Organizations representing veterinarians are fundamentally political in nature, and their leaders respond to the will of their constituencies. I have often written about the American Veterinary Medical Association (AVMA) in the context of alternative therapies and evidence-based medicine. While the organization has adopted some policies I believe are scientifically sound and in the best interests of veterinary patients and clients as well as veterinarians, there is no question that the group answers to veterinarians first and foremost, even when these conflict with the scientific facts or the interests of clients and patients. And within the veterinary profession, there are different and often competing constituencies that leaders of groups like the AVMA must respond to.
In regards to complementary and alternative veterinary medicine, CAVM, I have often been disappointed in the AVMA’s positions, though I understand the political realities that shape them. There is a constituency of pro-CAVM veterinarians which is small but vocal and well-funded. The constituency devoted to science and evidence-based medicine is smaller, less vocal, and not nearly as well-funded. And the large majority of veterinarians appear to have little interest or opinion concerning CAVM. This leads the AVMA as a whole to rather tepid positions on CAVM that reflect the political landscape far more than the scientific evidence.
The handling of the resolution introduced into the AVMA House of Delegates in 2012 discouraging the use of ineffective therapies, and specifically identifying homeopathy as such a therapy, illustrates the politics of CAVM within the AVMA. The science conclusively shows homeopathy to be nothing more than a placebo, despite attempts by homeopaths to claim otherwise, and the AVMA’s Council on Research supported this conclusion. However, the House of Delegates voted overwhelmingly against the resolution anyway because of vociferous opposition from pro-CAVM veterinarians, a general lack of interest in the scientific issues on the part of most members, and a deep cultural reluctance among veterinarians to criticize the practices of colleagues.
The AVMA also has a general statement on CAVM which used to be a fairly thoughtful, though still politically circumspect, document. It at least identified some core issues raised by the use of CAVM:
The theoretical bases and techniques of CAVM may diverge from veterinary medicine routinely taught in North American veterinary medical schools or may differ from current scientific knowledge, or both.
The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method….Practices and philosophies that are ineffective or unsafe should be discarded.
The AVMA does not officially recognize diplomate-status or certificates other than those awarded by veterinary specialty organizations that are members of the AVMA American Board of Veterinary Specialties (ABVS), nor has it evaluated the training or education programs of other entities that provide such certificates. Recognition of a veterinary specialty organization by the AVMA requires demonstration of a substantial body of scientific knowledge. The AVMA encourages CAVM organizations to demonstrate such a body of knowledge.
The quality of studies and reports pertaining to CAVM varies; therefore, it is incumbent on a veterinarian to critically evaluate the literature and other sources of information. Veterinarians and organizations providing or promoting CAVM are encouraged to join with the AVMA in advocating sound research necessary to establish proof of safety and efficacy.
In this document, the AVMA refrained from passing judgment on the scientific merits of CAVM, but it at least acknowledged that science was the standard by which veterinary therapies should be judged and that, as of yet, few CAVM practices have met such a standard.
The new AVMA position on CAVM has been stripped of essentially all content and says merely that all therapies should be held to the same standard (without indicating what that standard should be) and that nobody should break the law. This revised statement moves further away from the notion that veterinary medicine is, or should be, a science-based profession. It reflects the growing political reluctance to make critical, evidence-based judgments about claims or practices so long as a licensed veterinarian is employing them.
Other veterinary organizations have been more faithful to the role of science as the foundation of veterinary medicine, with many specifically acknowledging the unacceptability of homeopathy in a science-based profession, and many identifying science and evidence-based medicine as essential to veterinary medicine.
A recent statement on CAVM from the British Small Animal Veterinary Association (BSAVA) takes a fairly moderate, political position on the issue of CAVM, though still one more robust than that offered by the AVMA. Like the previous AVMA statement, the BSAVA document acknowledges science and scientific research as the essential foundation for veterinary medicine, and explicitly endorses and evidence-based approach:
The BSAVA recommends that owners consider the evidence for a particular treatment and the qualifications and experience of the practitioner before embarking on any complementary or alternative therapy for their pet.
The BSAVA strongly recommends that whenever possible treatment decisions are based on sound scientific evidence to support the safety and efficacy of the therapy.
Assessing the evidence
Some people, including owners, therapists and veterinary surgeons, may perceive that the therapies work as a result of belief in the therapy (placebo effect); anecdotal evidence (extrapolation from hearsay or personal experience of a single or small number of cases) or errors in inference (cognitive bias).
There are three factors strongly associated with whether or not any one medical treatment is likely to be efficacious:
1. A rational scientific basis
Modern medicine works, and it works because it is founded on a scientific base. Although not all treatments used in conventional medicine have a strong evidence base in the sense of rigorous clinical trials showing their efficacy they do have a rational scientific / pathophysiological basis for their use.
2. Degree of certainty
The effects of some treatments are so clear cut that further testing is not required. It has famously been pointed out that rigorous clinical trials are not needed to prove that parachutes reduce morbidity and mortality among people falling from aeroplanes. Similarly, one does not need rigorous trials to show that intravenous anaesthetics cause a rapid, profound loss of consciousness suitable for carrying out surgery. However, the effects of many treatments are much less certain; e.g., they are less closely associated in time with their effect, or the effect caused is much less dramatic, smaller and/or more variable in magnitude and/or time of onset. In such circumstances, given the variable time courses of many diseases, it can be remarkably difficult to determine whether a given treatment is actually efficacious or not.
When there is anything less than absolute certainty about the efficacy of a treatment, then evidence is important in deciding whether a treatment is safe and efficacious. However, history has also shown that evidence – both in the form of clinical experience and individual clinical research results – can be misleading. The process of evidence-based (veterinary) medicine exists to improve our confidence by formally and systematically searching for all of the relevant evidence and formally and systematically grading the quality and reliability of that evidence.
The organization also acknowledges that the evidence for most CAVM is poor and that safety or efficacy is largely unknown for many CAVM practices:
Health claims for many complementary and alternative therapies are far in excess of the available scientific data, and sometimes in frank contradiction to scientific evidence.
In making decisions about the use of complementary and alternative therapies it is important to consider their safety and efficacy. Many people assume that all complementary and alternative therapies are natural and therefore safe, but this is not always the case. All therapies may produce unwanted side effects or may interact with other therapies. In the case of alternative therapies it is also important to consider the welfare implications of withholding conventional treatments.
There is a great deal of variation in both the degree to which various complementary and alternative therapies have been scientifically tested, and to which such testing has provided evidence supporting their efficacy.
While I believe it would have been appropriate to go further and acknowledge that at least some CAVM practices are completely without merit and should be discouraged, such as homeopathy and so-called “energy” therapies, I think this is a solid statement supporting the important role of science in veterinary medicine. Relying on science to understand and predict nature has led to far greater health and well-being and far less physical suffering than human beings, and our animal companions, experienced in all the thousands of years before we developed the scientific method. Acknowledging the unparalleled power of science to guide us to the right answers in healthcare is essential in maintaining and extending the gains science has allowed medicine to achieve.
This statement seems to indicate that the constituency of the BSAVA, like that of other veterinary groups in Europe and Australia, is moving in the right direction with respect to deepening the reliance on science and evidence-based medicine in the veterinary field. Sadly, the recent actions of the AVMA would suggest that here in America, as seems evident in many other areas, we are moving in the wrong direction, away from rationalism and science and towards an epistemology that privileges personal experience and belief over objective, scientific evidence. This is not in the best interests of our patients, our clients, or our profession.