The regulation of complementary and alternative medicine professions in Ontario, Canada

Abstract

Background

This paper explains the regulation of complementary and alternative medicine (CAM) health professions, through the comparison of four distinct examples in Ontario, Canada including: chiropractors, naturopaths, homeopaths, and traditional Chinese medicine (TCM) practitioners.

Methods

This study analyzes the agenda setting and formulation stage of the policy process. In other words, it explores what happened between stakeholders before each of these CAM professions achieved regulation. Alford’s model of dominant, challenging and repressed structured interests (DSIs, CSIs, and RSIs respectively) is used to describe the competition between various players within the healthcare system and their position in the health policy process.

Results

All four CAM professions have existed as a RSI at some point in their history, however, over the last century has sought to align themselves with various (or even become) challenging structural interests (CSIs) in order to be recognized as a regulated health profession. Dominant structural interests (DSIs), particularly the medical profession, initially largely ignored these professions’ practices, unless sufficient public support of CAM practitioners’ therapies warranted them to consider the need to regulate them.

Conclusion

Unregulated CAM professions may increase their likelihood of becoming regulated if they: (1) gain popularity/strong support from patients or the general public, (2) organize themselves sufficiently that they pose a direct threat to one or more scopes of practice desirable by the DSIs and/or (3) are willing to adopt standards in education, training, and ethics that may [initially] reduce their scope of practice or profession’s membership or slow their profession’s growth.

1. Introduction

Stemming from an influential report written by American science administrator and politician Abraham Flexner in 1910, medical practitioners and their therapies were subsequently categorized as legitimate and “scientific” or illegitimate and “unscientific”, in reference to the body of scientific knowledge at that time.¹ To Flexner, practitioners such as naturopaths, homeopaths, chiropractors, and osteopaths were “unscientific” healthcare practitioners, who were actively competing with the scientific paradigm of research and education represented at North American universities of the time.² Throughout the 20th century and even today, many of these professions still remain outside the purview of conventional medicine, and are categorized as complementary and alternative medicine (CAM) practitioners.²

One of the ways in which CAM professions have sought legitimization is through state regulation. The province of Ontario, Canada serves as a particularly interesting example as it has regulated numerous CAM professions since the publication of the Flexner report, including many that Flexner himself perceived as “unscientific”.

This paper explores the trajectory of CAM profession regulation in Ontario, using four distinct CAM professions including: chiropractors, naturopaths, homeopaths, and traditional Chinese medicine (TCM) practitioners. These four were specifically selected because of the opportunity to compare those regulated long ago with those regulated more recently. Two were regulated nearly 100 years ago (naturopathy and chiropractic both in 1925, under the Drugless Practitioners Act (DPA)),³ and two were regulated less than 7 years ago (TCM practitioners in 2013 and homeopathy in 2015, both under the Regulated Health Professions Act (RHPA)).4, 5, 6, 7, 8 It should be noted that homeopathy was initially regulated in 1869 before being deregulated after being removed from the Ontario Medical Act in 1970.9, 10 Furthermore, chiropractors and naturopaths continue to be regulated, however, now under the RHPA.4, 11, 12, 13, 14 Discussions surrounding these events are largely beyond the scope of this paper, and instead the focus is an analysis of events leading up to the first instance whereby a profession was regulated and remains regulated to present day.

The regulation of a healthcare profession serves to provide health services to the public in a safe, professional, and ethical manner. In Ontario, the legislative framework, known as the RHPA, establishes regulatory colleges which regulates healthcare professions in the interest of the public.¹⁵ The Health Professions Regulatory Advisory Council (HPRAC) is established under the RHPA to advise the Minister of Health and Long-Term Care on regulatory matters in Ontario. This includes whether unregulated health professions should be regulated and vice versa.¹⁶ The decision for a given jurisdiction to regulate any given healthcare profession is often complicated and time-consuming,¹⁷ however, regulating a CAM profession is especially difficult, as stakeholders from the biomedical and CAM sides often do not define evidence, or even safety, in the same way.¹⁸ As CAM practitioners and therapies exist in virtually every jurisdiction in the world,¹⁹ the trajectory leading up to a CAM profession’s regulation in Ontario, the way in which Ontario has regulated various CAM professions, and the consequences of the decision to regulate (or not regulate), can all provide valuable lessons to policy makers seeking to regulate CAM professions existing in their own jurisdictions.

Specific to practitioners of chiropractic, naturopathy, homeopathy, and TCM, the research question is “How can the regulation of complementary and alternative medicine professions be explained in the Province of Ontario?” This purpose of this study is to present a health policy analysis (HPA) of the regulation of four CAM professions in Ontario, Canada, by analyzing the agenda setting and formulation stage of the policy process (i.e. what happened between stakeholders before each of these CAM professions achieved regulation?).

2. Methods

The present study utilizes a HPA methodology. HPA is defined as “a multi-disciplinary approach to public policy that aims to explain the interaction between institutions, interests and ideas in the policy process”, and is conducted to better understand past policy failures and successes, in addition to planning the implementation of future policies.²⁰ This study adopts one of the most well-known and widely accepted policy frameworks known as the “stages heuristic”, which divides the policy process into four stages as follows: agenda setting, formulation, implementation, and evaluation.21, 22 Described briefly, the agenda setting stage involves sorting issues, whereby a small subset of a large number of societal problems will capture the greatest amount of attention of decision-makers. The formulation stage involves legislatures and other bodies tasked with decision-making to design and establish policies to address these problems. The implementation stage involves governments carrying out these established policies, and finally the evaluation stage involves assessing the impact of having carried out these policies. This study focusses on the agenda setting and formulation stage of the policy process surrounding the regulation of CAM progressions, and is informed by Alford’s model of structured interests.

Alford’s model of structured interests is used to describe the competition that takes place between various players within the healthcare system and their position in the health policy process.²³ He describes the concept of dominant, challenging, and repressed structural interests, which are applied in this paper to explain the regulation of four select CAM professions in Ontario. Dominant structural interests (DSIs) contain “professional monopolizers”, which over approximately the last 100 years represent conventional practitioners and biomedical researchers, most notably the profession of medicine. They are described as controlling major health resources, and benefit from the existing social, economic, and political structure of institutions. Alford describes politicians, hospital administrators, and government health planners as challenging structural interests (CSIs), in other words, “corporate rationalizers” challenging DSIs with the aim of improving the provision of health services. Lastly, repressed structural interests (RSIs) exist in “community populations”.²³ All CAM professions, at some point, have existed as a RSI, however, over the last century each of the four CAM professions, albeit during different time periods, have sought to align themselves with various, or become, CSIs in order to be recognized as a regulated health profession.18, 24, 25, 26, 27 It should be noted that the three components comprising Alford’s theory of structured interests (i.e. dominant, challenging, and repressed) should not be used to define a profession’s existence absent of situational context. Instead, Alford’s theory serves to explain these relationships between and among members of both conventional and CAM professions at different stages over the period of time when each of the four aforementioned CAM professions sought and achieved professional regulation in Ontario.

2.1. Evidentiary sources

This paper draws on the peer-reviewed literature detailing the history and/or regulatory structure of the four CAM professions, government acts under which these aforementioned professions are governed in the Province of Ontario, documents from HPRAC, as well as information freely available from websites of the four Ontario health profession associations and regulatory colleges. An initial literature search for peer-reviewed articles was conducted on PubMed, which included the terms “chiropractic”, “naturopathy”, “homeopathy” and “traditional Chinese medicine” each combined with the term “regulation”. Given that many of the documents included in this analysis would not be found using standard systematic search strategies, combined with the fact that the author is fairly knowledgeable about this subject area, it was decided that this study would instead involve a targeted literature review. The full-texts of articles that discussed the regulation of any of the four aforementioned CAM professions were reviewed, in addition to any relevant articles found in their reference lists, which yielded other peer-reviewed literature, but also government documents and websites. To maximize the comprehensiveness of the targeted literature review, the author also visited the websites of the four CAM professions’ colleges or associations for both Canada and Province of Ontario, and contacted authors of documents in the event that clarification or additional resources were warranted.

3. Results and discussion

3.1. Chiropractic, naturopathy and the drugless practitioners act

Daniel Palmer opened the first school of chiropractic in Iowa in 1897 and is regarded as the founder of chiropractic.²⁵ Around the same time, Benedict Lust, largely considered to be the founder of naturopathy in North America, founded the first school of naturopathy in New York in 1902.²⁸ The histories of chiropractic and naturopathy are largely intertwined, as both health systems arrived in Ontario around the same time, in many regards both groups faced similar criticisms,²⁴ and both ultimately became regulated under the DPA in 1925.3, 24, 25

Graduates of Palmer’s chiropractic school had already formed different points of view on how chiropractic should be practiced and taught, leading to divisions in the profession. Chiropractors of the time were largely divided into two groups: “straights” who advocated for solely providing care in the form of spinal manipulation, and “mixers” who believed that chiropractors should also diagnose diseases and use adjunctive therapies in their practice, such as vitamins and electrotherapies.²⁵ Starting in 1910, the term “drugless practitioner” was used in reference to healthcare providers who treated patients without medicine or drugs.²⁵

In 1914, World War I played a key role in the history of the Canadian chiropractic profession. The Hodgins Commission was tasked with reporting on medical education in 1915.25, 29 By the time the Commission began its hearings, it had become aware that a large number of injured soldiers were not receiving help from conventional medical and surgical treatments, and had instead received benefit from chiropractic treatment. Commissioner Hodgins reviewed many reports, and identified many chiropractic practices such as “bonesetting” and “manipulation” to be of great importance to the public.³⁰

In 1915, a Drugless Physicians Association was formed in London, Ontario. Its initial membership of approximately 40 were comprised of those trained as chiropractic “mixers”, who combined chiropractic with osteopathy, electrotherapy, and naturopathy. In contrast, “straight” chiropractors formed separate organizations around the same time.²⁴ Historians date naturopathy as having first established itself in Ontario in 1916, yet the term “naturopathy” itself was not widely used until the 1920s.²⁸

Given the widespread support of both chiropractic and naturopathy by the general public despite the divisions that existed both between and within professions in regards to education and practice, both types of practitioners were relatively well-established in a few provinces in Canada, including Ontario.²⁵ This public support concerned the Ontario Medical Association (OMA) which first released its viewpoint regarding chiropractic in 1921. In their report, they expressed that chiropractic should be “given no consideration in law” and that it is founded on “a complete negation of all medical science and progress”.³¹ Public support for chiropractic, among other drugless practitioners, was so great in fact, that following consultations with the OMA, the College of Physicians and Surgeons asked the Government to establish the DPA of Ontario in 1924. This act ultimately became law in 1925,²⁷ however, it was designed to limit the practice of these drugless practitioners and prevent them from using the title of “doctor”.²⁵ The College of Physicians and Surgeons stated that if the public accepted care from those with “inferior qualifications, [they] would only have [themselves] to blame”, however, they would at least be able to distinguish a medical doctor from a drugless practitioner.³²

3.2. Applying Alford: the regulation of two CAM professions nearly 100 years ago

Stemming from the Flexner report effectively establishing legitimate “scientific” medicine (or what was thought to be at the time), all practitioners adhering to it were considered a DSI. At the time, Flexner viewed only science-based medical schools to be legitimate, and this greatly impacted practitioners of chiropractic and naturopathy after 1910.¹ Applying Alford’s theory, the years that followed served to group Flexner’s preferred medical practitioners as the DSIs. All schools – including chiropractic and naturopathic – who did not or were unable to meet Flexner’s standards were RSIs, and in many cases, many of these schools were forced to close their doors permanently.¹ Despite this, one of the key hallmarks assisting the naturopathy, and especially, the chiropractic professions, was support from the public, as both professions strategically aligned themselves with CSIs.24, 25 The chiropractic profession, in particular, took advantage of their European colleagues’ ability to help injured soldiers and ensured that this message was conveyed to Commissioner Hodgins in 1915³⁰ – someone outside of the medical profession but nonetheless highly influential. Medical officers in military hospitals, including Robert Tait McKenzie, were following the advice of Sir William Osler – a well-known Canadian physician – to learn these chiropractic treatments, as many of the injured were not benefiting from the conventional medical and surgical treatments of the time. Furthermore, because many patients believed that they were benefitting from drugless therapies, perhaps even preferring them over drug therapies, this provided both professions with the popularity and backing of the public they needed to attract the attention and consideration from CSIs with the power to influence how the CAM professions were perceived.

The fact that the OMA sought to repress the chiropractic profession is one of the clearest examples of a group (i.e. the medical profession) being reluctant to yield rights and privileges that they have already exercised, an idea which Alford attributes to medical sociologist David Mechanic.²³ In 1921, the OMA stated that chiropractic should not be given any consideration in law, however, their strategy clearly changed in 1924, given that the demand for drugless practitioners and their therapies was so great, that the OMA later sought to use their regulation as a tool to impose as many limits on their practice as possible as opposed to give them no consideration in law as they had originally stated. In line with Alford’s theory, had these professions not been supported by the public, the medical profession would not have had to organize and act to defend their interests; the Flexner Report and the governmental regulations that implemented the report’s suggestions largely retained medicine as the DSI.

3.3. Traditional Chinese medicine, homeopathy and the regulated health professions act

Homeopathy was founded by Samuel Hahnemann in 1796 in Germany, and has since expanded internationally.³³ Of all of the four CAM professions discussed in this paper, homeopathy was the first to be regulated in Ontario in 1869 under the Ontario Medical Act.9, 34 After three years of consultations, this act integrated “regular” physicians, homeopaths and eclectics in a provincial body, the College of Physicians and Surgeons of Ontario (CPSO),³¹ yet information about why this decision was made is virtually non-existent. The last homeopathic CPSO representative served from 1956 until 1960, after which the Ontario Medical Act was amended to exclude homeopathy in 1970.9, 34 Homeopathy was thus unregulated once again in Ontario until it was re-regulated under the RHPA in 2015.⁴

In contrast, TCM is based on a much longer history of 2500 years of medical practice in China³⁵ compared to the other three CAM professions. Discussion surrounding the desire to regulate TCM practitioners in Ontario, however, began much later than the others, in the 1980s. It took TCM practitioners approximately 30 years to achieve professional regulation in 2013.26, 36 In 1995, the Ontario government received requests from the Chinese Medicine and Acupuncture Association of Canada, the Ontario naturopathic profession, and a provincial coalition of acupuncture-practising biomedical health professionals, to regulate a new TCM profession specifically regarding regulating the procedure of acupuncture.36, 37 In order to determine whether it was warranted to regulate acupuncture, the HPRAC studied these requests, and sought to characterize acupuncture’s risk profile by appealing to various stakeholders which included: medical doctors; Chinese medicine practitioners; naturopaths; chiropractors; nurses; and physiotherapists.36, 37 While the stakeholders generally agreed that acupuncture was sufficiently unsafe to warrant some type of regulation, acupuncture and the TCM profession remained unregulated for so long because the Ontario government, despite the recommendations of HRPAC, determined that acupuncture was not “inherently dangerous” and was therefore not of high enough risk to warrant regulation.³⁷

Interest was renewed to evaluate the regulation of acupuncture in 2001, and the same council re-examined this issue, albeit comprised of some different members. The idea of safety associated with the procedure was again central to the stakeholders’ discussion, however, how each group made reference to risk was different this time.³⁸ TCM practitioners argued that in order to prevent patients from potentially suffering ill side effects, the regulation of acupuncture should be based on the premise that those who practice it have training in TCM, because it belongs to the traditional Chinese system of medicine. Physiotherapists and podiatrists, among other “conventional” practitioner groups, however, claimed that acupuncture should be regulated based on the procedure itself posing a risk to the public if a practitioner is ill trained, arguing that acupuncture falls within the scope of their respective practices, while divorcing acupuncture from TCM knowledge.³⁸ The HPRAC, ultimately concluded in favour of the “conventional” practitioners describing that the safe practice of acupuncture was irrelevant to a practitioner’s knowledge of TCM.³⁸

In 2006, the College of Traditional Chinese Practitioners and Acupuncturists was established based on the creation of the Traditional Chinese Medicine Act, allowing the TCM profession self-regulatory status.⁵ Ontario formally regulated the TCM profession under the RHPA in 2013.⁴ Beyond TCM practitioners, medical doctors, dentists, naturopaths, and nurses, all of whom were recommended to practice acupuncture in the 2001 HPRAC report, were granted permission;³⁸ chiropractors, physiotherapists, occupational therapists, massage therapists and chiropodists were also authorized. Interestingly, the education and training required for each profession’s members differs greatly. While medical doctors, dentists and nurses have no standards by which to abide, the TCM profession is required to adhere to the most rigorous standards of all professions permitted to practice acupuncture, with all other included professions’ standards falling somewhere in between.³⁶

Little information is publicly available about homeopathy over the three decades during which the TCM profession sought to be regulated. Only the Homeopathic College of Canada (HCC) provides a brief history of the profession’s trajectory to re-regulation, though there is no mention that this information has been peer-reviewed (or even reviewed). The website states that from 1992 to 1995, the president of the HCC supported efforts to re-regulate the profession, submitting an official document to the Ontario government in 1999, and re-submitting it in 2005.²⁶ Given that homeopathy was unregulated since having been removed from the Ontario Medical Act in 1970, it is explained in the article that not only the government and the medical profession were initially against the idea of the profession’s regulation, but even other homeopaths opposed this idea.²⁶ As divisions in ethics and standards had been created during this period of unregulation, many homeopaths feared that they would not be able to meet the standards proposed if the profession was re-regulated, and thus lose their ability to practice.³⁹ Virtually no information is available in regards to the interactions between these divided groups leading up to regulation, however the Homeopathy Act was created in 2007.⁷ In 2010, the Ontario government established the Transitional Council of the College of Homeopaths of Ontario,⁴⁰ and formally regulated the profession under the RHPA in 2015.⁴

3.4. Applying Alford: the regulation of two CAM professions in modern day

Some parallels can be drawn between the drugless practitioners regulated in the 1920s and homeopathy and TCM practitioners in modern day, most notably that all started out as RSIs. Initially, both TCM practitioners and homeopaths (following their removal from the Ontario Medical Act in 1970), were largely of little interest to other social institutions, and their practices were largely outside of the purview of the medical profession.26, 27 In the more recent years leading up to their regulation and re-regulation in 2013 and 2015 respectively, however, it could be argued that both groups aligned themselves with or became CSIs, evidenced by the fact that both groups’ leaders spearheaded campaigns to have their respective professions recognized by the province by submitting reports to the Ontario government in order to request that their profession be regulated.26, 27

In contrast to the drugless practitioners of the 1920s whose regulation was initiated by the DSIs, however, in the case of both homeopaths and TCM practitioners, the goal to achieve regulation was self-initiated. This is arguably because DSIs, beyond just the medical profession, saw no need to initially restrict the scope of these two professions as they did with the drugless practitioners. While some public support surely existed for both TCM practitioners and homeopaths,18, 41 this level of support was not nearly as high as it was for the drugless practitioners in the early 1900s.24, 25 In fact, the government and medical profession initially largely ignored both professions’ requests to be regulated.26, 27 Furthermore, the histories of both homeopathy and TCM practitioner professions is filled with much infighting, likely because both groups remained unregulated for multiple decades, fostering the creation of divides within the professions themselves,26, 42, 43 similar to chiropractic “straights” and “mixers” prior to being regulated in 1925. This presents an exceptional challenge for unregulated RSIs, as they need to find a way to be united, not only in their standards of education, practice and ethics, but also in their desire to become a regulated health profession. In both professions’ cases, this meant that some individual members (or even intraprofessional groups) needed to be divorced from the group spearheading their alignment with the CSIs to gain regulation for the overall profession.

In reference to the second half of Mechanic’s quote in Alford’s article, this is an excellent example of the DSIs “resist[ing] significant restructuring unless it appears that there is something in it for them”.²³ In this case, the medical and allied healthcare professions argued that acupuncture should be regulated in such a way that its safety and efficacy is divorced from that of its history in TCM, thus allowing them to also assume acupuncture, now as an authorized act, into their scope of practice, as well as assert that the regulation of acupuncture does not necessarily validate TCM training experience thereby allowing themselves to evade standards associated with training and education in acupuncture.³⁸ While little is mentioned as to why homeopathy practitioners’ requests to be regulated were seemingly straightforward, one can hypothesize that unlike the DSIs’ desire to adopt acupuncture into their own scope of practice, homeopaths offered practices or procedures that were of little interest to them. In the case of both professions, it can be hypothesized that the DSIs may have also agreed to their regulation based on their knowledge of both professions’ long histories of infighting. It could be predicted that regulation would thereby further limit their scopes of practices (as what has been historically observed in chiropractic limiting their scope to the spine in modern day⁴⁴), reduce membership within the professions, and slow the professions’ growths.⁴⁴

4. Implications and conclusion

Analysis of the trajectories of four independent CAM professions in Ontario using Alford’s model of structured interests has reinforced the idea that regulation is a double-edged sword. Visible advantages exist for DSIs in advocating for (or leaving) a RSI to remain unregulated, as this often fosters intraprofessional divides, however, these advantages diminish once an unregulated profession can be characterized by a number of factors. While exceptions certainly exist, this analysis would suggest that beyond time and financial resources, unregulated CAM professions may increase their likelihood of becoming regulated if they: (1) gain popularity and strong support from patients and/or the general public (i.e. chiropractic and naturopathy), (2) organize themselves sufficiently that they pose a direct threat to one or more scopes of practice desirable by the DSIs (i.e. acupuncture for TCM practitioners) and/or (3) are willing to adopt standards in education, training, and ethics that may [initially] reduce their scope of practice and/or profession’s membership or slow their profession’s growth (i.e. all four CAM professions). Furthermore, regulation typically also comes at the cost to the previously unregulated profession of having to align itself with the DSIs. This is made clearest by TCM practitioners being regulated under the condition that the safe and effective procedure of acupuncture is divorced from its roots in TCM knowledge itself!38, 46 While beyond the scope of this paper, both the chiropractic and naturopathic professions also made compromises in order to advance their professions in the time between their initial regulation in 1925 and present day, with the most obvious example being their commitment to offering therapies that are based on evidence-based medicine and biomedical research.47, 48 All else considered, becoming regulated can also serve as an unregulated profession’s first step in gaining the opportunity to work with or become CSIs to legitimize the therapies they offer as well as gain greater public trust. At the very least, regulation can increase the likelihood of DSIs acknowledging a profession, and eventually provide them with the means to obtaining [partial] acceptance to work alongside them.

Author Contribution

This is sole author's work.

Conflict of Interest

The author declares no conflict of interest.

Funding

No funding was received for this study.

Ethical Statement

This study involved the analysis of peer-reviewed literature and publically available documents and websites only; it did not require ethics approval or consent.

Data availability

All data associated with this study is included within this article.