Public outcry over the death of Ezekiel Stephan, the 19-month-old Alberta toddler who died of bacterial meningitis in 2012, continues to grow following last’s weeks court decision, which found both of his parents guilty of failing to provide the necessaries of life. David and Collet Stephan failed to seek appropriate medical care for their obviously-ill child, instead relying on a variety of vitamins, supplements, and remedies from the family’s own home business, Truehope Nutritional Support. While sentencing will not take place until later this year, David Stephan hasn’t hesitated to lash out with an open letter to the jury that suggests he remains unrepentant for the series of decisions that led to the death of his son:

I only wish that you could’ve seen how you were being played by the Crown’s deception, drama and trickery that not only led to our key witnesses being muzzled, but has also now led to a dangerous precedent being set in Canada.

The precedent referred by Stephan seems to his perceived “right” to prioritize his beliefs in what is demonstrable pseudoscience and quackery over the “right” for his child to receive appropriate medical care. Ezekiel had never seen a physician. He had received no vaccinations, including vaccination against Haemophilus influenza type b (Hib), a vaccine which protects against bacterial meningitis. And as he lay dying, the parents chose to use an Echinacea tincture recommended by a naturopath, Tracey Tannis, who never even examined Ezekiel. Given the involvement of Tannis in this tragedy, there are renewed questions about naturopathy in Canada, whether naturopaths are capable of self-regulation, and the standard of care they provide.

Accountability demanded from the College of Naturopathic Doctors of Alberta

In a letter signed by 43 medical doctors from across Canada, the CNDA has been asked to investigate Tracey Tannis, and provide a public accountability of the care the public should expect from naturopaths (emphasis in original):

By any objective measure of a healthcare professional licensed to care for children Dr. Tannis did not meet the standard of care. According to what has been given as evidence in the Stephan trial, Dr. Tannis did not physically examine Ezekiel, who was so stiff from meningeal inflammation that he could not sit in his car seat when his parents took him to the Lethbridge Naturopathic Medical Clinic. Dr. Tannis has stated that she did not communicate with Collet Stephan, yet two other people have given statements that Dr. Tannis did in fact discuss viral meningitis with Collet, and gave her echinacea anyway. At no point did Dr. Tannis advise Collet that a lumbar puncture (typically performed by an emergency orpediatric physician) is the only way to distinguish between viral and bacterial meningitis. It’s unclear if Dr. Tannis is aware that bacterial meningitis is fatal if not treated with antibiotics and can cause permanent brain damage if treatment is not initiated promptly.

Regardless of how much direct communication occurred between the Stephans and Dr. Tannis, they left the Lethbridge Naturopathic Medical Clinic with an echinacea tincture they felt had been recommended by a registered naturopath. Dr. Tannis has stated that she was aware a woman was in her clinic that day requesting a treatment for a child under the age of 2. She was involved in some way in the sale of this medication yet never examined the child it was intended for. It is up to the CNDA to determine to what degree Dr. Tannis engaged with the Stephans about their very sick toddler, and to what extent she was aware that they thought he had viral meningitis. She has stated in court that the Stephans simply purchased an over the counter herbal remedy, yet they chose to go to a naturopathic clinic to make this purchase. If patients are drawn to buying treatments from a clinic rather than a health food store it is because they have a greater sense of security in doing so. That security comes with an attendant responsibility on the part of the clinic.

The degree of responsibility that Dr. Tannis bears for the tragic outcome Ezekiel Stephan suffered is a matter for the CNDA to explore and publicly address.

The letter raises an important question. What is the standard of care for naturopathy? And should it be the same as for medical doctors, as these physicians argue? After all, naturopaths claim that they are primary care providers, just like medical doctors. From the Association of Accredited Naturopathic Medical Colleges:

Naturopathic physicians learn to treat all aspects of family health and wellness, from pediatrics to geriatrics. They tailor their therapies to meet the individual needs of each patient, factoring in physical, social, emotional and spiritual aspects before prescribing a course of treatment. Because they view natural remedies as complementary as well as primary, naturopathic physicians cooperate with other medical professionals, referring patients to allopathic medical doctors, surgeons and other specialists whenever appropriate.

What standard of care should be expected when treating children?

The physician’s letter raises an important question – did Tannis meet a “standard of care”? The letter goes on to describe what it believes constitutes that standard:

Albertans should expect that any regulated healthcare professional meeting the standard of care for treating children would have basic knowledge about meningitis. Albertans should also expect that any regulated health professional using the designation “Dr.” would not recommend a treatment for a child without first physically examining them in order to arrive at a diagnosis. If Dr. Tannis continues to practice as a registered naturopath, it is incumbent upon the CNDA to reassure Albertans that they have adequately investigated this case and are satisfied that her clinical judgment is sound.

What constitutes the medical “standard of care” is a legal term based in evaluations of malpractice. Malpractice cases evaluate whether a health professional was negligent or not. Negligence is determined by comparing the care provided, to the expected standard of care. The standard of care is what a reasonably competent health professional would do under the same circumstances. The standard of care does not mean perfect medical care, or even average care. It is usually established through the testimony of other health professionals – peer health professionals. Who decides on the standard of care for naturopaths? Given some states and provinces (like Alberta) have determined that naturopathy is a self-governing profession, it will be up to the CNDA to define the standard of care for naturopaths.

In a post on a white paper prepared by the Oregon Association of Naturopathic Physicians (and reviewed by our own Mark Crislip in 2012), the OANP made the following statement about practice standards:

There is no naturopathic-specific standard of care. Naturopathic doctors are taught and held to the same standards of care as conventional providers.

Britt Hermes, a former naturopath turned science advocate (and blogger at Science-Based medicine), disagrees, noting that naturopathic students may not receive any first-hand training with patients suffering from actual medical conditions:

I can guess why this naturopath did not perform a physical exam before she made a diagnosis and dispensed a substance. Naturopaths are trained to work through imaginary cases rather than practice on real patients. I know why the naturopath recommended an herbal preparation even for something as serious as meningitis. Naturopaths, more frequently than not, attempt to treat viral infections and other aggressive diseases with herbs. I often used echinacea for ear infections and colds on my former patients of any age. My former boss was using all sorts of “natural” substances on patients with terminal cancer.

In another post, Hermes points out that what naturopaths recommend goes far beyond anything that can be considered science-based or evidence-based medicine:

There are no naturopathic standards of care. Students and residents at Bastyr University have compiled documents explaining the diagnosis and treatments for a variety of diseases, which are available to students and faculty on the university’s online portal. A review of these documents reveals a large degree of untamed variability that is reflected in naturopathic medicine.

For example, the entry on angina includes a variety of treatment options: nutrient therapy with selenium, CoQ10, magnesium, and niacin; limiting fat intake; removing sucrose, alcohol and caffeine from the diet; botanical medicine in the form of doses of ginger, ginkgo biloba, aconite, and bromelain; at home exercises; recommendations to address a type A personality; a detoxification diet; colon hydrotherapy (i.e. enemas); castor oil packs; food allergy elimination; juice fasts; hormone replacement therapy; lifestyle changes; and monitoring of uric acid levels. Of the documents I’ve reviewed, all fail to mention any standard of care, which for some conditions, at a minimum should include an immediate referral to the emergency room or medical specialist. I know it sounds cynical, but naturopathic medical care is like picking treatments out of a magical hat.

Naturopaths reject a standard of care based on evidence

In the SBM naturopathy vs. science series of blog posts, the antagonism of naturopaths towards scientific evidence and reality has been well documented. One need only look at opinions from naturopaths on whooping cough, diabetes, autism, infertility, allergies, and vaccinations, to name a few. While naturopaths claim that they practice based on scientific principles, examinations of their literature, practices and statements suggest a more ambivalent attitude.

This is where naturopathy departs from health professionals like medicine and the allied health professions like nursing, pharmacy, dentistry and physiotherapy: all of those professionals are grounded in science and rely on evidence to guide the standard of care. Naturopathy is a philosophical belief system, and not a science, which picks and chooses what’s appropriately “naturopathic care” – not because of the scientific evidence, but despite the scientific evidence. As long as a practice is acceptably “naturopathic”, then it’s acceptable. After all if homeopathy is a “clinical science” in naturopathy, and is on the naturopathic certification examination, is there any likelihood that any practice, no matter how useless, would fail to meet the naturopathic standard?

Given there is a lack of objective evidence that determines what naturopaths offer, concerns have been raised about the naturopathic standard of care. A letter published in Allergy, Asthma, & Clinical Immunology documents the concerns about naturopathy in Canada and any naturopathic alignment to science-based methodologies. Timothy Caulfield and Christen Rachul found that the most widely advertised practices in Alberta and British Columbia lacked a sound evidence base. They concluded:

A review of the therapies advertised on the websites of clinics offering naturopathic treatments does not support the proposition that naturopathic medicine is a science and evidence-based practice.

Among the interventions promoted by naturopaths were homeopathy, chelation, acupuncture and hydrotherapy, none of which have any credible science to back them up.

Earlier this week, Carly Weeks at The Globe and Mail examined the practices of naturopaths in a manner similar to Caulfield and Rachul. Weeks noted that advertising standards state that advertisements must be “accurate, verifiable, comprehensible, professionally appropriate and in compliance with the standards of practice of the profession.” Her investigation reveals that when held to a scientific standard, naturopaths are routinely violating their own advertising standards:

I recently analyzed the websites of the naturopaths licensed to practice in Toronto. Of the roughly 300 regulated, active Toronto naturopaths with an online presence, nearly half appear to be in breach of the college’s rules based on claims made online. The promises are wide-ranging, from naturopaths describing their services as “cutting edge,” to those claiming they can reverse the course of dementia, to others who make blanket statements that naturopathy can help anyone with any ailment fully restore his or her health.

One Toronto naturopath, Mark Fontes, promotes himself online as an oncology expert who says naturopathic treatments can have a “significant impact” in cancer care and that in some cases, naturopathic medicine can “act as primary treatment” for cancer. He promotes remedies such as high doses of vitamin C, which he says can break cancer cells “from the inside out.” There is no solid evidence that this is true. The U.S. National Cancer Institute says some studies involving animals show high doses of vitamin C can slow the growth of cancer, while other studies show it makes cancer drugs less effective. Fontes did not respond to an interview request.

Naturopath Pat Nardini wrote a blog post on his site touting unproven homeopathic remedies for the prevention of flu – which is also breaking the rules – and reminding anyone feeling “pressure to get vaccinated” should be aware that “nature offers safe and effective options for the prevention and treatment of many seasonal infections, not just the flu.” The college’s policy on vaccinations states “there are no known alternatives to vaccinations … and a member should offer no alternative therapy.” Nardini declined an interview request.

Allison Freeman advertises breast thermography as a non-invasive, painless alternative to mammograms. Her website says thermography, which uses digital infrared imaging, can detect early breast changes “before the growth of a tumour.” Both Health Canada and the Canadian Cancer Society have issued public warnings about the ineffectiveness of breast thermography and note the machines aren’t authorized to detect cancer. After I contacted her, Freeman deleted references to thermography from her website. She said in an e-mail that she stopped offering the service to comply with the province’s new rules, but hadn’t had time to update her website in the past nine months.

The naturopathic profession bristles when anyone suggests that naturopathy should actually be based on scientific principles. The American Naturopathic Research Institute-Naturopathic Oncology Research Institute advocates the following (emphasis in original):

Standard of Care treatments as defined by the AANP shall not be construed as synonymous with evidence based treatments. Rather naturopathic physicians shall have the broadest latitude for treatment options as it is recognized that advances in medicine come from ideas and observations by the astute physician and are then validated by the scientific method.

In other words, naturopaths want the liberty to ignore evidence and make things up as they go, and hope the evidence emerges someday to validate what they are doing. Naturopaths maintain their own version of wikipedia, ndhealthfacts, with their own version of evidence. The entry on naturopathic research is telling:

There are many ways in which the scientific method is used and applied appropriately to naturopathic medicine, but there are also many ways in which this method is neither appropriate not applicable.

No standard of care for naturopathy

There is no naturopathic standard of care. Without “naturopathic medicine” being tethered to principles and practices that are scientific, then naturopathy will remain an “anything goes” profession – which is exactly what naturopaths seems to prefer. Held to their own non-standard, it’s not clear how a naturopath could ever be said to have failed to meet a “naturopathic standard of care”. The question that remains is whether or not naturopaths will be held to the same standards of care as medical doctors, given their claims that they are as capable of providing primary care just like medical doctors. Let’s hope there are no further tragedies like that of Ezekial Stephan that leave us continuing to ask this question.


Posted by Scott Gavura