The SkeptVet Blog

Dr. Shawn Messonier, a highly visible alternative medicine veterinarian with a blog, radio program, and a couple of books, recently wrote an opinion piece for the online edition of USA Today claiming that changing vaccine recommendations were validation of his personal beliefs and clinical experiences about vaccines. Rather than recognizing that science is a process, not a fixed conclusion, and that such changes based on new evidence are exactly what good science and medicine are about, he prefers to interpret changes in vaccination practices as validation of his alternative medicine perspective, and he recommends we vaccinate even less (based, of course, on his clinical experience and intuition, not any specific evidence). I’ve investigated and written about veterinary vaccination in detail, and while there weren’t many specifics in his piece, I did feel he was too casual about implying that titer testing could be a wholesale replacement for vaccination and in citing his personal experiences as if they were a sound basis for a medical recommendation.

Rather than respond to my quite limited critique, Dr. Messonier chose to create and them attack a strawman with my name on it. He began by defending personal experience (though only of holistic doctors) as solid evidence and then referring vaguely to supposedly supportive studies:”I’m not surprised that “skeptvet” is skeptical of the recommendation for titer testing or other proven natural therapies. The “personal experience” of thousands of holistic doctors constitutes proof, as do controlled studies.”

He then raises some irrelevant uses of titers to test for infectious diseases and ends with the assertion that ” I’m all for scientific proof, but let’s not discount numerous cases of pets who improve with “natural” remedies simply because an admitted skeptic chooses not to “believe” in the facts.”

I responded trying to clarify his mischaracterization of my position and what my specific concerns were and left it at that. I then got an e-mail form Dr. Messonier asking me to appear on his radio program, chat a bit and take some calls from listeners. I got the impression that he was looking for a “sacrificial skeptic” rather than a substantive debate, so I declined. This concern has been confirmed by his recent blog post adding some features to his strawman version of me.

He starts by assuming my objections to CAM must be personal rather than principled and fact-based: “I’m not sure what his argument has to do with the fact that pets no longer need vaccines, but it’s obvious this anonymous person has some sort of grudge against alternative medicine and alternative doctors.” I’m not sure if he got carried away or really believes pets “no longer need vaccines,” but that is certainly a more radical position than he took in the USA Today article. As for having a “grudge” against alternative medicine providers, that is just an ad hominem to invalidate my points without actually addressing them.

He then tried to make hay out of suggesting there was something sinister in my not blogging under my real name: “I decided to check out skeptvet’s website. It was no surprise to find this person still does not identify himself on his website, which automatically raises a red flag for me. If you have a difference of opinion I respect that, but least don’t hide behind some anonymous moniker. In order to judge anyone’s credibility, it’s important we know who is making the statements. So from the outset skeptvet has one strike against him.”

What anonymity has to do with the substance of my positions I don’t know, but as I explained in my response to him, I blog under a nom de plume partly because the blog isn’t about me personally, it’s about the issues in veterinary medicine I am addressing. I don’t have any craving for the media spotlight, as he seems to. I also don’t wish to court unnecessarily the sort of pointless personal attacks he made in his post since adherents to alternative medicine seem to greatly resent criticism. If he is really interested in my identity, it would take about 5 seconds on Google to find it, so I don’t see that little bit of innuendo as meaningful.

He then went on to defend clinical experience as a form of evidence, with rather more passion than clarity of thought. Finally, he wrote me off as a closed-minded skeptic, thus dispensing with my arguments without so much as a glance in the direction of their substance or evidence:”Ultimately like many other skeptics, skeptvet will never be convinced that various therapies with which he does not agree may be helpful for people and pets. For those with an open mind, and the willingness to accept the time-honored tradition of clinical experience, a new world of healing awaits where true health can be obtained. An open mind is needed for change, and with change comes endless possibilities!”

Very convenient, and very consistent with the general world view that places personal faith above objective research in the hierarchy of evidence. Believe hard enough, click your heals together three times, and anything is possible! I’ve written about what real open-mindedness is before, but I doubt he took the time to read or consider that.

Though it was probably pointless, I responded on his blog, chiding him for personalizing his comments and attacking his imaginary image of me rather than dealing with what I actually say. Here’s part of what I said:

“I am quite open-minded to any therapy that is demonstrated to work in a reliable scientific way. I submit I am more open-minded than you are since I acknowledge that my personal intuition and experiences may be mistaken, while you stick by your own beliefs regardless of what the research evidence says. Pick something specific I have said doesn’t work, show me real evidence it works, and I will be happy to admit my error for all the world to see… If I am opposed to alternative medicine it is only because I am opposed to gambling and experimenting on our patients. The problem is not with my closed-mindedness or prejudice, it is with your standards of what constitutes reliable proof… Clinical experience is evidence, yes, but it is weak evidence and progress in medicine will not come from adhering blindly to tradition or simply trusting your gut, it will come from vigorously investigating new ideas to see if they are worthy of applying to our patients.”

This exchange is paradigmatic for the conflict between science-based medicine and faith-based medicine. Challenging a belief based on intuition, experience, faith in folk tradition, and so on automatically creates personal animosity and resentment. Since the basis for the belief is personal, any challenge to it must be taken personally as well. If my clinical practices are challenged and the evidence shows I am wrong, I may be embarrassed, but I will be grateful for the guidance, not resentful of it because the truth is more important than my feelings or my ego.

Sure, clinical experience and intuition form part of the basis for my beliefs just like anybody else. I am human, and I share in all the genius and all the stupidity of human nature. However, I accept that science is a set of tools that compensates for human cognitive flaws, and when the choice is between good science and intuition, I’d bloody well better abandon my intuition or I am valuing my ego above the truth and following in the venerable tradition that brought us therapeutic bloodletting, faith healing, homeopathy, and all manner of ineffectual or dangerous nonsense.

I’m happy to cordially discuss and disagree with Dr. Messonier about veterinary medical practices, and I’m open to the possibility that he knows things I don’t know and that he might be able to show me things I’m wrong about. But he seems more interested in demolishing strawmen, so it’s unlikely I’ll get the chance to learn anything he might have to teach me, and it’s certainly unlikely he’ll be able to learn anything from me.

There was a thoughtful and cogent essay on the Kevinmd Blog today about a key element in doctor/patient (or in the veterinary case doctor/client) relationships: what happens to the relationship when you say “No” to people. This is certainly a common challenge for veterinarians, and it set me to thinking about situations in which we are required, in my opinion, by ethics to tell our clients things they don’t want to hear, and things that will not endear us to them.

In America there are be two well-known rules:

1. Nothing is ever nobody’s fault.

2. There is never nothing to be done.
(I apologize for the grammar, but I feel the emphasis is more appropriate than the better-written versions of these statements)

As an advocate for science-based medicine, because I truly believe it leads to better health and well-being for patients than opinion and faith-based medicine, I have an ethical responsibility to own up to the limitations of scientific knowledge. I cannot claim one unifying cause for all disease (toxins, subluxations, unbalanced ch’i, dietary deficiencies, and on and on). And I cannot claim to always know why a particular clinical problem affects a particular pet. Philosophically and personally, I am comfortable with some degree of scientific indeterminism, and I believe it is possible that some things simply can never be predicted or fully understood. But even in the more pragmatic, practical world of applied medical science, the reality is that there is much we don’t know, and pretending that we have all the answers is misleading and wrong.

Unfortunately, people don’t like uncertainty, especially when it involved illness, and they tend to view the claim that something bad happened for reasons we don’t understand, or even possible just by chance and so for no good reason at all, as unacceptable and likely a cover for incompetence. Not being able to identify a clear and simple cause for something means we cannot control or prevent it, and this makes us afraid, and fear makes us angry. Facing this anger and dealing with it compassionately, and yet honestly, is a tough part of our job as veterinarians.

It is very difficult to tell a client that we do not know why their pet has a particular medical problem, and even more difficult to then deny them the comfort of the unproven, or even outright bogus theories they come up with or that others offer them. But part of our ethical responsibility to our clients, and the way we earn the trust they must ultimately have for us to do our jobs, is that we must be honest, even when dishonesty might provide some comfort or make us look better.

Along with admitting to the limitations of our knowledge, I believe we must be honest about the knowledge we do have. When we know that 98% of cats under 10 years of age who present with bloody urine do not have urinary tract infections, we must deny the client the antibiotics they may want from us even if we could make the client happy and get the credit for the pet’s subsequent improvement. We know they won’t help, and may even hurt the patient, and we have a responsibility to admit and make appropriate use of that knowledge. Giving antibiotics for infections that are likely viral and vitamins and other supplements that have no demonstrated value are common practice among physicians, and likely veterinarians as well. They serve our need to do something, and the clients’ need to get something for the trouble and expense of coming to see us. However, they are illusions, not medicine, and ultimately I don’t believe they benefit our patients, clients, or profession.

The same holds true for any implausible or outright unproven medical approach. While our clients are likely to perceive improvement, at least in the short term, with almost anything we do (thanks to a placebo effect by proxy), giving a placebo is a form of lying and is essentially unethical and contrary to the principles of a legitimate veterinarian/client relationship. This is especially true for vets as the placebo is more likely to benefit our clients than our patients, who are better served by real therapies.

CAM therapies can have an advantage over science-based medicine in that they frequently offer direct and simple (though false) explanations and treatment protocols. CAM providers seem rarely at a loss for an explanation or a treatment, and though I am sure it must sometimes happen, it seems very rare that a CAM provider will admit that they don’t know why something bad has happened and that they do not have anything but comfort and support to offer. Part of the mythology that CAM  treats causes rather than symptoms, and part of the reality that CAM often makes clients more satisfied with their care than mainstream medicine, has to do with the sense of confidence and certainty (however unjustified) that allows CAM providers to avoid admitting helplessness or uncertainty when we who are dedicated to dealing in evidence and truth cannot avoid it.

There are many other examples of situations in which we are obliged by ethics to say no to clients or tell them something they don’t want to hear. Denying requests for tests, medications, or procedures that are not appropriate for the patient, recommending tests and procedures which are appropriate even if we fear the client may object to the costs, honestly (though gently) explaining their own responsibility for some medical problems and the actions they need to take (overfeeding and obesity, poor medication compliance, etc), and admitting our mistakes are all painful but necessary elements to a veterinarian/client relationship.

It is understandable that we may be tempted to shirk such painful communication, and it is certainly easier in the short run to do so. I have even met veterinarians who based long, financially successful careers on the routine practice of giving clients want they want regardless of what is medically appropriate or best for the pet, and of routinely lying to clients. However, I believe the ethics of our profession, the dictum to do no harm if we are not certain the need or benefit justifies it, and the principle of trust based on honesty in our relationships with clients often requires us to say “No” and to tell clients things they would rather not hear from us In the long run, I also believe we provide better care for our patients if we act this way, and that the short term advantages of false hope and even outright dishonesty cannot compete with the benefits of sticking with the truth, even if it may not always be what we wish it were.

This is an insightful essay illustrating the ultimately faith-based nature of much CAM. Statements about safety and efficacy and the indications of a treatment are determined by tradition, appeal to authority, or instinct and then justified by anecdote without any objective supporting evidence. What I find as informative as the essay are the voluminous comments, including from the legendary CAVM guru Dr. Pitcairn, illustrating how passionate people become when you suggest that their intuition and personal experience, their faith, may not be a sufficient justification for medical recommendations that don’t have any other evidentiary basis. Enjoy!

Peter Lipsom has written a concise and insightful post at the Science-Based Medicine Blog, entitled The Death and Rebirth of Vitalism. It illustrates why the underlying philosophical position of faith-based medicine is unteneable. Magical entities, such as Ch’i in acupuncture, Innate Intelligence in chiropractic, Water Memory in homeopathy and so on, are required by CAM practices that cannot demonstrate plausible rationales by mainstream scientific methods. This contrasts with the Methodological Naturalism required by science, and the true philosophical naturalism and materialism many scientist accept as the truth about the nature of the universe.

As the comments that follow the post illustrate, pointing out the intellectual bankruptcy of the philosophy behind most CAM approaches can lead to resistence against science-based medicine even among scientists and people not otherwise sympathetic to CAM. This is at least partly because looking at the underlying philosophical and epistemelogical distinctions between science-based and faith-based medicine can lead to awkward questions about other faith-based beliefs.

The human mind is miraculous in its ability to hold contradictory ideas at the same time, so many scientists can go about their lives practicing methodological naturalism while believing in the eternal soul, reincarnation, or other non-material entities without trouble, so long as the conflict isn’t shoved in their faces. When it is, some attempt to work out acceptable philosophical compromises, such as Stephen Jay Gould’s Non-Overlapping Magisteria approach. Others simply choose faith over reason and most simply decide not to dwell on the issue. A few, think and read and meditate deeply about the controversy and elect to try and extend their professional naturalism into all areas of their lives. As far as I’m concerned, these are all fair and legitimate responses to a tough question.

But what is not legitimate is when the challenge to faith in areas outside of science is so threatening that scientists choose to let go of their methodological naturalism and embrace faith-based medicine uncritically. Not everyone cares to conduct difficult and complex investigations into the philosophical underpinnings of theri work or their personal life, and this isn’t by any means a requirement for a productive life in science or medicine. I happen to think it can enrich anyone’s life and work, but that may just be my personal intellectual tastes. However, when it comes to the material world, which includes the bodies and minds of our patients and the tools with which we treat them, there are right and wrong answers. Vitalism may stumble on the right answers by accident from time to time, but science and methodological nauralism consistently get the answers right far more often. To ignore this and cling to faith-based medical practices simply to avoid uncomfortable questions about other deeply held faith-based beliefs is intellectually dishonest and not in the best interests of our patients.