The leadership of the American Veterinary Medical Asociation (AVMA) has recommended the House of Delegates (HoD) reject a resolution discouraging the use of ineffective therapies and identifying homeopathy as ineffective. While not disputing that there is no clinical evidence to support any benefit from homeopathy, the leadership does not want the organization to get involved in evaluating or discouraging any veterinary therapy.
The case for this position begins with a positive statement about the role of science in veterinary medicine:
The AVMA believes that scientific discovery is critically important for the continual evolution of clinical practice and should be the basis for the development of public policy in veterinary medicine, public health, agriculture, food safety and the environment.
It is the role of the scientific community to engage in high-quality research and publish their findings in the scientific literature. Clinical practitioners must critically review the literature to determine the best practice for their patients; this is the model for evidence-based medicine. These standards are, of course, constantly evolving and should be the subject of vigorous debate.
It is encouraging to see the AVMA indicate that science, and critical evaluation of scientific research, should be the standard by which veterinary therapies are judged, and to acknowledge the role of evidence-based medicine. It is unfortunate that the organization has not been willing to make such an assertion in the policy concerning complementary and alternative medicine, and that there has been little public support for the centrality of science and scientific research in validating veterinary therapies.
However, part of the reluctance to make such a public statement may stem from the inevitable inconsistency that arises when the organization then refuses to discourage therapies that are inconsistent with science and science-based medicine. The AVMA has acknwledged the overwhelming case against homeopathy and admitted that “there is no clinical evidence to support the use of homeopathic remedies for treatment or prevention of diseases in domestic animals.” So if scientific research should be the basis of veterinary medicine, and if after 150 years of study there is no scientific research the convincingly demonstrates the value of homeopathy, why shouldn’t the AVMA acknowledge this method is a failure and that veterinarians shouldn’t be inflicting it on their patients? The AVMA answers this question with a classic slippery slope argument:
There is a role for professional organizations to convene experts to review the scientific literature on broad subjects, and to develop evidence-based guidance for developing policy. However, as the board of the national organization for the veterinary medical profession, the AVMA must ask itself whether it is the proper arbiter of specific clinical practices. Furthermore, the Executive Board must ask itself whether going down the path of reviewing and judging particular clinical therapies, whether traditional or alternative/complementary, will be supportive of our mission or divisive in our community.
Where does it stop? Consider the wide range of current medical and surgical interventions that could be adjudicated by the AVMA, many of which have varying and conflicting levels of scientific evidence. Popular practices, over time, often turn out to be ineffective, or even harmful.
The claim here is that while organizations like the AVMA should see establishing evidence-based guidelines as part of their mission, they should not challenge the validity of specific clinical approaches because it would be “divisive” and becasue there are a lot of practices they might end up being asked to evaluate.
The first part of this claim is simply a reflection of the fundamentally political nature of the AVMA. The organization exists, of course, to serve the needs of verterinarians, as a lobbying and marketing entity. The needs of veterinary patients and their owners are not a central priority for a professional lobby. This is fair enough so long as the AVMA does not portray itself as serving the larger public. The mission and objective statements of the organization are vague, and open to interpetation in this respect.
The mission of the Association is to improve animal and human health and advance the veterinary medical profession.
The objective of the Association shall be to advance the science and art of veterinary medicine, including its relationship to public health, biological science, and agriculture.
It seems that improving animal health and advancing the science of veterinary medicine could legitimately include discouraging ineffective therapies left over from the days when bloodletting was the chief tool of mainstream medicine. But there is no question that challenging any therapy supported by more than a few veterinarians would be divisive and alienate some part of the AVMA’s constituency. The reluctance to do this is understandable for a membership-based professional lobby, but it does reinforce that the public cannot look to the AVMA as an advocate for their interests or the interests of their animals. When member veterinarians encourage the AVMA to take controversial positions on animal welfare issues, including discouraging pseudoscientific practcies like homeopathy, this challenges the core mission of the group, and so resistance is to be expected.
The slippery slope claim, however, is less convincing. There is quite a large window of opportunity for positive action between tolerating any and all therapies veterinarians wish to employ and micromanaging every clinical practice. A general statement that science and evidence-based medicine should be the foundation for veterinary practice, and specific policies discouraging egregiously and ridiculously pseudoscientific practices like homeopathy, does not commit the AVMA to evaluate every single medical practice available.
The question “Where does it stop?” cuts both ways. The choice the leadership has made not to take a position on any therapy no matter how inconsistent with science-based medicine, is just as extreme as the imaginary problem of having to investigate and rule on every possible therapy. I have heard veterinarians who rely on psychics to guide their patient care, who use astrology to help choose the timing of surgical procedures, who actively discourage the use of vaccines and all other conventional therapies, and who employ other similarly indefensible practcies even more irrational than homeopathy. Is anything a veterinarian wishes to do to a patient, any practice they choose to sell which is not illegal, acceptable? Does the profession, and its most influential organization in the United States, have no responsibility to set standards for patient care or honest informed consent? It seems we have already slid quite a ways down the slippery slope towards medical anarchy and a complete lack of reasonable standards if even something as clearly contrary to established science as homeopathy must be protected from even a purely advisory, non-binding public censure.
The leadership’s statement concludes with assertion that they are taking no position at all on homeopathy by recommending the House of Delegates reject a statement against it
For the AVMA not to condemn homeopathy should not presume endorsement; it simply means that we trust our system of research, practice, teaching and continuing education to sort through the evidence and determine appropriate therapies.
It is disingenuous to suggest that the AVMA leadership can actively oppose a policy identifying homeopathy as ineffective and still claim to be neutral on the practice. To refuse to inform the public of the state of the evidence against homeopathy is certainly to facilitate its continued use, and to put the unity of the veterinary profession above any commitment to a scientifc basis for veterinary medicine or the interests of patients and owners. Though the political realities that inform this position are understandable, it is still choosing sides, and it is still in conflict with the purported belief that science should be the foundation of veterinary medicine.
The leadership claims that we can trust the system to sort out legitimate medical therapies from pseudoscientific nonsense. To a certain extent this is true. The process of scientific investigation can give us reliable information about the value of specific therapies. In the case of homeopathy, over a century of extensive research has been conducted. Most of it is poorly done and highly biased towards demonstrating what the homeopaths conducting the research already believe. However, the better the methodological controls for such bias are, the less likely one is to find any effect, and the balance of the evidence is against any clinical benefit. Combined with the fundamental inconsistency of homeopathic theory with basic principles of established science, the system has rendered a verdict, and that verdict clearly identifies homeopathy as nothing more than a placebo for owners and veterinarians, not an effective therapy for veterinary patients.
The vast majority of the veterinary profession has accepted this verdict and left homeopathy behind, along with many other mainstream and alternative practices of the 18th and 19th centuries. Unfortunately, some veterinarians refuse to acknowledge reality, and they continue to mislead animal owners into believing homeopathy has value. It seems that the system has failed these patients and these owners, and the AVMA could choose to take a stand for science and for our patients and clients by providing a clear statement that homeopathy is not consistent with scientific medicine. This would not make homeopathy illegal or unavailable, or limit anyone’s choice of therapies. It would simply inform the public that the mainstream veterinary profession, committed to science as the foundation of medical care, recognizes homeopathy as a pseudoscientific relic of history and does not support its continued use.
It seems unlikely that the organization will do so in the face of the opposition of senior leaders. While this is disappointing, it is not entirely surprising. And it at least serves the interests of the public that this debate has happened and that the positions staked out by various parties, along with their rationales and evidence, are clearly and publically visible.