The Ethics of Herbal Prescribing

While teaching ethics classes, I often encounter licensed acupuncturists who are surprised that our use of herbs and supplements has a specific section in the material. It is often an aspect within ethics that clinicians don't think of in practice. With that in mind, the focus of this article is about ethical considerations related to the herb and supplement side of our practices. My intent is to open up the topic, get you thinking ethically about things you might not have thought about, and to provide suggestions to help you analyze and continually improve your best practices related to products in your practice.

As is common with most topics within ethics, there is no nice, neat list of "do and don'ts." And while making ethical choices depends on each situation and is quite context based, the bottom line in ethics always comes back to the basic tenets: Put the patient first, do no harm and never compromise the safety of the patient.

Treat Within Your Knowledge

One of the most ethical decisions we make as clinicians is to treat within our knowledge base. If uncertain of how to treat a particular health challenge, we should be honest by letting the patient know, and then not treat them, or that condition. This is particularly true when working with herbs and nutritional supplements.

It is dismaying to me how many practitioners turn to social media when they encounter a condition they don't know how to address: "A patient with [blank] came into my office today. Does anyone out there have experience with this? What herbs should I use for this?" Not only is this a legally high-risk behavior – admitting that you don't know what something is, or how to treat it, and leaving a traceable trail that you don't know – it's also very questionable from an ethical point of view.

When using herbs and nutritional supplements, select formulas and dosages that match your level of training and knowledge, as well as your ability to monitor the patient and their progress moving forward. If you have high-level herbal training and experience, by all means, customize formulas and use the upper end of dosage ranges. If not, stick with pre-made products of formulas you learned in school and use conservative dosages.

Another simple suggestion is to refer out when you encounter a case outside of your knowledge base. Refer to a licensed colleague who has the appropriate type and depth of knowledge for the case. This sounds like common sense; however, I hear of countless situations where clinicians have gotten in to trouble when not referring out. Especially when dealing with trending health concerns like vitamin D supplementation. Don't jump on a bandwagon of prescribing beyond your knowledge base just because it's the latest trend.

Scope of Practice

Along with treating within your knowledge base, I cannot stress enough how important it is to practice within your state license and scope of practice. This is where ethics and the law overlap. Professional organizations, such as the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), utilize codes of ethics to set standards and guidelines for conduct and appropriateness in the industry. Government entities utilize laws and regulations for the very same reason and it is common to see identical or near identical phrases and terminology.

I am frequently asked if it is ethical to go ahead and provide a specific learned treatment that is outside the scope of one's state license. It is my experience that this question usually relates to recommending and prescribing herbs and supplements. Let me be clear: It is not ethical, nor legal, to practice beyond the scope of your state license in any circumstance. The NCCAOM Code of Ethics specifically states, "Treat only within my lawful scope of practice." If you are a NCCAOM certified practitioner, you have committed to this and are expected to adhere to it.

Be Careful of Financial Incentives

When we prescribe products, which one(s) should always be driven by the patient's need, not by a need to increase revenue. Patients come to us because they are in need, sometimes even desperate. Because we are the health care expert they trust us, and trust should not be exploited. This is why mainstream medicine separated out sales of products from medical practices many years ago.

It is a fine line to walk because, as a business owner, you have every right to re-coup overhead costs for having and managing product inventory. However, when price mark-ups exceed a certain point, the temptation of potential financial gains to influence prescribing decisions is possible. While presenting numerous ethics and practice management courses to licensees, I am fascinated that a surprising number of acupuncture and Oriental Medicine clinicians have chosen to only have a small inventory on hand and predominantly send products directly to the patient without a mark-up.

Likewise, using multi-level marketed products can be particularly troublesome for clinicians to sell. This sales model is known for an intense focus on high pressure sales methods, expectations of sold quantities, and persuading more people to sell items for you. I do not recommend using products with this type of model because there's a very good chance that financial incentive could begin take precedence over what is actually best for the patient.

Know Your Suppliers

It is my observation that too many in our profession know too little about the products they use, particularly the attributes that most affect quality, purity and safety. Not only does this represent significant safety vulnerability, it has an ethical component. When patients come to us for help, they assume we know and understand the herbs and supplements we recommend and dispense.

Yet, how much do you know about your suppliers? Are you making informed and ethical decisions when it comes to selecting your suppliers? Ask yourself if you know the answers to these questions: What are their ethics? How focused are they on quality control? Proper species identification? Cleanliness? Testing? Consistency? Being sticklers for perfection? Honesty? How much do they give back to the Oriental Medicine community?

Invest your time and give due diligence by really studying your herb and supplement suppliers to answer these questions. Learn about good manufacturing practices (GMPs) set by the Food and Drug Administration (FDA) for dietary supplement manufacturers, so you can understand how compliant they are with the FDA's GMPs. This is great for your business and safety reputation, and shows your practice reflects a high level of ethics.

I suggest you look for brands that truly go above and beyond to provide safe, pure and ethical products. Look for brands that are open about their manufacturing practices and those that can tell you how they source ingredients. When possible tour the company's plant and see for yourself what manufacturing practices are adhered to. When you attend a conference, take time to visit their booths and meet company representatives in person. As you talk with them, ask pointed and specific questions regarding their product quality control methods.

Remember, as licensed acupuncturists we are considered the experts in guiding patients to a healthier lifestyle. Therefore we have a responsibility to be moral and ethical when we prescribe herbs and supplements, and as stated before, to always put the patient first, to do no harm and to never compromise the safety of the patient.