On January 12, the Institute of Medicine (IOM) at the National Academy of Sciences released its Report on Complementary and Alternative Medicine. This report, by a highly respected organization within mainstream health care, offered a series of recommendations to influence legislation and public policy regarding complementary and alternative medical (CAM) therapies. The broad definition of CAM therapies in the report would include, in addition to modalities such as chiropractic, massage therapy, and acupuncture, practices such as yoga and meditation. In this issue, we examine how emerging models of conceptualizing and regulating CAM therapies in the IOM report may affect the future of yoga teaching and the business of yoga.
While in ancient times, yoga teachings were transmitted from master to disciple in private settings, often as part of a rigorous spiritual initiation, today yoga classes are offered in a variety of contexts: from private settings to ashrams, yoga studios, gyms, and spas. And, like many other ancient healing arts, yoga is even offered in some hospitals as a clinically-recommended practice. For example, some cardiologists may recommend the Ornish program, which includes yoga and meditation practices, to help reverse heart disease.
This means that, within the broad context of healing arts in the United States, many clinicians and researchers would consider yoga to be a "complementary and alternative medical" (CAM) therapy—a healing modality outside conventional medical care. Understanding how yoga fits within the social and legal paradigm of CAM therapies is increasingly important for yoga teachers and studios who interact with licensed health care providers, consider whether to make claims about specific yoga practices, or receive requests from students for health advice (see Legal Implications of Health Advice for Yoga Teachers, Parts 1 and 2), or consider ethical and legal issues surrounding touch (see The Ethics and Liabilities of Touch).
The IOM report marks an effort by a distinguished panel of clinicians and researchers to make recommendations concerning U.S. policy about "integrative medicine"—the effort to integrate CAM therapies within conventional medicine. According to the report, "hospitals are offering CAM therapies, health maintenance organizations (HMOs) are covering such therapies, a growing number of physicians use CAM therapies in their practices, insurance coverage for CAM therapies is increasing, and integrative medicine centers and clinics are being established, many with close ties to medical schools and teaching hospitals."
In light of these trends, the report's essential recommendation is this: "In determining what care to provide, the goal should be comprehensive care that uses the best scientific evidence available regarding benefits and harm, encourages a focus on healing, recognizes the importance of compassion and caring, emphasizes the centrality of relationship-based care, encourages patients to share in decision making about therapeutic options, and promotes choices in care that can include complementary therapies where appropriate."
The term, "focus on healing," the emphasis on the "importance of compassion," and attention to the "centrality of relationship-based care" may resonate with yoga teachers and studios as entirely consistent with the heart-centered, spiritually mindful approach that characterizes yoga philosophy. Teachers and studios also may resonate with the report's emphasis on encouraging individuals to share fully in important decisions about their health care. Also noteworthy is the recommendation that health care providers and institutions promote a comprehensive spectrum of health care choices—a spectrum that could include yoga, meditation, and other practices considered within the realm of CAM therapies.
On the other hand, the quoted language also emphasizes reliance on "best scientific evidence available regarding benefits and harm," suggesting that clinicians whose patients practice yoga will scrutinize whether yogic practices have benefits demonstrated in the medical literature. As integrative medicine takes hold in more medical schools and hospitals, yoga teachers may find that information they give in class about the benefits of a pose may be validated, augmented, or even contradicted or corrected by a health care provider.
This clinical orientation toward yoga will be supplemented by new research to test the claims and potential clinical benefits of specific yoga poses. With regard to research, the report recommends that: "the same principles and standards of evidence of treatment effectiveness apply to all treatments, whether currently labeled as conventional medicine or CAM." In other words, CAM therapies will be subjected to the same rigorous testing requirements as conventional therapies.
This approach, while even-handed, also carries the potential downside of reductionism—the possibility that a comprehensive set of theories, philosophies, and practices represented by yoga will be divided into parts and analyzed in isolation from the rest of the practice, and medical conclusions will be drawn based on such an isolated analysis. Concern about such criticism, acknowledged in the report, has been the core of objection to many current research methodologies being applied to other holistic therapies such as acupuncture and traditional oriental medicine. To address this concern, the report does specify certain innovative research designs that may be more appropriate to test some CAM therapies.
While research ultimately may reveal the presence or absence of claimed benefits from yoga, it also might illuminate new contraindications for specific practices. Knowing about existing contraindications—such as Headstand when a student has a serious neck injury—already forms an important component of ethical yoga teaching. Given the movement toward integrative medicine, checking in with students about existing health conditions and being alert to possible contraindications relating to those conditions becomes an increasingly important risk management tool, as well as part of responsible teaching and studio management (See Should Yoga Studios Ask Students to Sign a Liability Waiver).
Ideally, the integration of complementary and alternative medicine with traditional conventional medical practices should encourage CAM providers to learn more about the medical understanding of their healing modalities without "medicalizing" all CAM therapies. The IOM report expresses the concern that integration not be "cooptation" by conventional medicine. Rather, integration suggests a partnership in which the features of different healing modalities will influence one another.
In fact, one of the report's chapters, titled, "An Ethical Framework for CAM Research, Practice, and Policy," emphasizes "medical pluralism" as a core value in moving toward clinical, research, and legislative and policy agendas. Medical pluralism means "acknowledgement of multiple valid modes of healing," including non-medical ways of conceptualizing the whole person and promoting healing.
The value of medical pluralism requires considering the "vast array of perspectives that constitute the national (and even international) heritage of healing traditions" on the planet. Such language directs health care professionals and organizations to move "beyond any medicocentric claims" to "exhaustively account for the human experiences of health and healing."
Thus, the stated ideal for this new world of integrative medicine should be broad enough to include the full range of yoga philosophy, practice, and experience, integrating the subtle wisdom of yoga with specific knowledge from the scientific domains. In the meanwhile, yoga teachers and studios, like their counterparts in health care organizations and educational institutions, will likely benefit from exploring some of the conceptual frontiers of this new map for integration.
Michael H. Cohen, JD teaches at Harvard Medical School and publishes the Complementary and Alternative Medicine Law Blog (www.camlawblog.com).
The materials in this website/e-newsletter have been prepared by Michael H. Cohen, JD and Yoga Journal for informational purposes only and are not legal opinion or advice. Online readers should not act upon this information without seeking professional legal counsel.