In addition to substantive arguments about evidence, clinical studies, and underlying biological or physical rationale, many arguments between supporters and skeptics of veterinary CAM involve myths, stereotypes, logical fallacies, and other rhetorical devices or conceptual errors unrelated to the actual merits of the case being made. The recent discussion in response to Narda Robinson’s article on the Pet Connection Blog has revealed some of the archetypical forms of these, and I thought I’d offer a few possible responses.
1. Argument from Faith-
This, of course, underlies much CAM. Supporters “know” things work because of their firsthand experiences or they have faith in the wisdom of tradition or individual gurus. Apart from the cognitive errors that make anecdote and firsthand experience rather unreliable, the propensity for self-validating belief is a problem in itself. Faith is, by its very nature, self-reinforcing. Belief begets belief, and humans are notoriously loath to give up beliefs regardless of evidence. We hate to have to accept the ambiguity and uncertainty of knowing our personal impressions are less reliable than the objective and impersonal process of science. There is a powerful psychological incentive to reject evidence-based medicine because it takes away our illusions. Supporters of CAVM can claim that because they have believed and practiced these methods, because they have “seen for themselves,” that their wisdom and position of authority must be respected. Sadly, their intelligence and passion and conviction may make them convincing to others, but they don’t make them right. Only well-designed and conducted research which take the biases of passion and conviction out of the evaluation process can prove their case, and they often disdain such because it seems to them beside the point, a mere frill to “prove” what they already “know.”
The emotional intensity of true faith also contributes to the tendency of CAM supporters to perceive disagreement as disrespect, or to act as if respect ought to be a substitute for evidence, but such is the nature of faith-based medicine.
While we should be free to disagree about facts, I find CAM proponents often identify disagreement with suppression of the truth, ignorance, or some sort of political conspiracy. This is part of the David and Goliath Myth I’ve written about before. I try to take their belief in the benefits of the methods they espouse in good faith, and I believe they have their patients’ best interests at heart. Mature and respectful disagreement requires that they treat dissenting opinions likewise because their belief is often a matter of personal faith, they can be quick to dismiss other opinions as disingenuous or motivated by something other than the best interests of our patients.
There are several versions of the “you too” argument. One is that mainstream medicine is itself not evidence or science based and so CAM has an equal claim to legitimacy and efficacy. The specific citation that “only 15% of allopathic medical treatments were based on scientific studies” has been well-debunked.
There is a grain of truth to this assertion. Many mainstream practices have been “grandfathered in” (as, I might add, has the US Homeopathic Pharmacopeia, which was automatically exempted from proving safety and efficacy when food and drug safety laws were instituted in the U.S.). These practices do not have the level of evidence behind them they would require if newly discovered today. However, the level of evidence behind mainstream medical practices is far higher than for alternative practices. And the underlying principles are not grossly inconsistent with established principles of the biological or physical sciences, as is often the case for CAM methods. And rather than considering centuries or millennia of unquestioned use to be a point in favor of a therapy, as does the CAVM community, scientific medicine holds all practices as open to criticism based on logic, reason, general scientific principles, and of course clinical evidence.
Another fallacious form of this argument says that because mainstream scientific medicine makes mistakes and there are bad doctors in scientific as well as alternative medicine, that this is somehow evidence in support of homeopathy, TCM, or other alternative therapies. There is no connection. Scientific medicine makes mistakes, but science is always changing and improving and these mistakes eventually get corrected. Scientists are imperfect human beings, but the scientific method applied over time but many individuals compensates for our flaws. Therapies based on unwavering respect for ancient traditions and validated primarily by personal experience and belief, on the other hand, have no reason to seek and correct mistakes. If Palmer and Hahnemann and the ancient Chinese physicians had it right, then our duty is to follow their advice and not question or challenge it. Western mainstream medicine made this mistake in canonizing Galen and the other Greek physicians and accepting without question both what they were right about and what they were wrong about. And medicine stagnated in a miserable state for centuries. The scientific method changed that and made active questioning and critique a virtue. I know some CAM proponents will disagree and say that we are all drowning in toxins and disease and that the pre-scientific age was a Golden Age, but the history of the succeeding couple hundred years suggests to me that the scientific approach works much better.
In any case, the lack of perfection in scientific medicine is not an argument that no progress has been made or that the method doesn’t work. And it’s certainly not an argument that the exact opposite philosophy is the better alternative.
3. Health Care Choice
A popular defense of CAM in the U.S. these days if the argument that consumers (not “patients”) should be free to choose what kind of health care they want, apparently regardless of whether it works or not. The “free choice” argument is a popular strategy as it plays into the general cultural suspicion of government and the respect for individual freedom. But the “choice” between methods which help and those which do nothing or even harm a patient is not a truly free choice. If one accepts that the government has any role at all in protecting public health, than one has to accept that establishing some reliable and objective standards of safety and efficacy is an appropriate government activity. If, of course, you believe government should stay out of everybody’s business altogether, than you won’t accept this, but that’s really a political not a scientific debate. There is a segment of the libertarian movement that aggressively supports CAM for clearly political reasons, though thankfully there are also many solidly skeptical libertarians as well.
History suggests to me, that the methods of science are better at determining safety and efficacy than tradition and personal experiences. For a thousand years doctors and patients believed bloodletting, purging, cupping, casting out demons, and lots of other non-scientific method of treatment were helpful. Those people were just as smart as we are, but they had the same flaws and cognitive vulnerabilities. We now live longer and healthier lives and eschew those methods because we have developed a better way to determine what works and what doesn’t. This is not cultural chauvinism, it’s just a pragmatic evaluation of reality. And if this is true, then a caveat emptor approach to health care where we are “free” to choose whatever snake oil is sold to us, and the salesmen are free to claim whatever they like without reasonable proof, seems a step backwards and a guarantee of much unnecessary suffering.
The history of government regulation of food and drugs shows some real benefits to limiting the medical therapies that can be made available to those which have some reasonable, scientific plausibility, and the weakening of such laws through legislation such as the 1994 Dietary Supplement and Health Education Act have clearly led to harm, and this argues against the benefits of so-called “health care freedom.”
An extract from “Science-based medicine” on the US delegation to observe operations performed under acupuncture anaesthesia:
“The delegation observed one veterinary case:
A healthy aging horse was observed during demonstration of an exploratory laparotomy performed with the aid of acupuncture hypalgesia. It seemed less than a dramatically successful performance, as the horse appeared glassy-eyed and frequently struggled.”
Poor bloody animals – experimented on for EBM, experimented on for woo………
Rita
I got a headache from reading updated posts on that blog.
The veterinarian homeopath, who’s no longer a veterinarian, but has cases. That “observable Energetic patterns in the Universe” to prove homeopathy works, and it’s popular in England because the Royal Family uses it, therefore it must be effective. Ugh.
And another vet, claiming the principles of homeopathy continue to apply to patients today as they did more than 200 years ago. Um, ok, the principles haven’t changed, but what about the fact it never worked 200 years ago and it doesn’t work today!
It was quite frightening however, to see yet another vet so ignorant in treating pancreatitis, that she fails to see the need for additional treatments (ie., antibiotics, anti-nausea meds) and thinks homeopathy should be just as effective. She “decided” to go on VIN to see how pancreatitis was being treated these days, but failed to note that IV fluid therapy is NOT the only protocol in treating pancreatitis. I shudder to think of the pets she’s treated without additional therapy, the pain, the suffering…
What makes a conventional vet (if the ones on that blog are even vets at all), disregard all that they know about the scientific method, to persue methods that don’t have one chance in hades to work? What gives them the right to dictate a pet’s treatment who can’t speak to inform them nothing’s working and they’re feeling worse? When does a pet get to say enough already, I want real treatment? There is no ethical boundary with these people, when that line gets crossed, the veterinary oath is null and void. This is wrong on so many levels.
You have much more tact than I, I loved your “Homeopathy certainly is used to a far greater extent in the UK and parts of Europe than it is here. Yet there is, again, no evidence that it works any bettter there than here.” Priceless.
I see Robinson finally admitted that reiki is a faith-based approach, but claims if it helps the owner, why shouldn’t it be used? Because, Robinson, it doesn’t help the PET.
*rolls eyes*.
I posted on my blog another factor which is almost certainly at work here-Cognitive Dissonance.
http://skeptivet.blogspot.com/2009/07/cognitive-dissonance.html
Bartimaeus, I read your well-thought out post this morning, and wanted to offer a comment. How does one join your blog/comment other than choosing from the drop-down menu for “profile”? Unfortunately, I am not subscribed with any of them. Does one have to have a username with one of the options in the profile to join your blog?
Thanks V.T. Tact is certainly something I have to struggle for, but I find the more dispassionate and polite I am, the more effectively I caputre the sympathies of the uncommitted, which is really the only point. The true believers, of course, will likely never change their minds no matter what evidence they are presented with.
Yes, Bartimaeus, cognitive dissonance is another huge factor in the rigidity and dogmatism of all ideas, and certainly applies to CAVM often. And, FWIW I agree it’s awkward to post comments on your site. I happen to have a gmail account, so I finally found a way to do it, but I can see how it might deter people, so if there’s another way to permit comments I bet you’d get more feedback.
Thanks for the heads up V.T. and skeptvet. I did not realize it was that hard to comment-I just checked the settings and I think I fixed the problem. Anyone should be able to comment without registering now.
Thanks, Bartimaeus! FWIW, there’s nothing wrong with registration, in fact, it helps keep out the weirdos, spammers and spambots, I’m not familiar with blogspot but I know other blog software like wordpress allow easy registration and a good spam control method.
skeptvet, I tried that, you can catch more flies with honey, but I’ve found it usually results in a coin toss, ultimately the person has to be receptive to critical thinking, learning, and evaluation of the facts before them. Rational debate always helps 🙂
Nonetheless, I enjoy reading the articles here and on skeptivet, you present the information concisely, honestly and the facts speak for themselves. Thanks for stepping up to the plate in such a difficult area.
http://www.telegraph.co.uk/news/newstopics/howaboutthat/5912759/US-pets-treated-with-acupuncture-by-their-vets.h
“Accepted” by AVMA – what is going on here?!!
Rita,
The link you posted didn’t work, here it is again:
http://www.telegraph.co.uk/news/newstopics/howaboutthat/5912759/US-pets-treated-with-acupuncture-by-their-vets.html
AVMA does not have an official policy on acupuncture. As a political organization, it tends to adopt vague policy statements on controversial issues which don’t say much of anything. Here is the official policy on CAVM:
http://www.avma.org/issues/policy/comp_alt_medicine.asp
It is true that AVMA permits lectures on a wide range of CAVM topicas at its meeting, which implicitly endorses these practices. Given how many vets believe in them, it would probably not be politically possible to do otherwise. That’s why some of us have gotten involved in the EBVMA (Evidence Based Veterinary Medicine Association, http://www.ebvma.org) and are trying to add a voice for EBM to the mix. We have initiated a regular feature in JAVMA to begin apppearing late this year or early next, and some of us are trying to organize a booth and presentations for next year’s AVMA Meeting.
As long as the media is not willing to provide opposing views with facts, articles like the one linked above will always appeal to the masses. The media is largely responsible for the propagation of nonsense as it regards CAVM, you see it all of the time, every day! “Alternatives for Fido, acupuncture cured him!” and the like. You rarely ever see an opposing viewpoint from a conventional vet who does not subscribe to CAVM. We need more investigative journalism, not sensationalism.
The following paragraph in that link:
“acupuncture has now been recognised as a valid treatment by the American Veterinary Medical Association (AMVA).”
Is the exact same, word for word, I’ve seen on numerous news articles, pet media sites ad nauseam. Try arguing them with the facts, try providing them the resources to dispute the claims. They don’t want the debate, they’re only interested in selling news. Unfortunately, the gullible and uneducated eat it all up like candy (including the reporters).
“I am not against ‘classical’ but they are the last resort only.
My homeopaths are official veterinary and doctor in medicine.
My acupuncturists, same story but the one is specialist in human-acupuncture and the other one in horses and -in lesser cases- dogs” –
from a (Belgian) correspondence on a horse forum about “alternatives”. I know vets here (Barcelona) who have switched their practices to acupuncture and homeopathy. How is the hapless customer to stem the tide of nonsense?
“(AVMA)….implicitly endorses these practices. Given how many vets believe in them, it would probably not be politically possible to do otherwise.” As you say – but WHY do so many vets believe in CAVM?
Theories?
Best of luck with the EBVMA – I only hope it’s not too late!
Rita
Well as I pointed out in a previous post, referring to an SBM article, there is a big difference between a medical education and a scientific education. Vets are not always scinetific in their outlook, though they tend to think they are, and they are prone to all the unsound bases for unjustified belief as everyone else. All too much of vet med is not backed by the high-quality evidence human medicine often expects, and since vets are not watched like hawks by lawyers the ay MDs are, there is a culture of trying out things that sound like a good idea and then evaluating the outcomes informally by yourself. All of this predisposes one to succumb to CAVM.
And there is no question that vets make great efforts to make a living at what we do. When clients clamor for something, when there is at least anecdotal or even weak scientific evidence that it might be helpful, and little evidence of harm, it is tough to refuse to offer a service on pure principle. At my own practice, my efforts to counter the advertising of CAVM services to clients with evidence-based information has met little success even though a majority of the owners are not big believrs in CAVM. They are, however, believers in keeping clients happy, and in the absence of evidence that we’re really hurting our patients, they don’t have the same sort of ethical concerns I do about offering woo.
I have a problem with vets telling their clients “well, it won’t hurt, so we can try” regarding CAVM. It does hurt, because it doesn’t help the pet, and it only serves to reinforce the client’s belief that you, the vet, are open to consideration when you should be trying to develop a means of effective communication. The client will be conditioned to believe you will indulge their every whim, and expect other vets to do the same. You’re not treating the client, you’re treating the patient, and coddling the client shouldn’t be part of the treatment, you’re actually doing a disservice to them and the pet by doing so. Unfortunately, it’s difficult when the client has high expectations and isn’t willing to face reality and if a treatment isn’t working, you’re left in the position to do or recommend *something* rather than nothing to ease clients’ emotions or fears. How to change that?
This isn’t aimed at you, skeptvet, it’s just an observation I see in other vets whether they are strictly EBM or alternative.
Communication with clients is a delicate and challenging aspect of veterinary practice. I agree that one should keep the patient’s best interests as the primary focus. But ultimately everything we do for the patient is mediated through client and paid for by the client. If the client’ needs aren’t dealt with, they simply go elsewhere and their pet either doesn’t get care or gets it from someone willing to do whatever they want. So sticking to a principled position of EBM and still keeping open communication and keeping the trust of the client is an ongoing
I tend to toe a pretty tough line on what I will or won’t do therapeuticallly, but I’m unusual in that. I’ve been in practice a while, I work at a large practice ith lots of vets and a large, affluent clientele, so I can afford to occassionally alienate a client with strong feelings about CAVM. On the other hand, by trying to maintain an open mind and respecting the client’s perspective, I’ve been able to keep people on track with therapy that ultimately benefitted their pet when they were prepared to give up and run to someone in the exclusively alternative style. I hear what you’re saying, but I also think there are seldom easy answers to the dilemma.
I do agree, and I understand that sometimes very fragile vet/client relationship, it’s necessary to maintain communication for the pets’ best interests. Not saying you have to deny the client’s wishes, just would like to see more vets approach clients in a more productive way (instead of saying, well homeopathy isn’t going to hurt, go ahead, instead imply homeopathy won’t hurt but won’t help in the least either). You’re right, the client has every option to get their “fix” from any other vet who will oblige them, but that one appointment, that one CAVM request is usually the best opportunity to make the best impression. Some vets are very skilled how to say it in few words, others don’t have the time to say it, and still others for whatever reason, simply won’t say anything at all, as if it’s simply easier to avoid the situation entirely. If nothing is said, the client is going to keep on believing that magic remedy is the cure, this time, and the next, and the next.
I know there will always be those clients who know more than you and there’s nothing you can do.
In my experience, most clients that ask about CAM have read something or had a friend or relative recommend something. Often a little time explaining the ideas behind homeopathy, or acupuncture, etc. can really make a big difference. Many people just don’t really understand what the rationale (or lack thereof) is behind these things until someone explains it. A little time spent explaining why I don’t use CAM usually works wonders. I have had a few “true believers” whom I could not convince, but I could see that problem coming because they are often opposed to most or even all vaccinations, any pharmaceuticals that come from drug companies etc.
Fortunately there have only been a few of those in my career, and they usually disappear when they find a vet who will go along with what they want. There has only been one client who I just could not work with, and had to refuse further service when she would not accept any legitimate treatment for her pets advanced cancer and also refused to consider euthanasia.
I’ve just finished (I hope) a long discussion about CAVM on a horse forum and have found that the nastiness of Big Pharma is the number one reason given for turning to woo. Pointing out that criticism of A does not entail the correctness of B goes nowhere, people just keep refering to malpractices, profit motives etc etc – and, of course, there’s plenty of stuff to adduce, unfortunately.
On the “positive” side, what gets brought out is pretty much what one would expect: antiquity; more savvy cultural practices; natural beneficent design of the universe; EBM only treating symptoms, not the whole organism; toxicity of modern life. I thought people here might be interested in having an encapsulated list of these factors in others’ thinking – if “thinking” is actually the right word……
When I read V.T.’s post about a vet using CAM to (not)treat pancreatitis, it made me soooo angry. As a nurse, I know how painful and life threatening it is. I can only hope that this vet comes down with pancreatitis and uses CAM for him/herself. I’ll bet it won’t last for more than an hour, before they beg for morphine or fentanyl and other ‘coventional’ treatments.
Yes, as I always emphasize, stories like that are the kinds of tragedies that show us CAM isn’t merely silly and harmless but really can lead to great, and often unecessary, suffering.
gwen, that’s how I felt as well. What struck me as negligent was the mere mention she went on VIN to see how pancreatitis was being treated. Since pancreatitis is a severe condition with the potential to turn into liver disease or even triaditis, I’d think she’d be more educated on the subject and follow the hard and fast rules of treatment. There’s NO room for nonsense CAVM speculation for such a condition (or any other condition requiring aggressive treatment for that matter).
Thinking a bit about the predicament of vets (and human-type doctors, come to that) in dealing with woo-demanding clients – surely it’s down to the governing body of a profession to be upfront about what will and will not be dealt with by qualified practitioners of the profession? Clients are entitled to expect another level of responsibility from the learned professions – that’s why they’re professions and not trades. How would a comparison with the Law play out?.
One cannot expect individual vets to fight the good fight the whole time when the governing body has not come down with a pretty unequivocal ruling on what’s what.
What is the ruling on woo in the US veterinary profession?
Rita; The problem with state veterinary boards is that they are at the mercy of state government to some extent. In Arizona (also notorious for licensing homeopaths and naturopaths) the State veterinary board is appointed by the Governor and consists of 5 licensed veterinarians and 3 members of the public, one of which must be from the livestock industry.
The political aspect of the board makes them reluctant to take on alternative medicine, and the definition of Veterinary medicine is this;
” “Veterinary medicine” includes veterianry surgery, obstetrics, dentistry, acupuncture, manipulation and all other branches or specialties of veterinary medicine and the prescribing, administering or dispensing of drugs and medications for veterinary purposes.”
At least in Arizona, that allows veterinarians to use almost anything that looks like it might be “medicine” (there are a few things under the definition of “malpractice” and “gross incompetence” that would make me nervous if I was thinking about using woo, but that is just me.
It seems as if someone in state government specifically wanted to leave the door open for things like acupuncture, herbal medicine, and chiropractic. The board is not all that well staffed and the board members are not paid much, so I think their main concerns are protecting public health and the economic interests of the livestock industries. I have seen two local vets loose their licenses in the lat 10 years or so-one was an alcoholic who could not count to two any more and the other seemed unable to follow sterile technique or safe anesthetic protocols. They both caused much more mayhem than they should have before they lost their licenses and frankly made a lot of the CAM practitioners around here look good.
Anyway, to make a long story short, it is going to take a lot of work and a long time to change attitudes enough for the state boards to start looking at most CAM more skeptically. Most state boards rely on the veterinary schools to define what veterinary medicine is, and as long as places like CSU can get people to pay thousands for courses in acupuncture, etc, things are not going to change much.
“In Arizona (also notorious for licensing homeopaths and naturopaths) the State veterinary board is appointed by the Governor and consists of 5 licensed veterinarians and 3 members of the public, one of which must be from the livestock industry”.
What fun it would be if human doctors were ruled by a board which obligatorily included someone dedicated to killing them!
Thanks for your reply – I must say it doesn’t sound too optimistic but let us hope for better things.
This is “Skeptico” on the formation of the British Veterinary Voodo Society – this is the legal position in the UK:
“The thing to remember is that unlike human medicine, the law states that only qualified vets are allowed to treat animals. This is because animals can’t choose for themselves. Therefore while the law leaves people free to go to unqualified quacks if they like, they can’t do that with their animals.
This creates a paradox. If vets were prohibited from offering SCAM treatments such as homeopathy, there would be no legal way for animal owners to access them. A responsible regulatory authority would simply say tough, we don’t allow non-evidence-based treatments to be used, and that’s that. However, the British Royal College of Veterinary Surgeons’ (RCVS) attitude is that it’s better for owners to be able to take their animal to a vet who will provide Supplementary, Complementary and Alternative Medicine (SCAM) treatment, than risk them going (illegally) to a lay quack. Consequently, the RCVS sanctions homeopathy.”
-hence the growth of veterinary practices where woo of all types is on offer……………….. is this unstoppable?
I don’t think it is unstoppable, but it will take a lot of work and time to get first the vet schools to start teaching more critical thinking and critical analysis of veterinary treatments, and then working on the state boards as well.
I also think that as the perceived emotional value of pets goes up, more lawyers may be interested in legal action against vets who use ineffective treatments. Advertising standards complaints may have some effect as well, as recently demonstrated in the BCA case against Simon Singh and the Australian Vaccination Network shows.
http://blogs.discovermagazine.com/badastronomy/2009/08/07/the-avn-is-reaping-what-they-sowed/
Sorry I haven’t reponded or posted lately. Been on vacation! 🙂
The legal questions are allways tough ones because, as Bartimaeus points out,the law is a political thing. While I consider certain CAM approaches to be tantamount to malpractice, I recognize that if enough people believe in them the law will never take this position, even if it is the most rational one. The political pendulum of woo swings just like all the others, and we seem to be in what one colleague of mine called a Golden Age of Woo, in the sense that the law is veery friendly to non-evidence-based practices, and there is widespread cultural suspcion of science. I imagine this will eventually swing back the other way, and all I can do is hope to nudge it a bit.
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