growth of the profession’s role in the broad spectrum of American health care, and to their own professional growth. Candidates seeking certification agree to be bound by the NCCAOM Code of Ethics. Commitment to the Patient I will: 1. Respect the rights, dignity, and person of each patient. 2. Render to each patient the highest quality of care and make timely referrals to other Oriental medicine providers or health care professionals as may be appropriate. 3. Avoid treating patients when my judgment or competence is impaired by untreated chemical dependency or physical or mental incapacity reasonably believed to be hazardous to the safety of the patient. 4. Accept and treat all those seeking my services in a nondiscriminatory manner. 5. Keep accurate records of history and treatment and respect the confidentiality of those records or any other personal information imparted by the patient in accordance with law. 6. Keep the patient informed by explaining treatments and outcomes and avoid making promises with regard to outcomes that will create inappropriate expectations. 7. Follow the U.S. Department of Health and Human Services regulations regarding the protection of human subjects in research studies and clinical trials (45 CFR Part 46). 8. Follow U.S. Public Health Service Policy on Humane Care and Use of Laboratory Animals (Office for Protection from Research Risks, National Institutes of Health, Revised September 1986).

18. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources (NCCAOM) Commitment to the Profession I will: 1. Continue to work to raise the standards of the profession. 2. Use appropriate professional mechanisms to report ethical and professional practice violations. 3. Maintain the highest standard of ethical and professional practice to the benefit of my patients and the profession. Commitment to the Public I will: 1. Provide accurate information regarding my education, training, experience, professional affiliations, and certification status. 2. Refrain from making public statements on the efficacy of Oriental medicine that are not supported by the generally accepted experience of the profession. 3. Respect the integrity of other forms of health care and other medical traditions and seek to develop collaborative relationships to achieve the highest quality of care for individual patients. 4. Refrain from any representation that NCCAOM certification implies licensure or a right to practice unless so designated by the laws in the jurisdiction in which I practice. 5. Use only the appropriate professional designations for my credentials.

19. Legal, Professional and Ethical Issues in Complementary and Alternative Medicine Resources (NCCAOM) NATIONAL CERTIFICATION COMMISSION FOR ACUPUNCTURE AND ORIENTAL MEDICINE Grounds for Discipline (Revised May 2001) Unethical Behavior · Making false, misleading, or deceptive statements or providing false, misleading, or deceptive information in connection with an application for NCCAOM certification or recertification or attempting to obtain certification by deceptive or fraudulent means. · Misrepresenting one’s credentials (education, training, experience, level of competence, skills, and/or certification status). · Engaging in false, misleading, or deceptive advertising. · Obtaining or attempting to obtain compensation or reimbursement by fraud or deceit. · Being the subject of final disciplinary action or being convicted of a felony for a violation of any federal, state, or local statute, regulation, or ordinance that relates to the practice of acupuncture or Oriental medicine or another health care profession. · Having a license to practice acupuncture or Oriental medicine or another health care profession limited, suspended, or revoked in any state or jurisdiction of the United States or its territories and possessions. · Having a sexual relationship with or engaging in sexual misconduct with a current patient or with a former patient within six months of the time a professional relationship or treatment ended. · Cheating or attempting to cheat on NCCAOM examinations. · Otherwise violating the prevailing standards of the profession relating to the safe, ethical, proficient, and/or competent practice of acupuncture and Oriental medicine. Incompetence Engaging in conduct that evidences a lack of knowledge of, or lack of ability or failure to apply, the prevailing principles and/or skills of the profession for which the individual has been certified. Impairment Being unable to engage in the practice of acupuncture and/or Oriental medicine safely, proficiently, or competently as a result of substance abuse or physical or psychological impairment. “Impairment” includes, but is not limited to: · Engaging in the practice of acupuncture or Oriental medicine while one’s ability to practice is impaired by alcohol or other legal or illegal drugs. · Engaging in the practice of acupuncture or Oriental medicine while one’s ability to practice is impaired by a physical or mental condition or disease reasonably believed to be a hazard to the safety of patients.