Ethical issues in the care process: the view of naturopaths

Abstract

Naturopathy is based on human health care through integrative practices, especially with elements of nature, aiming to maintain and recover health in a humanized process. This article aims to know the ethical problems experienced by naturopaths in the care practice and to know how these professionals seek to solve them, in the light of the ethics of care. It is a qualitative research with semi-structured interviews of which the responses were treated by content analysis. From these interviews the following categories of analysis were created: “limits of care”, “inter-professional relations” and “limits of professional practice”. Ethical conflicts have occurred both in the direct relationship of care and in indirect situations, such as those involving other professionals, colleagues in the profession and the society. The interviewees emphasized that the field of naturopathy is still not well defined and that, often, ethical conflicts appear due to lack of clear limits to the practice.

Bioethics; Ethics; Complementary therapies; Comprehensive health care; Ethics, professional

Resumo

A naturologia está pautada no cuidado à saúde humana por meio de práticas integrativas, sobretudo com elementos da natureza, visando manter e recuperar a saúde em processo humanizado. Este artigo objetiva conhecer problemas éticos vivenciados por naturólogos na prática assistencial e saber como esses profissionais buscam solucioná-los, à luz da ética do cuidado. Trata-se de pesquisa qualitativa com entrevistas semiestruturadas cujas respostas foram tratadas por análise de conteúdo. A partir dessas entrevistas foram criadas as seguintes categorias de análise: “limites do cuidar”; “relações interprofissionais”; e “limites da atuação profissional”. Verificou-se ocorrência de conflitos éticos tanto na relação direta do cuidado quanto em situações indiretas, como aquelas que envolvem outros profissionais, colegas de profissão e sociedade. Os entrevistados destacaram que o campo da naturologia ainda não está bem definido e que, muitas vezes, conflitos éticos aparecem por falta de limites claros de atuação.

Bioética; Ética; Terapias complementares; Assistência integral à saúde; Ética profissional

Resumen

La naturología está basada en el cuidado de la salud humana por medio de prácticas integrativas, sobre todo con elementos de la naturaleza, con el objetivo de mantener y recuperar la salud en un proceso humanizado. Este artículo tiene como objetivo conocer los problemas éticos vivenciados por naturólogos en la práctica asistencial y saber cómo estos profesionales buscan solucionarlos, a la luz de la ética del cuidado. Se trata de una investigación cualitativa con entrevistas semiestructuradas cuyas respuestas fueron tratadas mediante análisis de contenido. A partir de estas entrevistas se crearon las siguientes categorías de análisis: “límites del cuidar”; “relaciones interprofesionales”; y “límites de la actuación profesional”. Se verificó la presencia de conflictos éticos tanto en la relación directa del cuidado como en situaciones indirectas, como aquellas que involucran a otros profesionales, colegas de profesión y a la sociedad. Los entrevistados destacaron que el campo de la naturología aún no está bien definido y que, muchas veces, los conflictos éticos aparecen por falta de límites claros de actuación.

Bioética; Ética; Terapias complementarias; Atención integral de salud; Ética profesional

Naturopathy seeks comprehensive care for human health through integrative and complementary practices, especially those that use elements of nature. These practices aim at maintaining and recovering health taking into account the humanized process, in which the individual is approached as a whole ^1-3.

The challenges related to the limits of the naturopath practice have been pointed out because this is a recent profession in Brazil ². Likewise, training in ethics and bioethics in naturopathy has been problematized ^1,4, but no studies are found that address ethical problems in the practice in the perspective of these professionals.

The purpose of this work is, therefore, to identify: 1) the main ethical problems experienced by naturopaths in their care practice and 2) how these professionals have dealt with the resolution of these problems in the light of the ethics of care. Knowing the values and challenges of naturopaths is an important step in dealing with possible ethical problems in the work context of these professionals, and can help to consolidate and recognize the profession in Brazil.

The ethics of care and naturopathy

Although the notion of care follows the history of mankind, in the field of ethics and bioethics the emergence of the “ethics of care” has been attributed to Carol Gilligan in the early 1980s ⁵. Gilligan ⁶ presents the need for care to understand values rel4ated to the feminine view of the world, in which not only the results of the situation, but the concern with those involved in the process and the valuation of these subjects are at stake.

From the field research and analysis of other scientific works, the author ⁶ brings examples of how the “logic” of feminine ethics tends to consider different aspects of the situation in which there are ethical conflicts, in addition to questioning the results of certain conducts. The care with results is no less valued than the process of resolving ethical conflicts, taking into account different possibilities that do not seem to exist a priori but that emerge in the path of conflict resolution in dealing with each of the actors and possibilities. On the approach of the ethics of care as an attribute of the feminine, Gilligan highlights:

The different voice I describe is characterized not by gender but theme. Its association with women is an empirical observation, and it is primarily through women’s voices that I trace its development. But this association is not absolute, and the contrasts between male and female voices are presented here to highlight a distinction between two modes of thought and to focus a problem of interpretation rather than to represent a generalization about either sex⁷.

Thus, if Gilligan’s initial analysis of care occurs from the observation of differences in values between men and women, in a social context in which the masculine model is valued, including in the resolution of problems arising from the same model, as she points out, is not about the gender itself, but about the values that are at stake. From the feminine look, values emerge that can guide another way of solving everyday problems, an approach that values care with the process and those involved.

More than 30 years after the publication of this work, the dominant values still appear to be the same, those attributed to men in Gilligan’s approach, as justice, that is, “right” or “wrong” (e.g., is it right to steal medicine to save a life?), or what is “true” or not, among others ⁶. However, the attributes that emerge from the feminine world, according to Gilligan, as care and appreciation of problem solving and relationships themselves ⁶, have been pointed out by other authors ⁵ in the approach to everyday ethical conflicts.

There are several lines, or “dialects,” used in approaches to contemporary problems in the light of bioethics. That is, there are several theoretical currents in the field of bioethics ^8,9. Therefore, this area can serve as a “tool of interpretation of reality”, as an abstract system capable of producing reflexivity, and the criticism deriving from this exercise turns to the transformation of professional practices in the health area. As Ramos ⁹ points out, the choice of approach depends in part on the affinity of the theoretical approach with the problem in question.

The choice of the approach of the ethics of care to think ethical problems in the field of action of naturopath occurred because of the characteristics of this profession, as well as because it seems to be the main current of thought underlying the teaching of naturopathy in Brazil ⁴.

Methods

This is a descriptive research with a qualitative approach in the collection and analysis of data ^10,11. All participants signed a free and informed consent form and authorized the recording of the interviews, according to the protocol approved by the ethics committee. The number of participants was defined by the saturation of the themes, and the categories of analysis were constructed from the field findings (recurrent themes) and discussed through the theoretical reference of care ethics.

From a script with closed and open questions, adapted from Guedert’s data collection instrument ¹², thirteen naturopaths in professional activity for at least six months were interviewed, as shown in Table 1. These professionals were graduated by the only two universities which offer undergraduate courses in this area in Brazil - Anhembi Morumbi University and the University of Southern Santa Catarina (Universidade do Sul de Santa Catarina - Unisul). Data were interpreted according to the thematic content analysis, with categories defined a posteriori, from the field findings ¹¹. Names of plant essential oils were assigned to each one of the interviewees, in order to guarantee the confidentiality of the data.

Table 1
Characteristics of the naturopaths participating in this study, Brazil, 2016

Interviewee	Age (years)	Sex	Time of experience	School*	Categories of analysis**
Lavender	28	F	3 years	Unisul	A; B; C
Bergamot	33	F	4 years	Unisul	A; B; C
Ylang-Ylang	36	F	13 years	Unisul	A; C
Tea Tree	42	F	12 years	Unisul	A
Lemon	24	F	10 months	Anhembi Morumbi	A; B
Frankincense	30	M	8 years	Unisul	A; B
Geranium	28	F	4 years	Unisul	A; B
Orange	31	M	10 years	Unisul	A; C
Rose	31	F	8 years	Unisul	B; C
Rosemary	28	M	2 years	Unisul	A
Grapefruit	28	F	3 years	Unisul	A; B; C
Petitgrain	25	F	1 year	Unisul	A; B; C
Eucalyptus	25	F	1 year	Unisul	A; B; C

• * University of Southern Santa Catarina (“Universidade do Sul de Santa Catarina” - Unisul) and Anhembi Morumbi University.
• ** Statements of interviewees pointing to ethical problems/conflicts in the categories (A) limits of care, (B) inter-professional relationships, (C) limits of professional practice.

Results and discussion

The thirteen naturopaths interviewed identified situations that gave rise to the three main categories of analysis: the limits of care, inter-professional relationships, and the limits of professional practice (Table 1). With the exception of one of the professionals, all graduated from Unisul. It is worth to recall that naturopathy is a recent profession in Brazil, with two undergraduate courses recognized by the Ministry of Education, both of which have been working for less than 20 years: Unisul since 1998 and Anhembi Morumbi University since 2002 ^2,3.

Consistent with this fact, naturopaths are young professionals and, in the case of this study, only two respondents were older than 35. We also found more women than men (Table 1), a profile already described by Passos ¹³ when analyzing the characteristics of these professionals in a survey conducted with 386 naturopaths (at the time, the number of these professionals in Brazil was estimated to be around 1,200). The same research shows that 82% of the naturopaths were women and cites five other papers that point to this same female profile of naturopathy professionals ¹³.

Limits of care

In the naturopath-interagent interaction, difficulties about the limits of practice of the former appear, in the sense of emotional and personal involvement or the care with the disclosure of information about the one receiving the care. On the concept of interagent, as the one who receives care from naturopaths is called, Teixeira emphasizes that the term interagency relationship was coined a few years after the graduation of naturopathy and is therefore an emic category, intrinsic to itself. This category was created by thinking of a mutual action between naturopath and interacting that, since the creators of the term did not want to suggest neither the passivity of the person receiving the naturopathic practices (as the term “patient” seems to suggest) nor the commercial content of the encounter (as the term “client” seems to suggest)¹⁴.

The issue of secrecy and confidentiality in this relationship appears in the following statements as an important ethical aspect:

“Some issues, such as how to provide care to more than one person in the family, for example, mother and child. And there you have issues of secrecy that have to be treated very carefully, because it involves the relationship between them, right? This is an issue that occasionally appears, because it serves more people in the family” (Petitgrain);

“I have always treated the data of my interagents with high secrecy” (Lavender);

“The interagent said he was a pedophile, and it was very strong to me, for my beliefs. And I got scared about that ethical part, whether I would be being ethical or not by providing care to him... Not getting into issues of being right or wrong, but on issues of myself being able to deal with it. (...) I continued providing care to him for another four sessions. And then I told him that he needed to look for another professional, have a follow up with other professionals, and he did not show up any more” (Tea tree).

Still on secrecy, the difficulty as to what can be shared with the health team or not also emerges, in the sense of defining the limits of what is attributed only to the naturopath, without this exposing the interagent, as in the following statements:

“Because it is a multidisciplinary team, sometimes more than one professional provides care to the same person, and then, when we have case discussions, sometimes there are things that I know and the other person does not know, and it’s necessary to be very careful to deal with this among the other professionals too, to be very careful not to expose that sometimes she told me for a reason and did not tell him for another one” (Petitgrain).

In the context of naturopathy, the valuation of the therapist-interagent relationship and the approach of different aspects of life (physical, psychological, social and cultural) in the health-illness process seem to make it more difficult for professionals to visualize the ethical conduct regarding secrecy/confidentiality. This type of approach also makes the conduct more difficult at other times in the therapeutic process, such as when there are questions about the naturopath’s personal life, as pointed out by the interviewees:

“In the sense that she was getting into my personal world, you know? And this disrupts the interactivity. We were not having a professional relationship, it was a relationship of friendship. How would I charge? (...) I would play with her: ‘you’re going to have to start attending me’ because she saw the situations I was going through” (Bergamot);

“Sometimes the person wants to know about your life, ‘ah, but do you have kids, do you date, are you married, do you live alone’? They want to know, and then, as a professional, I think I can not speak, but at the same time, I do not think it’s human to change the subject or ignore it in any way. I think it’s important to respond like any other human, you know?” (Lemon).

The secrecy about healthcare data in the health area generates ethical problems for different professions, both regarding legal issues and how to deal with certain information about the family and other professionals. This is not a situation experienced only by naturopaths. In the area of family health, a field of action that also seeks an integral vision of the health-disease process and in which there are strategies that bring the therapist closer to the one who is cared for (home visit, group work, among others), these issues also appear ^15,16.

Lima et al. ¹⁵, when discussing the relationship of the professional that works in the area of family health, point out the need for dialogue to establish limits, in the case of care for more than one person in the family, in the search for secrecy of information. These authors also show that the distancing of professionals from certain situations that afflict them emerges as a strategy used by some because of the complexity of dealing with aspects that involve values that are difficult to accept. In the present study, such situation may have occurred in the case of the interviewee who attended an interagent who claimed to be a pedophile.

It is important to remember that in the interagency relationship, the notion of process is central, and the therapeutic encounter has references to humanistic psychology and to therapeutic rationalities that are different from conventional ones (such as Chinese and Ayurvedic medicines), as Teixeira points out ³. This author also recalls that, in this case, the exchange and the therapeutic link are important aspects, and that naturopaths say that many of the sufferings brought by the interagents resonate with their own personal processes¹⁷, providing them, later, with a change of look on themselves. Here it is possible to identify factors present in the ethics of care ⁶, such as the question of the professional look on oneself and the understanding of their role in the care process as something important, and not only as “the best possible” or “ right conduct “or” true “.

Two other aspects were pointed out as generators of ethical problems within the profession. The first is related to the naturopaths’ personal beliefs, which influence care and professional conduct. The second refers to harassment, especially reported by female professionals, of individuals attended that confuse the issue of touch - in the case of massages - with a non-therapeutic approach, but one related to sexuality.

The first issue may be illustrated by the following statements form an interviewee:

“I note that many naturopaths have a religious, esoteric, spirituality, which revolves around a New Age axis (...) This is applied within the office, and with the discourse that if interagent does not agree with that, it is because he/she does not have enough expansion of consciousness, or does not have a propitious opening for a given theme, and that the function of the naturopath, through the interagency, is to enlighten him/her and to promote this expansion of consciousness” (Frankincense);

“So the guy went to India, did a yogi, tantric, Buddhic, Krishna initiation... He returned to Brazil, thinking that he knew more about ayurveda, more than the ayurveda teacher herself. He arrived in the office, attended an interagent who was a homosexual man, who suffered sexual abuse in childhood, (...) he used hydrotherapy, leaving the interagent in his underwear with ice water and rubbing his body with a sponge, saying that this was based on something about ayurveda (...), and he was doing it to convert him. It was not quite the term ‘convert’ that he used, but the purpose was to convert him to heterosexuality” (Frankincense).

These statements seem to point to the influence of personal values within the scope of naturopath therapy. It is worth remembering that in the scope of naturopathy, there is the incorporation of different practices that were, and still are, part of other therapeutic traditions that involve different world views, including religious aspects. Regarding this question, Maluf, in discussing “New Age Therapies”, which include “unconventional” or “alternative” therapies, recalls that in this therapeutic space each individual - patient or therapist - uses in a singular way a varied repertoire, sometimes associating seemingly contradictory techniques and conceptions¹⁸.

The interaction between the therapeutic and spiritual dimensions (even though different interpretations may come from the same religious approach when addressing spiritual issues) seems to be a recurring characteristic when the protagonists of the therapeutic encounter refer to these experiences, as the same author points out ¹⁹. What seems difficult to accept, in the interviewee’s statement, would be the influence of the therapist’s personal values in the attempt to “convert” homosexuality. This attitude would not be expected from a therapist acting both in the context of “unconventional” or “alternative” therapy, as well as in the field of health care, recognized as an academic formation in Brazil, in this case, naturopathy.

On the issue of massage, statements about harassment were made by women:

“When I worked at the spa, there was a lot of this, right? It involved touch, then he had to ask me out, to ask me to do things, of real harassment, to take my hand and go through his body... When they came to make a proposal, I would say, ‘No, that’s not my job’. But you have that issue in the massage session. Often men have been waiting for this. Unfortunately, there is a social culture involving massage” (Tea Tree);

“There were two cases in which this really happened and then I had to talk, I talked to them, I said that my relationship there was purely professional. And I stopped attending them, I did not have any more contact, I preferred to refer them to another professional” (Geranium);

“Harassment from interagent, I don’t know… I have been hit on once or twice” (Orange).

This topic did not appear in the search for references in articles of the international databases, nor even in general search with the keyword “harassment”, in the attempt to find works on the subject, even in the scope of other professions. In the search of these situations in Brazil, it was possible to identify a physician’s report on harassment by a patient ²⁰. The professional chose to no longer treat him (conduct corroborated by the professional council that evaluated the situation), as well as the naturopaths interviewed in this research.

In the international literature, it was found that this topic has been addressed within the domain of the health professions ^21,22. In particular in the area of nursing, patient harassment has been identified in some studies ^23,24, although it also appears in the medical area ²⁵. The authors point out that this subject is difficult to approach and is often not mentioned clearly by professionals, who are embarrassed to talk about it ^21,24,25. They also point out that younger professionals, in the case of nursing, speak more about theme ²³, perhaps because they experience the historical moment differently from the older ones, which come from a tradition in which this theme would be considered “inappropriate.”

A possible hypothesis is that when receiving the massage, the interagent thinks about other types of approach. Or, in the case of those who provoked harassment, the connotation of massage could be linked to the role of prostitutes. On this issue, the following statements seem to illustrate this hypothesis:

“Unfortunately there is a social culture involving the massage ... (...) Because before the massage was seen as work of prostitute, right? (...) and some still have this [idea], right?” (Tea Tree);

“The issue of men having a preference for receiving massage from a woman, of having this prejudice in receiving massage from another man or, I do not know, the sexual interest behind that, I do not know. If the guy just wants to get a woman it is because there is something, right?” (Rosemary).

The reports refer to different places of care (including spas, clinics and physicians’ offices). It is worth remembering that someone looking for the services of a naturopath may have different views about what they are seeking, and their vision may be different from what this professional offers. Teixeira ³ points out that spas, for example, are territories where these professionals work in which the relationship with the interagent is not continuous or prolonged, since spas are places of “passage”, and the predominant view would not be naturopathy, but that of aesthetics.

This author further states that according to some naturopaths, both the public seeking a spa and the owners of these spaces prefer that women apply the practices, which makes it difficult for men to practice in these places²⁶. It seems that although for these professionals it is clear that massage is a therapeutic resource to treat health issues, there are other social visions about the meaning of the practice, to the point of making it difficult to hire men for this function, which leads to harassment of naturopaths.

It is possible to point out factors that lead to this interpretation, such as the work of prostitutes in places known as “massage houses” in different periods, including nowadays, as Rodrigues points out ²⁷. This theme has not yet been widely discussed and could be investigated in new research. The denomination “massage houses” influences the way the idea of the massage performed by naturopaths is perceived. The cultural interpretation usually widespread for this practice, especially when it is not prescribed by a physician and applied by a physiotherapist, has been linked to sexuality and prostitution.

Just as there are previous concepts regarding the meaning of massage for both interagents and naturopaths, it is possible to think that the idea of “naturopathy” leads to the universe of “alternative” practices. Such a universe, taken by interventions that consorted Oriental therapies, dietary guidelines, exercises and even religious conceptions, refers to contexts of health care less academically recognized from the perspective of the dominant biomedical culture. This situation may contribute to naturopaths being seen by those who act with hegemonic health care practices as a secondary professional, as identified in the previous speeches and in those that constitute the next category of analysis of this work.

In inter-professional relationships, approached from the ethical conflicts pointed out by the naturopaths, it is possible to identify behaviors and discourses that can be interpreted as a result of this dominant vision. Here it is possible to think of the context that leads to the origin of the prejudice, that is, any preconceived formulation about the value and meaning of the behaviors and social practices in a certain society or social group, from their culture(s).

As Geertz warns, man is tied to the webs of meanings that he has woven²⁸, and if we assume that culture is this set of webs and its analysis, as the author proposes, we may think that our cultural framework gives meaning to certain experiences to which the interviewees refer.

Inter-professional relationships

The professionals pointed out situations of conflict about the conduct of other health professionals in relation to the practices of naturopathy:

“Then I felt violated. (...) I indicate a phytotherapic (...) and then that person goes to the physician, the appointment was set previously, and then he says (...) ‘That does not work, it does not work’ (...)” (Bergamot);

“In relation to other professionals (...), the biggest problem is they do not know how far the professional naturopath goes, what I’m working on, what my job is. Then we end up having to talk, exchange, and sometimes these professionals do not take it very well” (Geranium).

These statements refer to the issue of the different knowledges that are present in health care. As Raymundo ²⁹, reminds us, integrative practices become part of the choices made by individuals who seek health services in the search for integral care, and are often associated with biomedical approaches. The acceptance of these non-hegemonic practices by professionals working on biomedicine values may or may not happen, as this author in citing the case of yoga practice, considered in a scientific study of the type meta-analysis, as valid to improve the levels of blood pressure in a given population group ²⁹.

It is worth remembering, as Camargo Jr. points out, that the term biomedicine, or contemporary Western medicine, refers to a medical rationality that has as main propositions: 1) the production of universally valid discourses, with laws and models of general application; 2) these proposed models have a mechanistic character (they see the universe as a machine, having as a model the machines produced by the human being); and 3) have an analytical character, when trying to understand the parts of this “machine” that constitutes the human being and to consider the sum of the parts as responsible for the functioning of the whole³⁰.

Regarding the lack of acceptance of certain therapeutic approaches and the conflict between agents of different health professions in the care of individuals promoted by more than one professional, Vidal et al. 16 also discuss the issue in a literature review of articles on family health. Even though scientific studies indicate that they promote benefits to individual health, the conflict regarding the choice of “unofficial” therapeutic practices is a recurring theme. For example, in relation to the use of medicinal plants, medical professionals themselves find resistance from colleagues of the same professional category about their use ³¹.

Limits of professional practice

Because it is a recent profession and encompasses different therapeutic practices that, in general, consider health issues in a multi-factorial way, as well as therapeutic interventions, often the practices developed and applied are also used by other health professionals. Although there are associations of naturopaths that outline some guidelines related to the occupation, the interviewees report difficulties regarding the limits of professional practice, mainly due to lack of recognition of the profession.

The Brazilian Association of Naturopathy (Associação Brasileira de Naturologia - Abrana), founded in 2004, and the São Paulo Association of Naturopathy (Associação Paulista de Naturologia - Apanat), founded in 2007 ², are the two associations that treat issues related to the practice of naturopaths. Regarding the ethical standards as a professional deontology, only in 2017 the “Code of Professional Ethics of the Naturopath” (Código de Ética Profissional do Naturólogo) ³² was published, a proposal elaborated by a working group of these associations that presents ethical guiding principles for the practice of the profession.

Although these associations have a recent focus on occupational limits, this issue appeared as an aspect of difficult delimitation in the practice of naturopaths, according to the interviewees. Knowing one’s limits of action appears in the following statements as a matter of ethical conflict:

“I think that’s it, naturopathy has something that sometimes gets in the way, which is to think that naturopath (...) accounts for everything, and I need to be aware of the limits of my profession and to know the naturopath’s responsibility and even where I need to refer to another health professional” (Petitgrain);

“A kind of code of ethics (...), something deeper to write a conduct, a manual, something that can give [us] support. Something official” (Eucalyptus);

“[It is] within the Abrana and Apanat that a code of ethics and conduct of this professional is being developed. Since we are not a council, we can not demand that every point be followed” (Lavender);

“I do not know, a council would be the ideal thing, I do not understand this part, but, like this: how long does a naturopath service have to last, how much do we charge? (...) What makes people insecure, even as a professional is, we are such a diverse group, and we think: such a person provides care in one way, I have a the same profession and provide care in another way, and we have the same profession. So how do you defend it facing a society? Not judging what care is better, it’s none of this, but these are completely different things within the same profession. And how [to say]: ‘look, what we do such and such’? It is very difficult. What profession is this that you can do so many things in so many different ways?” (Grapefruit);

“I think there is an ethical question, that we discuss very little (...), which is the question of discharge, of the discharge of the interagent. I think we have not discussed it enough in the course (...), and how far the interagent is going to stay in the therapy process and even when not, right? Because it seems to me that there is a common sense that the person should be eternally under care, with a justification that one always has something to work on” (Ylang-Ylang);

“It’s just a struggle to really try to make it very clear what the role of the naturopath is. The definition of the profession of naturopathy is somewhat confusing, it is not very clear” (Geranium);

“The profession has been around for a short time, so the population does not know what a naturopath actually does. When they ask me, ‘What do you do?’, I say, ‘I’m a naturopath’, then comes ‘natu... what?’ No one has much idea of what a naturopath is” (Bergamot).

It is possible to conjecture that, because naturopathy involves different therapeutic practices also related to disease prevention and to a healthy state, it seems difficult to establish the limits of its practice. Regarding these limits, the research conducted by Passos shows the lack of regulation and the lack of a professional council ³³ as factors that hinder the practice of naturopath, including as an argument of professionals who claim that they would not choose the profession again if they had to do so that moment. Although the “Code of Professional Ethics of the Naturopath” ³² exists, it was only published in 2017, and was still being elaborated at the time of this research. In addition, the association is not professional advice that can guide more incisively the limits of the profession, as pointed out by one of the interviewees.

Thus, on the one hand, there is difficulty in delimiting the profession, and this question generates ethical problems, because when the professional encounters some difficulty in relation to care, he can not define how far he should go. This raises questions such as, “Should I talk about my life, whether or not I have children?”; “How long should the consultation or treatment last?”; “What rules should I use if there is no professional council?”

On the other hand, the values that guide the profession include “putting oneself in the other’s place”, “empathizing”, “being guided by the therapeutic process”, among other things, pointing to the definition of naturopathy, that is not made official in some protocol. The need to put into words such limits and to establish rules seems to be what naturopaths claim for in order to facilitate the resolution of some ethical conflicts diagnosed in the everyday practice.

Final considerations

Care with the interagent appears to be humanized in the interviewees’ statements, which is in line with the literature on naturopathy ^1,2. However, naturopaths point to situations of ethical conflict within the scope of the direct relationship of care in the interaction process, as well as in indirect situations, such as those involving other health professionals, colleagues in the profession and the society. Regarding the latter, they emphasize that their field of action is still under construction and that many times ethical conflicts appear because the definition of limits of performance may not be clear.

In this sense, the existence of a deontological code that is not widely disseminated to such professionals seems to be an important factor in dealing with ethical problems in the daily life of the profession. On the other hand, although this code exists in an incipient way, another aspect must be considered when we are faced with the practice of naturopathy. It is about the existence of different counter-hegemonic practices (some stemming from millennial medicines, others contemporary, but mostly “unconventional” health care practices) that have been constructed from different fields of knowledge.

In this area of “unconventional” practices, therapeutic space, time of therapeutic relationship, “works” performed to recover health or prevent diseases, meanings for the appearance of diseases, among other aspects, can and are often different from those to which one is accustomed to find in the scope of contemporary Western medicine, as Maluf ¹⁹ reminds us. Perhaps one of the points of convergence that the naturopaths find in the course of their trajectory, as it transpires in their speech, has to do with the care with the interagent in different dimensions and the development of strategies to develop self-care.

It is worth remembering that although the notion of care refers us to writings of ancient times, we can affirm that there is not a unique idea of care, but a set of notions of care³⁴. Thus, although different professions in the health area are involved in caring for the individual, the look and the challenges arising from the look (and care) of these professional may also be different. In the case of naturopathy, some of the ethical conflicts experienced are related to the definition (still embryonic) of its field of practice and other issues, such as the therapeutic relationship and the relationship with other professions, which are also reported by other categories in the health area.

The ethics of care, when valuing the therapeutic relationship, the process of care itself (which occurs in the relationship between the health professional and the one seeking help) and the existence of different views about this relationship can help to understand the challenges and problems that arise in the context of naturopathy. As Gilligan points out, when referring to experiences of the self and social relations, different languages (with respect to values and moral aspects) can lead to systematic mistranslations, interpretations that hinder communication, and limit the potential for cooperation and care for the others ³⁵.

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• This article had support of the Institutional Program of Scientific Initiation Scholarships (“Programa Institucional de Bolsas de Iniciação Científica” - Pibic) granted by the National Research Council (“Conselho Nacional de Desenvolvimento Científico e Tecnológico” - CNPq).

Publication Dates

• Publication in this collection
  Jan-Apr 2018

History

• Received
  29 Mar 2017
• Reviewed
  11 Sept 2017
• Accepted
  13 Nov 2017