There have been a handful of recent court cases against people operating in healthcare despite dubious qualifications and defending themselves by asserting their right to free speech. The case of Heather Kokesch Del Castillo, who was a self-identified nutritionist and health coach in Florida, was rejected by the U.S. Supreme Court (Saunders 2022). Florida protects the title of nutritionist by requiring specific credentials, training, and background (NutritionEd 2020). Del Castillo was operating outside these requirements and attempted to assert that her freedom of speech allowed her to operate unqualified in this space. In Mississippi, health department officials have been slapped with a lawsuit asserting that they violated a woman’s freedom of speech for asserting that she cannot operate as a dietician even though she isn’t one (Ramseth 2020). These two cases are canaries in the coal mine, raptors testing the fences. The wellness industry is exploding and allowing several pseudo-healthcare professions to operate outside the bounds of regulated healthcare.

People have many reasons for seeking alternative medical treatment. For starters, they are displeased with the healthcare system, a sentiment exacerbated by the COVID-19 pandemic. And on a systemic level, the shortage of physicians (American Medical Association 2022) and mental health workers (Kaiser Family Foundation 2022) and the high cost of healthcare (American Medical Association 2023) are certainly not helping matters. But those reasons—personal and structural—are still not good enough to justify replacing the existing infrastructure with a different one.

Medicine, admittedly, had a shaky start. Before the scientific method was firmly established physicians were poorly trained (Barry 2019), and treatments were both scary and pseudoscientific (e.g., trepanning, bloodletting). But we’re a long way from those days. Physicians, nurses, and other providers are highly regulated (Federation of State Medical Boards n.d.) and require standardized education and training. Of course, as in any field, some incompetent people get through (Caulfield 2021)—but because of this system, we are more likely to get someone good than not. That is, in fact, why the system exists.

Despite all the hard work from scientific development to education standards, people still complain of mistrusting trained providers. People turn to the internet to find a solution for their health problems instead of, or in addition to, seeing a regulated provider. Several different untrained, unregulated competing alternative professions have popped up in healthcare. Health coaches act as physicians prescribing specific action plans and even drugs (i.e., supplements) that are available over the counter and are unregulated (Office of Dietary Supplements n.d.). Life coaches are competing with licensed therapists (Aboujaoude 2020). Nutritionists compete with registered dieticians. Fitness influencers act as physical therapists and recommend supplements, often selling them too (NOW Foods n.d.).

Compounding the problem, the internet has made it very easy to dispense health advice by providing a platform for people to offer content, entertainment, and various viewpoints. As such, some become famous all in service to clicks, likes, shares, eyeballs, and advertising dollars. Background, education, and training often do not seem to matter when it comes to creating content. As a result, healthcare advice and views effortlessly slip into influencer platforms, and, for better or worse, it has an impact (O’Donnell et al. 2023).

The impact of social media on the health and wellness space is far-reaching. Consider content created in the name of fitspiration (fitspo for short) (Hemendinger 2023). Influencers tout titles of health coach or lifestyle guru (Green 2023). Research has shown that social media content encouraging “clean eating” (Ambwani et al. 2019) or dieting through pseudoscientific claims can lead to obsessive behavior around dietary patterns. These unfounded “wellness” posts can lead to weight cycling, yo-yo dieting (Marks et al. 2020), chronic stress, body dissatisfaction and a higher likelihood of muscular and thin-ideal internalization (Fatt et al. 2019). Due to lack of regulations, anyone with access to the internet can start preaching about celery diets used to cleanse the body of toxic metals or ways to heal one’s inner child without ever having any training in dietetics or therapy (Wells 2019). Despite the danger in taking lifestyle and medical advice from someone with no training or experience, people continue to subscribe, follow, and like, further reinforcing the misguided idea that anyone can be an expert and leading even more influencers to flood the health and wellness alternative pseudo-healthcare professional market. Anyone can start their own social media account or website (Cowley et al. 2022) and start “consulting” as long as they fall under one of these alternative, unregulated professions. And the freedom of speech may cover this. Should it? Absolutely not. But depending upon the judge and the claim, it may. That’s why these lawsuits are being filed: to see who is receptive to this argument.

Thankfully, some groups and consumers are holding these alternative professions responsible for misinformation (Leskin 2020), lack of results or follow through (Kekatos 2023), and harm their subscribers may have experienced. People operating these businesses will often hide behind the First Amendment. Social media is the wild west of health promotion and education, with very few rules and little regulation. Content creators often argue that they have the right to post whatever they want and if people want to know more, well they can just go ahead and fact-check it for themselves (Sung 2021).

Scrolling through the endless posts from these influencers makes it clear that guardrails are necessary around unregulated, alternative healthcare professions, especially on social media platforms. The freedom of speech is not absolute. Of course, there’s the oft cited “You can’t shout ‘fire!’ in a crowded movie theater” example, but in healthcare we can do even better than that. There’s the case of the Diabetes Warrior in North Carolina (“Diabetic Blogger” 2012) who was diagnosed with type II diabetes. He then became a health and nutrition blogger, dispensing health and nutrition advice and meal plans. He was not a registered dietitian and received a cease and desist letter from the North Carolina Board of Dietitians, but his website and meal plans are still up. Then there’s the Competitive Enterprise Institute (Minton 2012), who’s tagline is “We fight for less regulation, more freedom, and fairness for all.” One of the policy points they’ve argued is to remove licensing “barriers” that prevent doctors, nurses, and others from providing the care they’re “trained” to provide (Young 2020). Even more recently, a family selling Miracle Mineral Solution attempted to hide behind the First Amendment protection of Freedom of Religion, which in this case is very closely tied with speech (Felton 2020). All these examples plus those of Del Castillo and Mississippi demonstrate that we have a problem of people operating in these pseudo-healthcare professional spaces, attempting to skirt regulation.

If you work in healthcare, you are signing up to provide the best care available for patients. Usually that is based on practice guidelines, which are based on evidence amassed by years of research. If places are not able to provide this level of care, they may not be reimbursed, their ratings may go down, their certifications can be stripped, and they may not even be allowed to provide care. Why are we allowing several new healthcare professions to gain popularity without holding them accountable for the bare minimum of training, credentialing, and foundations of practice? Holding these new professions up to even the slightest scrutinization reveals that they prioritize vibes and feelings over training, results, and science.

We’ve worked hard to advance our healthcare system by making it safer and more reliable and by implementing basic standards of care. This new crop of pseudo-healthcare professionals directly challenges the system we have worked long and hard to establish. They want to send us back to the times before specific educational and training requirements existed for providers. Would you want to go to a surgeon who simply felt they could perform surgery? The freedom of speech doesn’t imbue the right to operate in any space a person wants to regardless of education and training. That’s never been the case and shouldn’t be now.

Now, imagine a world where these new professions work with healthcare providers to fill the healthcare gap by taking and providing referrals to appropriate levels of care, posting evidence-based information on their social media, providing community and peer supports for people who need more than a once-a-week therapy session, or even working with a general practitioner to directly provide nutritional and behavioral health interventions for patients. Consider these examples of regulations for the new professions:

• A centralized organization to oversee each of these professions, such as the American Medical Association or for sub-specialties (i.e., those professions that could be seen as an extension of a regulated provider such as a life coach or health coach);
• Standardized requirements for licensing/credentialing and education with an organization responsible for disciplinary action in these areas, similar to The Federation of State Medical Boards;
• The development of practice guidelines establishing a standard of care by review of evidence-based practices and research.

This ideal world is possible—but only when these new professions are moved beyond self-regulation and when freedom of speech does not offer license to spread misinformation or claim expertise without relevant training and education.

References

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