Alternative treatment and grey areas



    Links are made in the media these days between alternative treatment and various health-related activities such as shamanism, aesthetic medicine and health blogging, which have widely differing responsibilities, duties and rights. What does the term alternative treatment mean?

    The National Research Center in Complementary and Alternative Medicine (NAFKAM) at the Department of Community Medicine, UiT The Arctic University of Norway, has the mission to develop knowledge about how alternative treatment can help with health problems and illness in the Norwegian population (1). In this 'Perspectives' article, we would like to help improve understanding of what is considered alternative treatment.

    What helps to define alternative treatment?

    What helps to define alternative treatment?

    The purpose of the Norwegian Act on Alternative Treatment of Disease (The Alternative Treatment Act) is to contribute to patient safety and to regulate the right to practise such treatment. The Act defines alternative treatment as follows: 'Alternative treatment is understood to mean health-related treatment which is practised outside the established health services and which is not practised by authorised health personnel. However, treatment practised within the scope of the established health services or by authorised health personnel is also covered by the term alternative treatment when the methods used are essentially methods that are used outside the established health services.' (2).

    The health authorities have expressed to NAFKAM that it is difficult to make a general statement on what alternative treatment is, and that it must be assessed on a case-by-case basis. The individual practitioner's view on whether the Act applies to their activity is not the deciding factor.

    The Norwegian Consumer Authority oversees compliance with the marketing regulations for alternative treatment. The definition it gives for alternative treatment is wide and also includes alternative treatment and services without physical contact between the practitioner and patient, for example, remote healing. Similarly, it also considers the use of alternative medical tests, devices and other tools to be alternative treatment (3).

    Both in its own role and as a dialogue partner for the authorities, NAFKAM meets parties wishing to define themselves outside the scope of the Alternative Treatment Act and thus be exempt from the responsibilities and duties that the Act imposes on practitioners.

    Approximately 80 % of the known alternative practitioner associations participate in the registration scheme, the Norwegian Register of Complementary Practitioners (4). Although listing in the practitioner register is voluntary, many practitioners have chosen to register themselves and their business.

    Until recently, an advantage of being listed in the register was exemption from VAT on services offered. Since the exemption from VAT ended in 2021, the number of registered practitioners has fallen by as much as 34 % in one year (1). The mass deregistration has made the register less useful in defining what can be considered to be alternative treatment in Norway.

    In the scientific literature, alternative treatment is divided into categories (5, 6) (Table 1), which can assist in clarifying what activities can be considered to be alternative treatment.

    Table 1

    Categorisation of alternative treatment in the scientific literature.




    Alternative medical systems

    Medical systems with their own theories about what disease is, causes of disease and treatment

    Anthroposophic medicine, Ayurveda, homeopathy, naturopathy, traditional Chinese medicine

    Body-based and physical therapies

    Therapies that treat various conditions through physical contact, stimulation and touch or manipulation of the body

    Atlas therapy, reflexology, cupping, massage, medical (western) acupuncture

    Mind-body therapies

    Forms of therapy based on the belief that our thoughts and mind can affect the body, bodily function and physical health

    Relaxation techniques, prayer, hypnosis, art therapy, meditation, music therapy, mindfulness, visualisation, yoga

    Biologically based therapies

    Substances that are intended to have an effect on the body and bodily functions to achieve better health

    Aromatherapy, dietary supplements, minerals, natural remedies, natural products, herbs, vitamins

    Energy therapies

    Based on the belief that the body has an energy system, and treatments consist of opening blockages and strengthening energy where it is weak

    Healing, Chinese (eastern) acupuncture, tai chi, qigong

    The categories illustrate different fundamental approaches to disease within alternative treatment. Some techniques are not too far removed from a medical framework of understanding. Medical (western) acupuncture is one example of an alternative treatment where the effect can be explained by western medical knowledge. Other forms of alternative treatment, for example Chinese (eastern) acupuncture, are based on energy pathways and meridians, for which western medicine has no frame of reference.

    The boundaries between alternative treatment and activities that often have aims other than health-related treatment are indistinct. There is a relatively large difference between yoga practised at home for one's own well-being and yoga practised with an instructor for health-related purposes in return for payment. These boundaries can be challenging for both patients and practitioners to assess (Figure 1).

    Figure 1 Alternative treatment has grey areas at the boundaries with several services and offerings. Contact with the health…
    Figure 1 Alternative treatment has grey areas at the boundaries with several services and offerings. Contact with the health service takes place when healthcare professionals within the primary care service, specialist health service or dental service use alternative treatment as part of the service provision within integrative treatment. Adjunctive medical treatment, for example vitamins, dietary supplements and dietary/lifestyle advice, could cross over to become alternative treatment when it is not used on a doctor's advice or not in accordance with the package leaflet. Self-help and self-treatment would be considered alternative treatment when offered for health-related purposes outside the health service. When practitioners of folk medicine offer health-promoting services with a clear patient-practitioner relationship, this would be considered to be alternative treatment. Service offerings involving well-being, beauty care, education and religious activities have not traditionally been regarded as health-related and, therefore, not considered to be treatment, but recently this interpretation has been challenged, including through 'aesthetic medicine'. Source: (1).
    Integrative treatment

    Integrative treatment

    The American doctor Andrew Weil is considered to be the founder of integrative treatment, in which licensed healthcare professionals offer alternative methods in combination with medical treatment. Integrative treatment is particularly well-established in the United States and UK.

    In Norway, the term has been used sporadically, and not all practitioners offering these services use the term. Examples of health-related services that can be described as integrative treatment might be needle treatment within physical medicine and acupuncture at pain clinics and in obstetrics.

    The mass deregistration has made the Norwegian Register of Complementary Practitioners less useful in defining what can be considered to be alternative treatment in Norway

    However, integrative treatment does not represent anything particularly new in the alternative treatment debate, since the methods offered by the healthcare professionals are still considered to be alternative treatment even if given in combination with evidence-based medicine. When healthcare professionals offer alternative treatment, they are still subject to the Norwegian Healthcare Professional Act regardless of whether the therapy is offered within or outside the health service.

    Adjunctive medical treatment

    Adjunctive medical treatment

    Adjunctive medical treatment can include, for example, dietary supplements and vitamins. Many of these products are supplied by pharmacies and health-food chains. Some of the dietary supplements are classified as foodstuffs and come under the administrative responsibility of the Norwegian Food Safety Authority (7). The use of dietary supplements and other products on a doctor's advice and in accordance with the package leaflet is not regarded as alternative treatment.

    However, it is not much of a stretch from widely accepted and scientifically well-founded advice to a more alternative lifestyle and alternative treatment, for example the blood type diet and alternative diet or alternative lifestyle as a cure for cancer.

    Natural remedies are a slightly more specialised form of adjunctive medical treatment. These undergo approval by the Norwegian Medicines Agency, but have less extensive requirements regarding the documentation of safety and efficacy than medicinal products (8). To be approved, there must be documented traditional use of the natural remedy's active ingredients for at least 15 years within the EEA or 30 years worldwide for the current area of use. These natural remedies are occasionally used within the health service, but are far more frequently recommended by alternative practitioners and, therefore, in practice should be considered to be alternative treatment.

    In contrast to natural remedies, natural products are not subject to medical evaluation and have no formal approval. Examples of natural products are herbs, bacteria (probiotics), plant extracts and raw materials from the plant, mineral and animal kingdom. Natural products clearly come under alternative treatment according to the Alternative Treatment Act. Some natural products, for example for digestive complaints such as motility disorders and constipation, are also used as adjunctive medical treatment.

    Exercise and physical activity result in positive effects on health, can increase quality of life and are part of adjunctive medical treatment. However, if more specialised variations of physical activity are offered outside the health service for health-related purposes by an instructor in a commercial context, they may come under the definition of alternative treatment in the Act. Examples of these can be found in traditional Chinese medicine, such as tai chi, medical yoga and qigong.

    In general, when adjunctive medical treatment is used in excess of the recommended dosage or outside the medical indication, and largely outside the health service, NAFKAM considers this to be alternative treatment according to the Alternative Treatment Act.

    Self-help techniques

    Self-help techniques

    A considerable proportion of the Norwegian population use alternative self-help techniques for health purposes. This use also seems to have increased during the pandemic and lockdown (9). As implied by the term, the methods and techniques are used by the patient on their own and without supervision by a professional. NAFKAM considers courses in self-treatment and self-help techniques and guidance from an instructor to be alternative treatment.

    Meditation, yoga and mindfulness are examples of techniques used by many people outside of a medical setting, which are also used to improve performance in business and elite sports. Although a considerable proportion of the users are healthy, these may still be health-related activities that are associated with relaxation and enhanced physical and mental well-being and health. The threshold at which these activities become treatment with health-promoting purposes is unclear.

    Another grey area for self-help is web-based alternative treatment. This varies widely, from dialogue, psychotherapy, health coaching and lifestyle guidance to healing, guided meditation and homeopathic consultation via telephone or video call. When these activities are offered for health-related purposes in a patient-practitioner relationship outside the health service, they come under the Alternative Treatment Act.

    However, health bloggers and Instagram personalities have a less obvious practitioner relationship and, therefore, do not usually come under the definition of the legislation, despite these parties providing more or less well-founded health advice and recommendations, including about the use of alternative treatment.

    Folk medicine and religious treatment traditions

    Folk medicine and religious treatment traditions

    Folk medicine is an umbrella term for health-related activities that are based on folk knowledge founded in beliefs and experiences rather than science. Common treatment elements in folk medicine include herbs, poultices and decoctions. When a practitioner provides this treatment in a clear patient-practitioner relationship, NAFKAM considers this alternative treatment.

    Other elements of folk medicine tradition and religious practice, for example rituals with more sacred or spiritual content, do not come under the definition in the Act. However, the boundary is pushed in cases where there is a defined patient-practitioner relationship. For example, religious intercession for the sick and shamanism (with or without amulets) can be covered by the Alternative Treatment Act, particularly if this takes place in a commercial setting.

    The patient as a user of alternative treatment

    The patient as a user of alternative treatment

    The vast majority of patients who use alternative treatment do so in combination with medical treatment. However, when patients seek alternative health assistance it may not be clear to them which form of healthcare services they are seeking.

    Challenges may also arise for patients who use alternative treatment when the practitioner describes their form of activity as, for example, education, or in cases where it is unclear whether the purpose of the treatment is health-related or not.

    In most cases, alternative forms of treatment, services and products can be identified by the fact that they are offered for health-related purposes outside the framework of the established health service, usually by parties who are not licensed healthcare professionals.

    Based on its mandate to conduct research and disseminate information, NAFKAM can support patients and healthcare services seeking information and clarification about the use of alternative treatment.

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