Cancer is a common and frightening disease, and many pet owners will have to face making decisions about cancer care for their pets at some point. While there are many therapies that can improve quality of life for a veterinary cancer patient, extend life, and even cure cancer in some cases, the painful reality is that there is much we don’t know about cancer. Often, cancer will be life limiting despite the best care possible.

This unpleasant reality leads many to seek alternative therapies for their pets with cancer. Unfortunately, those alternatives are almost never proven to be safe or effective, and many, such as homeopathy, are unquestionably nonsense. Yet despite the lack of evidence to support many alternative cancer treatments, and the evidence that shows some such treatments can cause real harm, some vets will try to frighten and mislead pet owners into avoiding scientific medical therapies and grasping at the various straws they offer, from homeopathy to acupuncture, from supplements and magical diets to outright magic such as so-called “energy medicine.”

A recent article in the always unreliable Dogs Naturally Magazine provides a number of examples of the kinds of opinion and advice pet owners should recognize as a sign of unreliable, unscientific, and untrustworthy alternative approaches. Along with other warning signs of quackery, statements like these should send pet owners running the other way and seeking legitimate medical advice from real veterinary cancer experts.

The conventional approach is that cancer is a disease separate from the animal, one to be attacked in various ways.

So the attitude is one of attacking something separate from the patient.

The homeopathic approach is to understand the new growth as being generated by the body – by the same energy (life force) that grew other parts of the body. So homeopathic treatment doesn’t fight against the growth or see it as separate.

Instead, nutrition and homeopathic treatment work with the natural healing mechanisms to rebalance the life energy so the tumor is no longer needed or supported.

Then it is resorbed or expelled.
Dr. Richard Pitcairn

Dr. Pitcairn is a leading figure in veterinary homeopathy. Which is to say he is an expert on a large and complex field with no connection to reality and no legitimate medical use. Here, he uses deceptive language to suggest that conventional cancer therapy is aggressive and brutal and that homeopathy is gentle and supportive. The reality is that conventional therapy for pets often provides significant comfortable, enjoyable time for pets with cancer and rarely has side-effects that outweigh the benefits. Homeopathy, on the other hand, is completely and utterly useless, and relying on it for cancer treatment is essentially letting your pet go without any treatment at all. (Here is more information on homeopathy).

Apart from surgery to de-bulk or (hopefully) completely remove the cancer, the conventional veterinary approach is to bombard an already compromised body (scarred by a lifetime spent consuming fake industrial food) with chemical poisons and radiation.

If these modalities don’t kill the patient immediately, they usually promote a more damaging and more aggressive form of cancer, further down the track.

Obviously there are exceptions to this dismal picture, but they are rare exceptions.

Meanwhile, the terminal part of the dog’s life becomes an endless round of treatments, tests and misery.

At this stage, everybody is clutching at straws, hoping against hope that this particular cancer in this particular patient proves to be the exception.

My work (and the work of others who understand that cancer is one of many degenerative disease processes) approaches cancer from the other end of the spectrum.

Instead of weakening the body with poisons and radiation, the far more rational (and genuinely scientific) approach is to strengthen the body, to give it the nutritional tools that allow it to fight the cancer and at the same time use appropriate nutritional means that weaken and take the power away from the cancer.

We find that in most instances, this not only allows longer survival times, but does so with a vastly improved quality of life.
Dr. Ian Billinghurst

Dr. Billinghurst is a well-known proponent of the unproven and theoretically dubious BARF diet (more information about raw diets). In this article, he repeats the inaccurate and misleading characterization of conventional cancer therapy as more harmful than helpful and, without seeing the irony of it, refers to it as “clutching at straws.” His alternative to this is vague and unproven but confidently claims about the ability of his personal dietary theories to provide better outcomes than conventional cancer care. Like Dr.Pitcairn, and the other vets cited in this article, Dr. Billinghurst presents as facts what are really merely his personal opinions. “We find” is code for “there is not controlled research or actual evidence, just our personal anecdotes and beliefs.”

I have written often about why such anecdotes are not reliable substitutes for real science, and this is as true for vets and for pet owners:

Why We’re Often Wrong Testimonials Lie
The Role of Anecdotes in Science-Based Medicine
Why We Need Science: “I saw it with my own eyes” Is Not Enough
Don’t Believe your Eyes (or Your Brain)

I like to use a Traditional Chinese Veterinary Medicine approach: clean up the food, detox the dog and use herbs as well as acupuncture.

I also use herbal chemotherapy agents like Neoplasene and Essiac.

Other options include intravenous vitamin C and B vitamins

The Banerji protocols use two or three remedies in each protocol, with amazing success.

I’ve used these protocols on a lot of animals and many got better.

Cannabis is another option, with different options for different types of cancer.
Dr. Patricia Jordan

Dr. Jordan is one of the most extreme a rabid anti-vaccine vets out there, and I’ve written about her bizarre ideas before. In this article, she illustrates one of the classic alternative practitioner approaches, which is to throw a hodgepodge of different and mutually incompatible practices together into an irrational amalgam that is united only by the practitioner’s fervent loathing for anything scientific or mainstream. I’ve written previously about why TCVM is mystical nonsense that is more religion than medical practice, Neoplasene is a dangerous poison, and cannabis is a mildly promising but as yet unproven remedy that might have some benefits in cancer patients but is not going to cure cancer. Others have discussed the complete lack of evidence to support claims of benefit for Essaic and Vitamin C. The Banerji protocol, of course, is just more homeopathic voodoo.

Apart from the fact that none of the methods Dr. Jordan refers to have any compelling scientific evidence to support their value, they are also completely incompatible in terms of the basic theories about cancer and its treatment that they rely on. Such a mélange exemplifies the desperate and irrational desire to reach for anything not associated with real scientific medicine, and pet owners should avoid any vet who takes such an approach.

Typical conventional medicine includes radical surgery, multiple doses of poisonous chemicals and multiple caustic burning “treatments” to the affected area … slash, poison and burn.

In my holistic practice, homeopathy is the headliner. I use constitutional prescribing to support the entire body, mind and spirit.
Dr. Dee Blanco

Another homeopath, Dr. Blanco repeats the typical fear-mongering mischaracterization of conventional cancer therapy and then promotes replacing real treatment with magic water. She reveals the ultimately faith-based nature of homeopathy by pointing out it is a therapy for the “spirit.” This idea, going back to the inventor of homeopathy, is often concealed by modern homeopaths who realize that many pet owners would be reluctant to replace scientific medicine with a treatment that is more of a religious practice than a medical therapy.

Reliable Cancer Resource for Pet Owners

In the face of the ubiquitous unreliable information from holistic vets such as these, it can be hard to sort out which information is truly useful. Here are some resources that are a good bit more trustworthy.

Veterinary Cancer Society (This group also has a tool for finding a board-certified veterinary cancer specialist.) Here are some of the links the VCS recommends:

• ACVIM Foundation
• American Animal Hospital Association Healthy Pets
• American Association of Feline Practitioners
• American College of Veterinary Radiology
• Animal Cancer Center at CSU
• Animal Cancer Foundation
• Animal Clinical Investigation, LLC
• Boo Radley Foundation
• Brazilian Society of Veterinary Oncology
• C3O: Center of Clinical Comparative Oncology
• Canine Health Foundation
• Cornell’s College of Veterinary Medicine “Consultant”
• ESVONC (European Society of Veterinary Oncology)
• Magic Bullet Fund
• Perseus Foundation
• PubMed
• QuitDay.org
• Morris Animal Foundation
• The National Cancer Institute
• UC Davis Comparative Cancer Center
• University of Pennsylvania’s “Oncolink”
• Vaccine Associated Feline Sarcoma Task Force
• Veterinary Center for Clinical Trials at the University of California-Davis
• Veterinary Society of Surgical Oncology

The Veterinary Cancer Center

I first wrote about the subject of hospice care for animals in the first year of this blog, 2009. I feel strongly that there is a need to adapt the concepts of hospice and palliative care developed in human medicine to the needs of veterinary patients. While euthanasia is, thankfully, an option for most terminally ill veterinary patients, this does not obviate the need for appropriate relief of the suffering of our patients and for thoughtful conversations with pet owners about death and how to approach end of life issues.

One of my favorite authors, Atul Gawande, has written a brilliant book called Being Mortal, which looks at the successes and failures of the medical system in America when handling the end of life. One of the bright spots is the role of hospice care in providing a comfortable, meaningful, and dignified end to human life. Our veterinary patients deserve the same.

However, while I have great respect for the vets who are trying to bring the benefits of hospice care to animals under veterinary care, I have some concerns as well. One is the role of spiritual questions in animal hospice care. Because the end of life brings our spiritual beliefs to the fore, the beliefs of animal owners are certainly relevant to how a veterinarian manages the care of a patient at the end of life. In the most extreme cases, euthanasia may not be an option at all due to some people’s religious beliefs. While I may disagree with such a position, it is not the role of a vet to challenge a client’s personal beliefs in this situation. It is, of course, a vet’s role to act as an advocate for the welfare of the patient. Hospice care provides a way to protect the welfare of the patient even when there may be a conflict between the needs of the patient as the veterinarians sees them and the choices of the animal owner.

However, there are some in the animal hospice community who actively insert their own personal spiritual beliefs into the practice of veterinary hospice care, and this is troubling. The International Association of Animal Hospice and Palliative Care (IAAHPC) specifically supports, for example, the right of a hospice veterinarian to “have a principled moral objection to euthanasia, in general, and refuse to perform the procedure regardless of the circumstances.”

This seems an untenable position for a veterinarian providing end-of-life care when euthanasia is almost universally seen as an appropriate choice to minimize suffering in terminally ill animals. While the IAAHPC does recommend such veterinarians tell clients about their position before taking on a hospice care role and refer for euthanasia if a client wishes it, this seems an ethically dubious position.

The right of service providers of any kind, including healthcare workers, to refuse to provide services that are legal and ordinarily provided by people in their role as a result of their personal beliefs, including religious beliefs, has generally not been widely recognized as a legitimate right, nor has it been generally upheld by the courts. Personal beliefs don’t typically exempt one from performing the expected duties of one’s profession, so this seems a questionable exception to carve out for hospice veterinarians.

Much more worrisome, however, is the strong and consistent role of alternative medical therapies in educational and policy documents from the organized veterinary hospice community. The IAAHPC guidelines specifically endorse “integrative medicine” and the inclusion of alternative therapies in end-of-life care:

An integrative approach, using conventional and CAVM therapies, is recommended using the most appropriate interventions that control pain or other clinical signs. It is the recommendation of this Task Force that veterinary practitioners and animal hospice team members maintain current knowledge of the available treatment options for patients, whether these options are complementary or allopathic, and to choose therapies that are the most effective in treating the patient’s condition, most beneficial to the patient’s overall quality of life and have the fewest undesirable side effects.

Given the robust reasons to doubt the safety and effectiveness of most alternative therapies, this seems a perilous and irresponsible position to take. If a treatment doesn’t work, it provides no benefit to the patient, and integrating it into patient care cannot improve quality of life. Integrating it at the expense of scientific therapies, however, can certainly worsen patient care. As I discussed in my previous article, this appears to be the result of the fact that many of the leading figures in the animal hospice movement are also CAM providers. They have faith in CAM treatments regardless of the lack of evidence or even evidence against this belief, and as a result they assume the value of these therapies and promote them as a beneficial part of hospice care. Substituting personal belief and experience for scientific evidence is not the best way to protect patients, especially those as vulnerable as animals in hospice care.

There is, of course, limited and weak evidence for many veterinary therapies, conventional as well as alternative. And the area of pain control is especially difficult to generate strong, objective evidence in because the challenges in measuring pain and the effects of pain relieving treatments. Some CAM therapies fall into a grey zone where there is at least some plausible reason to think they may have benefits, or at least a level of evidence no worse than that available for conventional therapies. For example, though the evidence is not strong, there is some reason to think cold laser therapy (1,2), massage, and other kinds of physical medicine may have some benefits in terms of comfort, wound healing, and other issues relevant to hospice patients. Even acupuncture, if divorced from the nonsense of Traditional Chinese Medicine, might have some small beneficial effects, though the evidence is complex and uncertain.

Use of such methods, so long as it is not to the exclusion of science-based treatments, is not entirely unreasonable if measured claims are made and clients are given honest information about the limitations of the evidence. However, there are also CAM methods recommended by proponents of animal hospice that are clearly ineffective and can have no benefits at all. For example, a prominent and extreme proponent of veterinary homeopathy, Christine Chambreau (3,4,5), has lectured at the IAAHPC conference on the use of homeopathy in hospice patients.  As always, suggesting that homeopathy has any legitimate role in veterinary care ignores the overwhelming evidence that it is ineffective, and this is completely unethical. Substituting homeopathy for any real medical therapy is dangerous and wrong, and this should never be even tacitly endorsed by anyone interested in legitimate compassionate end-of-life care.

Similarly, the IAAHPC has had proponents of Reiki speak at their conference, and the organization even has a link to a pro-Reiki web site on their own web page. Reiki, of course, is a variety of “energy medicine,” which amounts to nothing more than a non-denominational variety of faith healing. It is fundamentally a spiritual practice, not only not proven to have any beneficial effects but outside the domain of science altogether since it is entirely faith-based. Offering it as part of hospice care not only promotes an unproven and unscientific practice as if it were a legitimate medical intervention, it blurs the distinction between the veterinarian as a healthcare provider and a spiritual counselor. This intrusion of personal spiritual beliefs into animal hospice is not in the best interests of patients or the hospice movement.

The IAAHPC does appear to view CAM not only as likely to be effective, but potentially as a substitute for some conventional therapies. For example, in the organization’s hospice guidelines, they state, “CAVM therapies may aid in reducing the required dosages of certain drugs.” And the usual misguided notion of scientific evidence as an optional “extra” rather than essential to evaluating the safety and effectiveness of our treatments appears in IAAHPC conference talks about the use of CAM in hospice care:

These therapies are safe, noninvasive, relatively inexpensive, and accessible… Their use can promote natural healing mechanisms… and also will create a sense of wellbeing in the patient. Serious and life-altering medical conditions…have been found to be responsive, to some degree, to the use of diet, nutraceuticals and botanicals and acupuncture.

Patients who are in terminal care may not have the time to wait for the completion of more studies validating the benefit of the concurrent use of complementary therapies… Each clinician needs to decide where they stand in terms of the degree of rigor of the evidence versus the benefit-potential that complementary therapy could provide their patients’ QoL. In the hospice-palliative care realm, using evidence-based measures is of paramount importance, as long as the patient doesn’t suffer as a result of the time spent in academic bickering over the level of quality of the evidence.

This sort of position assumes the efficacy and safety of methods when these are often not, in fact, well-demonstrated, and it assumes that it is somehow better for patients to be exposed to therapies with little to no evidence of safety and effectiveness and significant controversy about their effects than to test these therapies before using them. The normal process of scientific investigation, which has brought such tremendous and unprecedented health benefits to the all of us, is dismissed as “academic bickering,” and it is assumed that any objection to trusting anecdote as the basis for using CAM treatments is a mere pedantry. Such views place the well-being of patients at the mercy of the beliefs and opinions of individual veterinarians, even when these conflict with scientific evidence.

Bottom Line
I believe hospice care has the potential to make the end of life more comfortable and peaceful for many veterinary patients, and I think it is crucial that we do a better job as a profession of serving the needs of patients and their human caregivers at this challenging and emotional time in the cycle of life.  However, I think our clients and patients are especially vulnerable when coping with terminal illness and death, and we have a responsibility at this time, perhaps more than any other, to be sure the care we offer is the best, safest, and most effective possible. Science and scientific evidence offers the best tool available for evaluating the treatments we offer, and it has earned the special roles it plays as the primary means of identifying the risks and benefits of the treatments we employ.  While we must often make due with less than optimal evidence in making clinical decisions, we are ethically obligated to rely on science to the greatest extent possible in choosing therapies and counseling our clients.

Unfortunately, the organized animal hospice movement includes a relatively high proportion of veterinarians who are believers in unproven or even outright ineffective therapeutic practices, including acupuncture, herbal medicine, energy medicine, homeopathy, and others. Because of this representation, organizations and individuals promoting hospice care are often also promoting the misguided “integrative medicine” approach (c.f. 6, 7 for more  on this concept). This includes treating both promising but unproven treatments (such as low-level laser therapy), disproven treatments (such as homeopathy), and even fundamentally spiritual or religious practices (such as Reiki) as if they were the equivalent of science-based conventional medical interventions. This misleads clients and places patient welfare at risk.

While the IAAHPC does acknowledge that hospice therapies should be effective and, to the extent possible, evidence based, in general it leaves the evaluation of these therapies to the discretion of individual veterinarians and takes a very weak stance on how efficacy and evidence are to be judged. While I truly do admire and share the goals of the animal hospice movement, and I appreciate the sincerity and commitment of hospice veterinarians, including those who offer CAVM treatments, to the well-being of hospice patients, I am troubled by the views of the IAAHPC and individual hospice providers towards CAVM and evidence-based medicine.

There is abundant evidence that our perceptions of the efficacy of our therapies are unreliable and misleading, and that caregiver placebo effects readily fool us into thinking we are alleviating suffering in our pets and patients even when we are using ineffective treatments. Sadly, the majority of veterinarians, whether primarily conventional of CAM-oriented, do not seem to appreciate this. In the case of hospice patients and their owners, this attitude has significant potential to lead to unnecessary suffering or ineffective care since there is often a perception of “nothing to lose” at the end of life. However, the experience of dying can be made more uncomfortable than it need be when ineffective treatments are used, and it is imperative the as a community veterinarians are vigilant in minimizing the risk of this in animal hospice patients.

The focus of this blog is the relationship between science and medicine, with an emphasis on skepticism, not politics. However, larger cultural problems in our attitudes towards science and reason are relevant in that they impact how people perceive science and scientific evidence, and the choices they make as a result. I was sufficiently impressed by some of President Obama’s recent remarks during a commencement speech at Rutgers University that I want to reproduce them here. I think they are an insightful commentary on a pervasive and dangerous anti-intellectualism that bedevils not only our political system but our ability to make choices, as a society and as individuals, about matters connected to science and health.

Facts, evidence, reason, logic, an understanding of science—these are good things. (Applause.) These are qualities you want in people making policy. These are qualities you want to continue to cultivate in yourselves as citizens. (Applause.) That might seem obvious. (Laughter.) That’s why we honor Bill Moyers or Dr. Burnell.

We traditionally have valued those things. But if you were listening to today’s political debate, you might wonder where this strain of anti-intellectualism came from. (Applause.) So, Class of 2016, let me be as clear as I can be. In politics and in life, ignorance is not a virtue. (Applause.) It’s not cool to not know what you’re talking about. (Applause.) That’s not keeping it real, or telling it like it is. (Laughter.) That’s not challenging political correctness. That’s just not knowing what you’re talking about. (Applause.) And yet, we’ve become confused about this.

Look, our nation’s Founders—Franklin, Madison, Hamilton, Jefferson—they were born of the Enlightenment. They sought to escape superstition, and sectarianism, and tribalism, and no-nothingness. (Applause.) They believed in rational thought and experimentation, and the capacity of informed citizens to master our own fates. That is embedded in our constitutional design. That spirit informed our inventors and our explorers, the Edisons and the Wright Brothers, and the George Washington Carvers and the Grace Hoppers, and the Norman Borlaugs and the Steve Jobses. That’s what built this country.

And today, in every phone in one of your pockets—(laughter)—we have access to more information than at any time in human history, at a touch of a button. But, ironically, the flood of information hasn’t made us more discerning of the truth. In some ways, it’s just made us more confident in our ignorance. (Applause.) We assume whatever is on the web must be true. We search for sites that just reinforce our own predispositions. Opinions masquerade as facts. The wildest conspiracy theories are taken for gospel.

But when our leaders express a disdain for facts, when they’re not held accountable for repeating falsehoods and just making stuff up, while actual experts are dismissed as elitists, then we’ve got a problem. (Applause.)

You know, it’s interesting that if we get sick, we actually want to make sure the doctors have gone to medical school, they know what they’re talking about. (Applause.) If we get on a plane, we say we really want a pilot to be able to pilot the plane. (Laughter.)  And yet, in our public lives, we certainly think, “I don’t want somebody who’s done it before.”  (Laughter and applause.)  The rejection of facts, the rejection of reason and science—that is the path to decline. It calls to mind the words of Carl Sagan, who graduated high school here in New Jersey—(applause)—he said: “We can judge our progress by the courage of our questions and the depths of our answers, our willingness to embrace what is true rather than what feels good.”

A while back, you may have seen a United States senator trotted out a snowball during a floor speech in the middle of winter as “proof” that the world was not warming. (Laughter.) I mean, listen, climate change is not something subject to political spin. There is evidence. There are facts. We can see it happening right now. (Applause.) If we don’t act, if we don’t follow through on the progress we made in Paris, the progress we’ve been making here at home, your generation will feel the brunt of this catastrophe.

So it’s up to you to insist upon and shape an informed debate. Imagine if Benjamin Franklin had seen that senator with the snowball, what he would think. Imagine if your 5th grade science teacher had seen that. (Laughter.) He’d get a D. (Laughter.) And he’s a senator! (Laughter.)

Look, I’m not suggesting that cold analysis and hard data are ultimately more important in life than passion, or faith, or love, or loyalty. I am suggesting that those highest expressions of our humanity can only flourish when our economy functions well, and proposed budgets add up, and our environment is protected. And to accomplish those things, to make collective decisions on behalf of a common good, we have to use our heads. We have to agree that facts and evidence matter. And we got to hold our leaders and ourselves accountable to know what the heck they’re talking about. (Applause.)

He also touched on the issue of engagement with people and ideas with which one disagrees, another important and relevant issue:

If you disagree with somebody, bring them in—(applause)—and ask them tough questions.  Hold their feet to the fire.  Make them defend their positions.  (Applause.)  If somebody has got a bad or offensive idea, prove it wrong.  Engage it.  Debate it.  Stand up for what you believe in.  (Applause.)  Don’t be scared to take somebody on.  Don’t feel like you got to shut your ears off because you’re too fragile and somebody might offend your sensibilities.  Go at them if they’re not making any sense. Use your logic and reason and words.  And by doing so, you’ll strengthen your own position, and you’ll hone your arguments.  And maybe you’ll learn something and realize you don’t know everything.  And you may have a new understanding not only about what your opponents believe but maybe what you believe.  Either way, you win.

We need this perspective, in politics and everywhere else in our society, and it was inspiring to hear someone in the most prominent and visible public position articulate and defend it.

I recently came across an interesting paper that cited some of my previous writing about the relationship between evidence-based medicine and alternative medicine.

M.A. Memon, J. Shmalberg, H.S. Adair III, S. Allweiler, J.N. et al. Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges. Open Veterinary Journal, (2016), Vol. 6(1): 44-56.

This article presents an argument for how and why alternative therapies should be taught in veterinary schools under the heading of Integrative Medicine. This argument contains a number of reasonable points and also a number of significant flaws. I’ll begin with the points of agreement between my view and that of the authors.

Where I Agree
The paper starts by arguing that because many CAM therapies are sought by animal owners and have a certain degree of popularity, veterinarians are likely to encounter them. While the authors cite some specific numbers about the popularity for alternative therapies that are a bit misleading, there is no doubt that most vets will regularly encounter questions about alternative therapies from clients. Since one of the most important roles for a veterinarian is as an educator helping clients make fully-informed decisions about the care of their animals, it is necessary for vets to be knowledgeable about those CAM therapies clients may seek or already be using.

Of course, the most appropriate response to clients questions about such methods is often to explain the lack of plausibility and supporting evidence behind the practice and discourage its use. And if vet students are to be taught about CAM, the controversial issue, of course, is precisely what they should be taught about these practices. That will be addressed shortly, but in any case, vets do need to understand the claims made about CAM therapies and the evidence available regarding them, and having some formal introduction to this subject in veterinary school makes sense.

Another point on which the authors and I agree is that such instruction about CAM practices should not be provided or funded by organizations with a primary mission of promoting or teaching CAM. I have discussed previously the role of the AHVMA and AHVMF, the Chi Institute, and other CAM training and advocacy groups in promoting alternative therapies, often blatantly disregarding or misusing scientific evidence to further their agenda. Any involvement of such groups in teaching CAM would introduce a severe risk of bias and likely make such training more a marketing exercise rather than a legitimate, evidence-based means of preparing vets to answer client questions about CAM.

While I agree with the authors about the importance of minimizing the risk of bias in the teaching of CAM in veterinary schools, I am not convinced that this can be readily achieved. This article, for example, was itself a product of an effort initiated and conducted in association with the American Academy of Veterinary Acupuncture, so it already involves exactly the kind of support from a group advocating for a particular CAM therapy which the authors are acknowledging can introduce bias into the teaching of CAM. In addition, a number of the lead authors are also instructors at the Chi Institute, members of the AHVMA, and otherwise affiliated with CAM advocacy groups that have a clear bias with regard to the safety and efficacy of alternative therapies.

And as I have discussed before, the very question of expertise in CAM raises the issue of potential bias. Almost no one pursues advanced training or certification in an alternative medicine practice unless they are irrevocably committed to a belief in its value to patients. However, in the case of some such therapies, there is substantial reason to doubt whether the principles or practices for which such expertise is defined have any reality at all. Being an expert in homeopathy, for example, is a bit like being a Catholic priest. The expert undoubtedly has extensive knowledge about the relevant subject matter. But by itself, this knowledge doesn’t demonstrate the objective reality or truth of this subject matter to those outside of the belief system, and such expertise is of little value to those who are not already believers.

If only CAM “experts” are involved in teaching CAM to veterinary students, the content of this education is going to necessarily be rooted in beliefs about the underlying truth of the matter regarding these therapies which are not widely accepted by scientists and conventional healthcare providers. Even if an effort is made to include some skeptical input into these courses, it will be difficult to find outsiders who have put the time and effort into investigated the claims of CAM advocates and understand their theoretical and evidentiary limitations.

The inclusion of such skeptics, when they can be found, doesn’t entirely solve the bias problem in any case. This potentially sets up the presentation of CAM as merely a difference of opinion among scientists or clinicians. This may be true for some CAM practices, but for others (homeopathy being, again, the classic example) there really is no substantive difference of opinion among scientists, simply a consensus based on evidence which a small group of true believers refuse to acknowledge.

So while the ideal of a course which teaches vets what they need to know to effectively answer client questions and provide guidance about CAM in an objective, evidence-based way is laudable, in practice it seems very difficult to achieve. In fact, the very premise of his article, that there is benefit to patients in a strategy which integrates the disparate domains of conventional and alternative medicine, is debatable, as I will discuss shortly.

Finally, there are a number of other points on which I agree with the authors of this article. They are clear that any discussions of CAM with students should emphasize relevant research evidence appraised critically rather than simply personal or anecdotal experience, historical traditions, etc. The limitations of such evidence should be explicitly presented, the critical issue of placebo effects should be addressed, potential risks as well as potential benefits should be communicated, and CAM therapies should not be presented as replacements for established conventional treatments. I also agree with the authors that many conventional medical practices lack strong supporting research evidence, and it can be appropriate to consider alternative therapies that have the same level of basic plausibility and limited supporting evidence as such conventional treatments when the urgency of intervening justifies the uncertainty about the effects of doing so.

Where I Disagree
There are also, however, many points on which I would disagree with the authors of this article. Perhaps the most obvious is the merits of the very concept of Integrative Medicine. If we can demonstrate a particular therapy is safe and effective using appropriate scientific testing, why does it require a separate category, whether we label it “alternative or “integrative,” to be utilized as part of our overall treatment approach? If we test a therapy, show it works, and begin using, how is it not simply another tool of conventional or science-based medicine?

Tim Minchin has most eloquently delineated the real meaning of terms such as complementary and alternative:

By definition…complementary and alternative medicine…have either not been proved to work or been proved not to work. Do you know what they call alternative medicine that’s been proved to work? Medicine.

Or, perhaps less poetic but still to the point, as Dr. Marcia Angell has put it:

There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted.

The concept of integrative medicine requires that we combine therapies that are in some sense viewed separate but equal. But what is the nature of this difference? The usual differences that turn out to justify this separateness include: a theoretical foundation that is incompatible with established scientific knowledge; a lack of supporting scientific evidence; or a committed group of supporters who believe a therapy is safe and effective based on anecdotal experience or historical and cultural tradition despite the absence of supporting scientific evidence.

There is no reason to integrate a plausible and scientifically proven therapy into mainstream medicine but preserve for it a separate identity as “alternative.” If we treat all proposed therapies equally, evaluating their mechanisms and clinical effects at every level through rigorous research, then we can simply accept those that prove their value and abandon the rest. The only use for a special category of Integrative Medicine is to present some therapies as equal in legitimacy to conventional treatments before they have been properly tested and proven their worth.

Another problem with the concept of Integrative Medicine is that it is arbitrary in which practices it encompasses. Since most of the authors of this paper practice acupuncture, of course that is included in their suggested course material. Botanical or herbal medicine is also included, and one could claim this is justified since this is one of the most popular CAM practices. However, dietary supplements are arguably even more widely used, and they aren’t mentioned in this category or under “integrative nutrition.” Are these an alternative therapy to be integrated, based on scientific evidence, with conventional treatments? They are usually marketed as such by CAM practitioners. Or, if such supplements are shown to be safe and effective for particular conditions, are they simply yet another element of scientific medicine? My use of fish oils for atopic dermatitis and arthritis isn’t practicing “integrative medicine.” It is just making use of a nutritional intervention with reasonable plausibility and supporting research evidence in the usual course of scientific medicine.

Similarly, the authors identify Physical Rehabilitation as a key content category for an integrative medicine course. While there is a disappointing lack of research in this area involving veterinary patients, physical therapy is an established, ordinary part of conventional human medicine. There is no reason to create a special category to teach this in an evidence-based way to veterinary students. It should be included in the curriculum just like any other mainstream medical practice.

On the other hand, the authors suggest that the philosophical and theoretical principles of TCM and homeopathy should be taught as part of integrative medicine despite being completely inconsistent with the principles and established knowledge of basic science. The authors take something of a “teach the controversy” approach similar to that used by creationists.

The argument is that we should teach the different points of view and let students make up their own minds. Of course, this is nonsense when the context is the explicit education of students in science and science-based medicine. There is no controversy about biological evolution in science, so no need to teach religious or philosophical alternatives in the science classroom, though these may be worth studying in the domains of religion, history, cultural studies, and psychology. Likewise, there is no scientific controversy about potentization by dilution and succession or the role of Excess Wind in generating disease. These are religious and philosophical ideas which have no place in the science classroom.

If the authors believe it worthwhile to expose veterinary students to pseudoscientific or anti-science views of health and disease for the purpose of preparing them to refute these when asked about them by clients, there might be some merit to that idea. However, this needs to be done with the explicit and clear intent of inoculating students against such ideas. And the course material should then include energy medicine, Bach flower essences, Reiki, intercessory prayer, and other widely available faith-based health practices. However, the authors do not suggest that a major focus of the course should be preparing veterinarians to refute or discourage alternative medicine practices. The exclusion of some unscientific philosophical views and inclusion of others in the suggested curriculum seems to be mostly a feature of the authors’ own views of what is clinically useful. Once again, bias proves slippery and difficult to eliminate from a course on CAM approaches.

The reluctance to explicitly refute any CAM practice, regardless of the evidence, is a consistent problem in alternative veterinary medicine, though conventional vets sometimes seem just as unwilling to reject implausible or disproven CAM practices and CAM vets. Unfortunately, science works primarily not by validating but by rejecting hypotheses. The key to its effectiveness is that our biases tend to lead us to confirm our existing beliefs, and the tools of science that limit the misleading effects of these biases tend to help us reject our hypotheses when they are mistaken. While scientific research is often seen as primarily useful for confirming what we already think we know, this is actually not how it works best.

There is almost no hint in this article of the important role of any course addressing CAM in discouraging therapies that are clearly incompatible with science or have been shown pretty reliably not to be effective. How can we teach vets to respond effectively to client questions about healthcare practices if we are unwilling to ever acknowledge that some are ineffective or harmful and should be discouraged?

Conclusions
These authors represent a group of veterinarians with legitimate expertise in scientific medicine, and they have produced a thoughtful and interesting document. While I agree with a number of their key points, I think it is a bit misleading to call this a “consensus guideline.” It is only the consensus among individuals with a pre-existing belief in the premises of their own argument. All the authors believe acupuncture is a useful therapy, though that is not something one can reasonable call established by good science. Many believe more generally in the value of Traditional Chinese Medicine as a method for evaluating disease and choosing therapies, despite the deep incompatibility of this faith-based folk system of metaphors and the principles, methods, and knowledge base of science. And all the authors believe in the concept of Integrative Medicine as a useful schema for evaluating alternative therapies and integrating them into mainstream clinical practice. All of these beliefs are controversial and outside the mainstream scientific view.

Ultimately, the type of curriculum proposed here would almost certainly function as a Trojan horse for alternative therapies. CAM practices would be treated as different but equal to conventional practices, and this would create the impression that they can be reasonable accepted and employed regardless of the plausibility of their underlying mechanism or the evidence for their clinical effects. Though the authors claim to agree with my assertions elsewhere that all potential interventions should be assessed by the same, soundly scientific standards, they have advocated the concept of integrative medicine, which ultimately fails to accomplished that. Rigorous testing of individual interventions and acceptance or rejection on their merits does not require that some practices be viewed as special and be “integrated” with conventional medicine. These practices should, if they prove their worth, simply be “medicine,” and they should be taught as such.

I do still agree with the authors that some attention to CAM should be paid in the veterinary school curriculum in order to prepare students to answer questions and guide clients in the use or rejection of these practices. The best way to accomplish that, however, isn’t clear. I personally think an explicit course in Integrative Medicine will inevitably have an inherent bias towards promoting CAM practices as equivalent to conventional interventions regardless of the quality of evidence or the compatibility of the basic theory with established science. It might be better to have a section in a broader course about Evidence-Based Medicine which is devoted to Evaluating Unconventional Therapies. Such a section could illustrate the application of EBM methods to the panoply of CAM practices, from the plausible and well-studied to the disproven or inherently unscientific and faith-based. Students would learn about these approaches in a way that emphasized the need for a consistent, science-based approach to evaluating all potential interventions, rather than the perspective of seeking out CAM therapies to be integrated into clinical practice based on anecdote first and then scientifically evaluated later all while maintaining a distinct ideological identity as “integrative.”

This approach would best serve the needs of both vets and animal owners. Vets would get a better, more thorough instruction in how to use science most effectively to make decisions and recommendations about all possible interventions, and all ideas would be treated equally and fairly and judged by the same epistemological standards. The fundamentally ideological categories of CAM and Integrative Medicine would be unnecessary. Those practices that prove their value through the usual route of scientific investigation would simply be “medicine,” and those that did not would simply be unproven or failed hypotheses, not entitled to special treatment simply because of the faith some vets or owners have in them or their historical origins.