I’ve often thought that the following two maxims apply to American culture generally, but especially to medicine in the US:
1. It is never appropriate to say, “There is nothing that can be done.”
2. Nothing is ever Nobody’s Fault.
The latter, along with simple venality, explains the excessive litigation that helps make human health care so exorbitantly expensive here, though it is far less damaging to veterinary medicine, at least for now. The former, I believe, plays a large role in the popularity of alternative medicine.
While some few people reject science entirely, and turn to alternative approaches for ideological reasons, most people accept and eagerly take advantage of mainstream scientific medicine when possible. However, the epistemological and ethical nature of science is such that those of us who practice scientific medicine are obliged to admit to what we don’t know, and we are obliged to tell patients or clients when science has no answers nor effective diagnostic or therapeutic options. Alternative approaches based on faith, intuition, mysterious and undetectable forces, and so on are under no such obligation. So many people turn to CAM at the point where science has nothing satisfactory to offer them.
Accepting the inevitability or intractability of disease and death with only comfort measures to ease the passage is not an option for many people raised in the can-do, American culture. We are accustomed by our history and national temperament to subduing nature and continually improving our condition. Ironically, the successes of scientific medicine have contributed greatly to the expectation that there will always be an answer and a cure. And, of course, the natural drive to live impels us to reject any acceptance of dying as long as we can maintain the illusion that there is real hope.
All of this informs not only why people turn to CAM, but also how we handle people who have made such a choice out of desperation. One school of thought is that any comfort possible should be given those for whom no real meaningful therapy is available. If they feel better, despite the lack of any real, measurable change in their condition, that has real value. This is part of the argument for taking advantage of the placebo effect, and it has some merit, at least in human medicine. I have serious doubts, however, about the ethics of this approach in veterinary medicine, where the comfort obtains only for the owner, while the patient continues to suffer.
We must realize that allowing the comfort of false belief is not without risks. What’s the Harm is full of stories of people who died with much unnecessary suffering because accepting the palliative care scientific medicine had to offer was an acknowledgement of the inevitability of death, and so they chose the false hope of CAM treatments. Some alternative therapies have known risks, and because they are not adequately studied others may have risks we are unaware of. There is even some evidence that cancer patients who use CAM have worse outcomes than those who do not, possibly because they take less full advantage of scientific therapies or because of the deleterious effects of CAM therapies.
Nevertheless, we also have to acknowledge and have compassion for the fear and suffering that leads people to choose unproven therapies as a last resort. Discussions about the inevitability of death and the limits of human knowledge and technology are hard to have in our culture, but I don’t think they need be off limits for health care providers. Certainly, it is not appropriate or useful to challenge someone’s philosophical or metaphysical beliefs in a health care setting, but when we tell someone that the CAM straw they are grasping at is unlikely to help and has the potential to harm, I think it helps to acknowledge the feelings that lie behind the grasping and to offer the same kind of simple human comfort that CAM providers often give, without the concomitant false hope.
I recently met a smart, clever man living with diabetes who had written a very funny song about the Placebo Effect. He has spent much time and energy looking at the best way to manage his disease, and he has done his best to rationally evaluate the recommendations both of his doctors and of the friends, family, and strangers who promote alternative approaches. This has engendered a certain frustration and a bit of pessimism about the ability of human beings to understand and manage the complexities of living organisms and their diseases.
While we didn’t agree entirely on the reliability of scientific knowledge or the meaningful differences between CAM and scientific medicine, I was impressed by his intelligent and thoughtful approach to epistemological questions which had a sharply personal significance for him. Our conversation helped me to better understand the psychology behind people reaching for what seem to me to be clearly useless, irrational therapies. Contrary to the mythology CAM providers often promote, science-based medicine providers do care about the whole patient and the totality of their well-being, and this compassionate “holistic” attitude must always be at the center of our attempts to provide the best care and educate our clients/patients about the difference between science-based and faith-based medicine. If we understand and acknowledge the legitimacy of the needs that lead people to unproven therapies, perhaps we can better steer them to those approaches that are the most likely to benefit them.