This slide presentation, and narrated video version, look briefly at the danger of relying on individual clinical experience rather than formal scientific research in making medical decisions.
Slide Presentation
This slide presentation, and the narrated video version, are part of a talk given at the annual convention of the American Veterinary Medical Association. The subject was whether or not one can apply the approach of evidence-based medicine to complementary and alternative medical practices. The presentation reviews some of the philosophical principles underlying both approaches and discusses potential areas of conflict between them.
A slightly more detailed examination of the subject will also be available as a commentary in the upcoming August 15th issue of the Journal of the American Veterinary Medical Association.
McKenzie, BA. Is complementary and alternative medicine compatible with evidence-based medicine? Journal of the American Veterinary Medical Association. 2012;241(4):421-6.
Slide Presentation (Powerpoint):
Can Complementary and Alternative Medicine be Evidence-Based Medicine?
The direct quotations from Dr. Eisen’s web sites were temporarily removed pending the outcome of a DMCA copyright complaint. Since no legal action was taken during the 14-day waiting period mandated under the DMCA, the original quotations have been restored.
Most of the individuals I write about who are promoting questionable veterinary medicine, or outright nonsense, are veterinarians. Such individuals have some claim to legitimacy and authority in recommending veterinary treatments, and so their voices tend to carry more weight than those of most lay people. This isn’t always a good thing since veterinarians are no less prone than anyone else to getting bad ideas stuck in our heads or to being misled by all the features of the world and our own brains that so easily fool us. Experts, that is individuals with recognized credentials and formal training in a specific area of medicine, do tend to have more factual knowledge in that subject. But they are not immune to making mistakes, so as always it is the ideas and the evidence that must be given the greatest way, not the authority of the individual.
Because advice from veterinarians is more likely to be trusted, even when it’s bad advice, I focus on these sources when pointing out why certain ideas, practices, or products are not supported by good evidence and science. However, once in a while I run across a particularly egregious example of misleading a negative advertising for alternative medicine that I feel obliged to challenge even though the source is not a veterinarian. Here’s a quick example of why I noticed this one:
If your dog has been given the heart-breaking diagnosis of terminal cancer… Just About EVERYTHING Your Vet Told You Is WRONG!
Don’t Let Deadly Mistakes Take Your Beloved Companion Away From You –There IS a Way to Save your Dog
Subtle, thoughtful argument, eh?
Steven Eisen is a “Holistic Dog Cancer Expert.” How did he get to be an expert? Well, according to his website first he read about holistic medicine in college, then he studied at the New Age Esalen Institute, and then he graduated from a college of chiropractic. Oh, and when his own dog got cancer he ignored his veterinarian’s advice and made up a bunch of stuff about diet and supplements, and since his dog lived longer than he says the vet predicted, he must have discovered the cure for dog cancer. Now, he would like you to buy the secret to curing cancer from him in the form of his book, Dog Cancer: The Holistic Answer.
I wasn’t willing to support the promotion of this nonsense by buying the book, but Dr. Eisen does offer some glimpses of his ideas on his web site and in a number of free videos. [except, of course, he will threaten to sue you if you tell anyone what he says in them]. These exhibit nearly all the warning signs of quackery, and Dr. Eisen doesn’t provide any evidence beyond his own opinion and the usual unreliable miracle stories for his claim that he has a simple, safe, effective therapy that scientific medicine either doesn’t know about or doesn’t want you to know about.
His primary web site, DogCancerAdvice.com, offers the usual sorts of unsubstantiated attacks on the ignorance and futility of conventional veterinary medicine. For example:
“The training of these professionals [veterinarians] has superbly equipped them to treat acute problems like infections, heartworm, and trauma. However, there are no standard veterinary protocols for dog cancer. The only treatments taught in veterinary school are the toxic ones…despite the scientific evidence that they are not effective. “
“Although some veterinarians claim to combine conventional and alternative dog cancer treatments, it’s rare to find one that has a thorough understanding of the principles of holistic medicine and holistic treatments for cancer in dogs. An issue that’s consistently ignored is that the two approaches are often incompatible because the underlying assumptions are worlds apart. If a gardener said he would take care of your lawn with both pesticides and organic methods, I think you would wonder about his expertise, his intelligence and/or his honesty.”
“If there were a brush fire in the forest, would it make sense to set the rest of the forest on fire? That is essentially the conventional approach to treating dog cancer.”
“Unfortunately, many have been following dangerously mistaken advice from their vets. The quality of your dog’s life can improve, and even be healed from cancer with the right information. “
“In vet speak, a dog with lymphoma is considered “cured” by conventional treatment if it survives 8 months.” [This is simply untrue. No veterinarian wuth any knowledge of cancer therapy would claim to be able to cure lymphoma. The word he’s looking for is “remission,” and the mean remission time for lymphoma with conventional treatment is about 10-14 months]
Dr. Eisen then gives detailed numbers showing so-called “holistic” treatment is cheaper than conventional cancer therapy, which seems a transparent attempt to prey on people who would like the best care possible for their pets but have significant financial limitations. He lists the potential side effects of conventional treatment without any information about how common or severe these might be and no mention of the benefits of treatment. And he finishes with the usual nonsense that Quote removed which basically says alternative cancer treatments work without any side effects. The bottom line:
“Not only are alternative treatments less toxic and more effective, they also cost just a fraction of what you would pay for conventional treatments. “
So a cheap, simple, effective cure for cancer with no risks or side effects which, for reasons we can only guess at, almost none of the veterinarians (or physicians, for that matter) know about or use. Hmmm, how likely does that seem to you? Well, let’s see what Dr. Eisen’s argument is.
1. The Toxins Did It!
Part of being an expert in dog cancer is apparently being a toxicologist. Well, ok he’s not actually a toxicologist, but he says dog cancer is all about toxins, so we have to believe him, right?
Most of Dr. Eisen’s rant about toxins as a cause of cancer is indistinguishable from the usual oversimplified, mythologized nonsense about how the whole world is full of poisonous chemicals. The fact that some substances, both natural and human made, can cause disease, including cancer, in some people at some dose has nothing to do with the almost religious notions about contamination and purification behind the notion of “detoxification” as a treatment for disease.
Dr. Eisen lists a myriad of substances that are to blame for your pet’s disease, including vaccines, commercial pet food ingredients (including pretty much every part of the animal except muscle meat), bacteria as well as the antibiotics used to treat them, vaccines, flea and tick control products, and both tap water and bottled water (which are allegedly full of pharmaceuticals and that classic bugbear of quacks—fluoride). All of the accusations are presented as fact despite the absence of real data to support them. Nothing sells like fear!
Examples of Dr. Eisen’s sophisticated, thoughtful reasoning balancing risks and benefits include these remarks:
“If your dog has cancer, it is imperative that they never receive another vaccination. Not ever again for the rest of their life.”
“I can’t emphasize this too much. You need to eliminate the application of all commercial flea and tick products if you want to keep your dog healthy.”
2. My Diet is the Best!
Apparently, despite having no formal training in veterinary nutrition, Dr. Eisen is also an expert in cancer nutrition as well. With his usual abundance of confidence, and lack of evidence, he makes a number of claims about cancer and diet.
First, he recommends a homemade diet because, quote removed due to lega coplaint which basically says no commercial food is good for dogs with cancer. He dismisses the one cancer-specific diet on the market because of the usual myth about “byproducts” (the parts of the animal affluent Americans find yucky but that are routinely eaten by people in other cultures and universally enjoyed by wild and feral carnivores). And he completely ignores the strong evidence that homemade diets are almost always nutritionally incomplete.
Next he recommends a low-carbohydrate diet for dogs with cancer. There is some research which suggests carbohydrate restriction could have benefits for cancer patients. There is, as yet, no consistent body of evidence in humans or in dogs to indicate they actually do have benefits, so the idea is reasonable but still tentative.
He makes some arbitrary restrictions, such as banning pork as a protein source, and recommends a host of herbs which rumor, but no convincing scientific research, suggests might have anti-cancer properties. Despite the lack of any evidence to show this diet is nutritionally adequate, much less that it has a significant impact on the health or longevity of cancer patients, Dr. Eisen concludes, “This truly is healing food for your dog with cancer.”
Why? Apparently because he says so.
3. #1 Worst Thing
Dr. Eisen states repeatedly, that cancer is growing more and more common in dogs. He bases this on reports indicating cancer is diagnosed more frequently now than ten or twenty years ago. This is likely true, though the data is not from very high quality controlled studies. Unfortunately, one area in which Dr. Eisen is not an expert is epidemiology, the study of the occurrence and causes of disease. He assumes simplistically that more cancer diagnosis means more cancer, which he then goes on to attribute, again based only on opinion, to a more toxic environment. However, more diagnosis of cancer does NOT mean that our dogs are sicker than they once were or that the environment is less healthy. Here are other reasons why cancer diagnoses can increase:
a. An Aging Population– Cancer occurs more frequently in older animals because it is frequently caused by defects in the control of cell division that accumulate over the lifetimes of many cells. The longer you live, the more times your cells have had to divide, and the more opportunities there are for the kinds of errors that can lead to cancer. Every epidemiologic study must account for differences in age between populations when comparing the rates of cancer and other disease. So if our pets are living longer as a result of better nutrition, disease prevention, and medical care, then we will see more dogs with cancer.
b. Better Control of Non-Cancerous Disease– For most of human history, almost half of all people born died before they reached adulthood. Very, very few of these children died of cancer, which is much more common in the elderly. They died mostly of malnutrition, infectious and parasitic diseases, and accidents. As science improved the quality of our food supply, provided the technology that raised our standard of living, and generated vaccines, antibiotics, pediatric and neonatal intensive care units, and all the other healthcare interventions that prevent these kinds of deaths, guess what happened? Yup, more people lived longer, the average age of the population increased, and cancer became a more common cause of death. NOT because the environment got more toxic but because it got healthier and safer! Cancer is one of the things you die of if you succeed in avoiding the age-old standards that used to kill most people.
The same is true for our pets. The very vaccines and pet foods and medicines Dr. Eisen condemns so blithely are responsible for reducing deaths from many non-cancer causes, leading to an increase in the number of cancers seen. This is a sign of past success for scientific medicine, and a challenge for the future. It is not a sign of the failure of conventional healthcare or the poisonous nature of the environment.
c. Better Diagnosis and Treatment– Diagnostic methods like ultrasound, CT scanners, and biopsies are becoming more accurate and more available all the time, and more people are willing to pay for tests to identify cancer in their dogs. This alone can increase the number of cancers diagnosed. And as we develop the ability to diagnose cancer more accurately and at an earlier stage, and as we find treatments for cancer which can (contrary to Dr. Eisen’s misleading claims) benefit cancer patients and even sometimes cure cancer, more people are willing to test their pets for these diseases and consider treating them.
I certainly wouldn’t claim that there is clear evidence cancer rates are not truly increasing. The reality is that we don’t have the appropriate epidemiological evidence to know. What is clear, however, is that the claim that there is more cancer due to increasingly toxic environments is absolutely without legitimate scientific support
So what does Dr. Esien say is the #1 Worst Thing for dogs with cancer? It’s not the commercial pet foods, flea and tick products, and tap water that he claims are contributing to a supposed cancer epidemic in dogs. Bad as these are, apparently they pale before the worst toxin of all–vaccines.
“The #1 worst thing you can do to a pet with cancer is to have them vaccinated.”
“Vaccines are loaded with toxic heavy metals like mercury and aluminum”
“Cancer is an auto-immune disease, so vaccines can cause cancer”
“Most vets administer vaccines routinely to our pets and tell you that they are safe, with very little risk. The fact is, nothing could be further from the truth.”
“Immunity is an all or nothing thing, either you have it or you don’t.”
“Any vaccination given to your dog will further impair their immune system and greatly reduce their likelihood of recovery.”
Now, there is nothing wrong with suggesting that vaccination may not be appropriate for dogs with cancer, or any other serious illness. It is widely accepted and routine to defer vaccination of dogs when they are ill. The problem with Dr. Esien’s diatribe about vaccination is that is takes this sensible recommendation and expands it into an indictment of vaccines as toxic and as a routine cause of cancer. It is like saying that because you shouldn’t drive while drunk, having a glass of wine with dinner is a major cause of auto accidents.
There are examples of vaccines being associated with an increased risk of some cancers. A type of cancer called a sarcoma can occur in between 1 out of 1,000 to 1 out of 10,000 cats vaccinated with an aluminum-containing rabies or feline leukemia vaccine. Such cancer is likely triggered by inflammation, which can also be induced by trauma, parasites, and many other causes. As a result of careful research identifying this problem (which we would not have found out about simply by casual observation or guessing), vaccines and vaccination practices have been altered to reduce this risk.
This example is often misused to suggest that vaccines in general are a risk factor for cancer in general, which is not the case. And such arguments ignore the fact that vaccinations save many, many lives. It is easier to sell an idea that is simplistic and makes the world seem like a place where all risks can be controlled and we can have the outcome we want so long as we do everything “right.” But the world we live in is more complicated than that, and anyone who tells you differently is selling something.
Dr. Eisen also belabors the fact that vaccine manufacturers state their vaccines should only be used in healthy animals. While I agree this is usually true, vaccine manufacturers also state their vaccines are safe and effective. Why does Dr. Eisen reject these claims and yet accept the recommendation not to give vaccines to ill dogs? Simply because it fits his personal beliefs about vaccination and cancer. He picks and chooses which information to accept and which to ignore not based on the strength of any evidence but on his personal prejudices. This is called confirmation bias.
Finally, Dr. Eisen also argues that vaccines aren’t effective in dogs with cancer based on manufacturer cautions about using them in immunocompromised individuals. This is a reasonable hypothesis, but one that has rarely been tested. The only specific study of the subject in dogs actually found no difference between the response to vaccination in dogs receiving chemotherapy and dogs not being treated for cancer.
Effects of chemotherapy on immune responses in dogs with cancer J Vet Intern Med. 2006 Mar-Apr;20(2):342-7. Claudia U Walter, Barbara J Biller, Susan E Lana, Annette M Bachand, Steven W Dow Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Fort Collins 80523, USA.
Abstract- Chemotherapy is assumed to be immunosuppressive; yet to the authors’ knowledge, the effects of common chemotherapy protocols on adaptive immune responses in dogs with cancer have not been fully evaluated. Therefore, a study was conducted to evaluate the effects of 2 common chemotherapy protocols on T- and B-cell numbers and humoral immune responses to de novo vaccination in dogs with cancer. Twenty-one dogs with cancer (12 with lymphoma, 9 with osteosarcoma) were enrolled in a prospective study to assess effects of doxorubicin versus multi-drug chemotherapy on adaptive immunity. Numbers of circulating T and B cells were assessed by flow cytometry, and antibody responses to de novo vaccination were assessed before, during, and after chemotherapy. The T- and B-cell numbers before treatment also were compared with those of healthy, age-matched, control dogs. Prior to treatment, dogs with cancer had significantly fewer (P < .05) CD4+ T cells and CD8+ T cells than did healthy dogs. Doxorubicin treatment did not cause a significant decrease in T- or B-cell numbers, whereas treatment with combination chemotherapy caused a significant and persistent decrease in B-cell numbers. Antibody titers after vaccination were not significantly different between control and chemotherapy-treated dogs. These findings suggest that chemotherapy may have less impact on T-cell numbers and ability to mount antibody responses in dogs with cancer than was previously anticipated, though dogs with lymphoma or osteosarcoma appear to be relatively T-cell deficient before initiation of chemotherapy.
So while there are good arguments for avoiding most vaccination of dogs with cancer, Dr. Eisen isn’t making them. He is simply asserting that vaccinating dogs with cancer is ineffective (which there is evidence may not be true) and harmful (for which there is no evidence at all). In short, he is making stuff up to suit his phobia about vaccines and toxins, and he is willing to borrow and misinterpret any information from any source to do make his case.
4. Why Buy His Book?
“What I do is help people learn about holistic protocols for treating dog cancer so they can get their dogs better without the side effects and often life-threatening consequences of conventional treatments.”
Dr. Eisen makes the usual misleading arguments for why you should take his advice. He claims his dog lived longer than expected after being diagnosed with cancer, so that proves his treatment works. Such miracle testimonials are not, however, a reliable guide to what works and what doesn’t, for reasons I’ve discussed before. He talks about individualizing therapy, which is a common marketing ploy for alternative medicine that doesn’t mean what he wants you to think it means. And he claims that many of his recommendations are “scientifically proven,” which is another empty marketing phrase. And, with the usual ambivalence towards science that characterizes most promotion of pseudoscience, he claims it as a source of legitimacy while simultaneously deriding it as worthless:
“Limiting your treatment options for dog cancer only to those proven by scientific research could be harmful to your dog’s health.” [he then goes on to talk about how individual observations are often so obvious that clinical research isn’t necessary, which is only rarely true, and how “today’s profit-driven scientific community” isn’t interested in studying treatments which are inexpensive, which is an unjustified slur on veterinarians who are just as committed to the welfare of their patients as Dr. Eisen].
Dr. Eisen offers tidbits of advice on three web sites, dogcanceradvice(dot)com (which mostly serves to advertise the book), dogcanceracademy(dot)com (which has a couple of videos you can watch in exchange for your email address, which allows more direct marketing), and bestdogcures(dot)com, which is a subscription site open to those who buy the book. All of this is classic internet marketing, very similar to what Dr. Andrew Jones does for his Veterinary Secret book and site.
Bottom Line
Dr. Eisen is a chiropractor who claims to be an expert in veterinary nutrition, toxicology, and cancer therapy based on having read a lot of books and invented his own “holistic system” by selecting which information he wanted to believe and which he felt he could ignore. The core of his marketing strategy is 1) to generate fear, by claiming that cancer is an epidemic and that we are surrounded by cancer-causing toxins in the very food and medicine we trust to keep our dogs healthy and 2) to claim that veterinarians have only dangerous and ineffective cancer treatments to offer and are ignorant of, or deliberately ignore, proven safe and effective alternative treatments. He provides no evidence for any of these claims, only his opinion and some testimonials.
A few of his claims are distantly based in real science and then stretched and twisted to support a pseudoscientific approach. Most of his claims are completely made up and contradict well-established science. He gets away with this by offering the usual unjustifiable promise of something for nothing, of effective treatments, or even cures, for cancer that are easy to use, completely safe, and cost little.
His web sites manifest many of the classic warning signs of medical quackery, including:
Claims of miraculous results
Claims of special knowledge unknown to or ignored by mainstream medicine
Claims of scientific legitimacy without any actual research data
Claims of expertise with no relevant credentials
Claims of simple and easy solutions to complex, difficult problems
Reliance on testimonials as proof
Claims that disagreement is driven by ignorance, fear, or greed
Misleading and selective use of real facts mixed in with made-up claims
And I have little doubt that, once his followers see this article, these signs will be joined by the inevitable personal attack on the critic rather than substantive response to the criticism, lots or testimonials supporting Dr. Eisen’s approach, lots of claims about the fear, anger, ignorance, greed or, most ironic of all, the arrogance of anyone who dares to criticize someone who has declared themselves an expert and who claims to know better than everyone with actual training and expertise in the subjects he talks about (true followers rarely see the irony in this).
The saddest thing about this sort of nonsense is that it is far more accessible and palatable to people whose pets have cancer than legitimate scientific information from true experts in veterinary cancer treatment. The bulk of what pet owners find on the internet is marketing materials designed to feed on their hopes and fears while not honestly helping their pets. Compassionate care is not limited to bogus “holistic protocols” like Dr. Eisen’s, despite the fact that he markets himself more effectively than genuine experts. True compassionate care is treatment based on legitimate science, not made up out of myths, misinterpretations, and wishful thinking.
Here are some real experts with real information for you if your pet has cancer:
Veterinary Oncolink, University of Pennsylvania
Pet Owner’s Guide to Cancer, Cornell University
The Cancer Center at Cares Canine Cancer Library, National Canine Cancer Foundation Animal Cancer Center, Colorado State University
In the true spirit of quackery, which cannot bear criticism or the exposure of its absurdities, Dr. Steven Eisen has expeditiously taken action to suppress my criticism of his marketing himself as a dog cancer expert despite no formal training in veterinary medicine, oncology, or any of the other areas of medicine in which he gives advice to dog owners. He has written to my internet service provider claiming that my quotations from his web site constitute copyright infringement. Here is the notice that was forwarded to me:
Sent via email and fax
re: DMCA Notice of Copyright Infringement
To Whom It May Concern:
My name is Dr. Steven Eisen and I am President of Pet Love LLC. A website that your company hosts (according to WHOIS information) is infringing on at least one copyright owned by my company.
Copyrighted text and graphics from several pages of our websites were copied onto your servers without permission. The original material, to which we own exclusive copyrights, ca be found at:
a) http://dogcanceradvice.com/about-the-book-2/
b) http://dogcanceradvice.com/canine-cancer-information/dog-cancer-treatments/
c) http://dogcanceradvice.com/canine-cancer-information/alternative-cancer-treatments-for-dogs/
d) http://dogcanceracademy.com/cancer-causing-toxins/
e) http://dogcanceracademy.com/the-dog-cancer-diet/
f) http://dogcanceracademy.com/canine-cancer-vaccinations
The unauthorized and infringing copy can be found at:
This letter is official notice under Section 512© of the Digital Millenium Copyright Act (“DMCA”), and I seek the removal of the aforementioned infringing material from your servers. I request that you immediately notify the infringer of this notice and inform them of their duty to remove the infringing material immediately, and notify them to cease any further posting of infringing material to your server in the future.
I have a good faith belief that use of the copyrighted materials described above as allegedly infringing in not authorized by the copyright owner, its agent, or the law.
Under penalty of perjury, I certify that the information contained in this notification is both true and accurate, and I have the authority to act on behalf of the copyright(s) involved. I am providing this notice in good faith and with the reasonable belief that rights my company owns are being infringed. Should you wish to discuss this with me please contact me directly.
Thank you.
Dr. Steven Eisen
It is likely that my use of statements made on Dr. Eisen’s site constitutes fair use under copyright law, but that decision would need to be made by a judge in the course of a copyright infringement lawsuit. I am perfectly willing to argue that the fair use provisions apply here, since I believe the attempt to suppress criticism by Dr. Eisen is an illegitimate misuse of intellectual property law.
Unfortunately, my options under the Digital Millenium Copyright Act (DCMA) for response are not great. I can leave the material up, in which case my IP will shut down my entire domain within 48 hours. I can remove the quoted material. I can contest the complaint, in which case my IP will shut down my entire domain for 10 days. If Dr. Eisen doesn’t sue in that time, the domain is reopened. If he does, then it remains closed until the case is decided.
Such flagrant misuse of copyright law deserves to be contested, so I will be seeking legal advice on the best way to do so. In the meantime, if the site diappears for a while, you’ll know why.
7/31/2012 Update
I have temporarily removed the disputed material from the site and filed a DMCA counterclaim. Dr. Eisen now has 10 days to decide whether or not to file for an injunction. If he does not, the original material will be reposted. If he does, then a court will decide whether my use of his words in a journalistic critique on a public interest, non-profit web site constitutes fair use of copyrighted material.
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Any time there is discussion of alternative medicine, of treatments that haven’t passed the test of rigorous scientific investigation (or even been tested at all), there are miracle stories. Testimonials, anecdotes, whatever you call them, they are tales of amazing recoveries from illness when everything tried had failed and all hope was lost. The comments on this blog contain many such stories for almost all of the products and methods I have questioned.
And such stories provide emotionally compelling evidence for the effectiveness of these interventions. If an owner has tried a hundred treatments for their pet, or been told there is no hope and nothing can save the animal, and then they try one more thing and their companion recovers, surely this means that final treatment must have worked? And yet, with all these testaments to the power of these alternative methods, I still have doubts. Let’s take a look at why that is.
There are a number of arguments against believing that testimonials prove anything about the effects of a medical treatment. Most of these, of course, will have no effect on the individual experiencing the miracle. It is in the nature of human beings to find their own experiences, and stories from others, deeply compelling, and sadly facts and logical arguments have little impact on that fundamentally emotional and irrational sense of certainty. Still, making the effort to understand the limitations of anecdotes has led us to this point in time, a point in which our medicine is more effective by far than any time in human history. So there is clearly value in understanding the problem of miracle stories even if many people will still find them compelling.
Things Aren’t Always What They Seem
The first classic argument is simply that things aren’t always what they seem. There are many reasons why the fact that a patient gets better after receiving a particular medical treatment doesn’t actually tell us the treatment made the patient better. The notion that if an action preceding an outcome means the action must have caused that outcome is known as the post hoc ergo propter hoc fallacy. In medicine, there is a long list of reasons why this kind of reasoning about causation isn’t trustworthy:
Most medical problems ultimately go away by themselves. Certainly minor ones nearly always do, and even major, life-threatening diseases like cancer resolve spontaneously despite our belief that they can’t or shouldn’t. It is natural to assume that whatever we did last, right before the patient got better, is the reason they got better. Natural, but not reliably true.
Chronic diseases, especially mysterious ones we don’t fully understand, tend to come and go. In addition to spontaneously going away altogether, which they can even after many years, they commonly tend to get better for a while then worse for a while and back and forth in an unpredictable cycle which we are always trying to understand and predict. Some stories of miraculous results from medical treatments are simply cases in which the patient was having a particularly bad run of symptoms and then felt better after getting treated.
If we systematically followed up all these stories, we would find a fair number of people whose symptoms returned despite continuing the supposedly effective treatment. Just like we find that almost any fad diet works for some people, and yet by a year most of them have gained back the weight they lost initially. Companies and practitioners selling alternative therapies, however, don’t make a point of systematically following up on all their satisfied customers’ testimonials to see which eventually got sick again. I wonder why that is?
Everyone hates this one because it means you believe something which isn’t actually true. You use a treatment and feel better, but if it’s just a placebo and your disease isn’t actually any different, that means you must be crazy or stupid, right? No! Claiming that a perceived change is only the result of a placebo effect isn’t an insult to the patient. It is simply a fact that all human beings see want we want to see a fair portion of the time, and that sometimes we interpret what we see to mean something that it doesn’t really mean.
In the case of medical therapies, almost anything I give a client, they will perceive some improvement right after simply because we’ve done something and we know we are supposed to be looking hard for any sign of an effect, especially since we really want there to be one. Again, systematically following up all these early responses often reveals no meaningful change, but if you ask at the right time, the answer will almost always be positive and suitable for use as a testimonial.
Sometimes, the reason a disease went away after an unconventional treatment (or a conventional one, for that matter) was used is because the disease was never there to begin with. Doctors aren’t perfect, and they sometimes diagnose diseases the patient doesn’t have. Any certainly people who aren’t trained medical professionals but who diagnose themselves or their pets are quite likely wrong a lot of the time. It’s easy to cure a disease that a patient didn’t have, so one of the first questions to ask about any miracle story is what hard, objective, tangible evidence is there to support the diagnosis? If your dog had cancer and it was cured by some kind of pseudoscientific nonsense like homeopathy, there had better be extensive imaging and before and after biopsies with long-term follow up before you start claiming homeopathy actually works and all the laws of physics and chemistry are mistakes.
You Can’t Prove It Isn’t a Miracle!
Another problem with miracle stories as proof that specific medical treatments actually work is that such stories can’t ever be proven wrong. And if something can’t be proven wrong no matter what, then you have to believe each and every one equally, which as we will see is probably the biggest problem with anecdotes.
Of course, the main reason you can’t disprove a miracle tale is psychological; cognitive dissonance is such a powerful and ubiquitous feature of the human brain, that it is almost impossible to convince someone they are wrong about a strongly emotional personal experience. Just as it is a great relief and comfort to know that you saved your beloved pet by using an unconventional therapy your vet said wouldn’t work, it is equally terrifying to believe that actually the therapy had nothing to do with your pet getting better and that not only did you waste your money and put your pet at unnecessary risk, but the world is ultimately unpredictable and uncontrollable and “As flies to wanton boys, are we to the gods. They kill us for their sport.” (King Lear) People cling to their miracles largely because these stories give them hope that bad things can be avoided or controlled if we just find the right things to do or believe.
Another reason miracle stories are unfalsifiable, which makes them largely useless as a form of evidence in science, is that they consist of very limited and selective information. By definition, anecdotes presented to show a treatment works contain only information that supports the effectiveness of the treatment. It wouldn’t be a miracle if at the end of the story the disease killed the patient. But does that mean there aren’t stories about the same treatment in which there was no benefit? Or even great harm? No, of course not. Testimonials are a form of “evidence” that is positive by definition, and that necessarily excludes negative evidence no matter how much of it might actually exist.
Of course, for a true believer, it would make no difference even if one could produce a story of failure for every single story of success. Cognitive dissonance would simply move the believer to say, “Well, maybe it doesn’t work for everybody, but it sure worked for me!” But for anyone trying to make an objective decision about how likely a particular therapy is to be effective, it is worth noting that testimonials and other anecdotes leave out all the stories that show the therapy failing, so they are an inherently biased kind of evidence.
Everything Works!
Though it doesn’t always show up on the typical lists of reasons why we shouldn’t trust miracle stories, to me the most damning argument against them is simply that they can be found supporting every medical treatment ever invented. On this blog alone, you can find a testimonial in the comments for nearly every product or therapy I have questioned, despite the fact that most of them have entirely different theories and methods by which they are supposed to work. And if you look at alternative medicine in general, there is not a single practice that you can’t find lots of people with powerful, emotional stories showing positive results.
But let’s go beyond the alternative therapies popular in the US today. Sure, there are plenty of testimonials for, say, Double Helix Water. How about for other kinds of magic water?
Homeopathy (after all, it’s just water)
Lourdes Water
Electron Water
pH Miracle Water
Kangen Water
Hexagon Water
Pranic Water
Ypsilanti Water
And even just Plain Water
So does every kind of water cure disease? Maybe the problem isn’t that testimonials aren’t unreliable. Maybe we’ve just stumbled across the fact that water itself is medicine? Ah, but I wonder then if we can find the same testimonials for every other therapy ever invented? Let’s see.
Christian Spiritual Healing
Islamic Spiritual Healing
Hindu Spiritual Healing
Christian Science Healing
Ancient Greek Healing
Ancient Roman Healing
Norse Magical Healing
Shamanic Healing
Theta Energy Healing
Ritual Child Sacrifice for Healing
Crystal Healing
Laser Healing
Bloodletting Healing
Magnetic Healing
Angel Therapy
Urine Therapy
Anyway, this list could be endless even without including the most popular alternative therapies. But it seems to suggest we should ask this question: If testimonials and miracle stories exist to support every medical treatment ever invented, does that mean every treatment works, or does it mean testimonials aren’t reliable?
Testimonials are useful only to generate hypotheses, or to illustrate theories that must be demonstrated by other means. By themselves, they prove nothing. Not only are they not reliable for all the reasons I’ve discussed, but if we accept them as compelling evidence, we commit ourselves to believing in everything at once, or simply arbitrarily choosing which stories to believe and which to doubt. This does not lead us to separating truth from error.
It is not unusual for people promoting unconventional, approaches to pet nutrition, such as raw diets, grain free foods, homemade diets, a preference for organic ingredients, and so on, to dismiss objections to these approaches made by veterinarians. These people will often claim that veterinarians know little about nutrition and that what they do know is mostly propaganda fed to them by commercial pet food manufacturers. Like most bad arguments, this one contains a few bits of truth mixed in with lots of unproven assumptions and fallacies.
Most veterinarians do have at least a semester course on nutrition in general. And a lot more information on the subject is scattered throughout other courses in vet school. So the idea that we know nothing about the subject is simply ridiculous. However, it is fair to acknowledge that most veterinarians are not “experts” in nutrition, if by this one means they have extensive specialized training in the subject. The real “experts” in this area are board-certified veterinary nutritionists, individuals who have advanced residency training in nutrition and have passed the board certification exam of the American College of Veterinary Nutrition.
Of course, as I always take great care to point out, expertise is no guarantee of never falling into error, particularly expertise based primarily on experience and a familiarity with the opinions of other experts rather than solid scientific research. Given the limited research data available on many important questions in small animal nutrition, even the real experts are often forced to rely on extrapolation from basic science or research in humans and their own clinical experience, which are important sources of information but always less reliable than studies specifically designed to answer these questions. Nevertheless, boarded nutritionists have a legitimate claim to expert status in this area. And as a group, they generally are skeptical of many of the alternative approaches to nutrition, as they should be give the paucity of data to support them As for the question of the role of the pet food industry in veterinary nutrition education, there is some truth to the claim that much of that education is sponsored by companies who make pet foods. Obviously, most veterinary nutritionists put their training to work researching and evaluating food for veterinary species, so the money and expertise in this area tends to concentrate in industry. And it is not entirely unreasonable to ask the question whether or not this influences the information veterinarians get about nutrition. It quite likely does.
This is not the same thing as saying that veterinarians are all lackeys or dupes of industry and unable to think critically for themselves, however. I am generally as skeptical and critical of pharmaceutical companies and mainstream pet food companies as I am of herb and supplement manufacturers and producers of alternative diets. All of them have both a genuine belief (most of the time) in their products, a genuine interest in the welfare of the animals they serve, and a high risk of bias and cognitive dissonance that impedes their ability to see and accept the flaws in their own reasoning or the data that contradicts their beliefs.
One should always be aware of bias, but that awareness does not justify ignoring the arguments or evidence coming from a source with potential bias, only evaluating it carefully and critically. The reason science is so much more successful than unaided reasoning is precisely because it is a method for compensating for human biases and other cognitive limitations that interfere with our seeing the truth. Mainstream pet food companies undoubtedly have biases, but often they also have good scientific data, which is rarely available for the alternative products and approaches. Ignoring this data in favor of opinion, theory, or personal experience is not a recipe for improving the state of veterinary nutrition.
The real issue is not so much what do general practice veterinarians know about nutrition as what is the evidence supporting the alternative theories and products being promoted? The accusation that vets know little about nutrition, even if it were true, doesn’t invalidate their criticisms. The classis ad hominem fallacy is the strategy of attacking a person and imaging that somehow this attack says anything about that person’s argument. It is the mirror image, in many ways, of the appeal to authority fallacy, which involves claiming some special wisdom or expertise on the part of a person making an argument and then imaging that claim somehow proves the argument. If proponents of raw diets or other unconventional nutritional approaches wish to make a case for their ideas, they have to do it based on logic and facts, not on the presumed expertise of supporters or the supposed ignorance of critics. As always, it is the ideas and the data that matter, not the people involved.
That said, there is a certain hypocrisy to many of these criticisms in that they come from sources with no particular right to claim expertise in nutrition anyway. Proponents of alternative nutritional practices are almost never boarded veterinary nutritionists. Often they are lay people who have labeled themselves as experts without even the training general practice veterinarians have in nutritional science. And while they may not be influenced by the mainstream pet food industry, this only means they are less subject to that particular bias, not that they don’t have other biases. People selling pet food or books on veterinary nutrition are all too often blind to the hypocrisy of claiming their opponents are under the influence of pet food companies while ignoring the fact that they make money selling their own ideas or products.
Others who frequently claim most veterinarians know little about nutrition are themselves general practice veterinarians or specialists in some aspect of veterinary medicine other than nutrition. It may very well be true that they are well-informed about nutrition because they have an interest in it, but this is not evidence that their arguments are true and those of their opponents are false. It is not even evidence that they know more about nutrition than their detractors, who may themselves have studied independently in the area. If you’re not a boarded nutritionist, you can’t claim to be an expert. And whether or not you are an expert, your ideas must stand or fall on their merits and the evidence, not on any presumed superiority in your knowledge over that of your critics.
So I think it is fair to say that most general practice veterinarians have only a fairly general knowledge of veterinary nutrition. And it is fair to acknowledge that much of this information comes from a source with a significant risk of bias, that is the pet food industry. However, I see no evidence that proponents of alternative approaches to nutrition have a reason to claim they know more about nutrition than most veterinarians, or that they are free from biases of their own. Only boarded veterinary nutritionists can legitimately claim to be “experts,” and even this is no guarantee of perfect objectivity or the truth of everything they believe. Claims about who is or is not smart or informed enough to have an opinion on a subject are mostly a superficial distraction from the important elements of any debate, what are the arguments and data behind each position. Awareness of potential bias only serves to make one more careful and cautious in examining someone’s arguments and data, it doesn’t get one a free pass to ignore what they have to say.
Posted today on the Science-Based Medicine Blog
Testing the “Individualization” of CAM Treatments
One of the common claims of alternative medicine practitioners is that they individualize their treatment while conventional medicine treats all patients the same. This is nonsense on several levels, but it is also a common excuse for why randomized clinical trials cannot be performed, or cannot be viewed as reliable evidence, in evaluating some alternative therapies. However, some trials have been done that attempt to account for this supposed individualization of therapy, and generally they have failed to show a benefit to the supposedly individualized approach. One of those, involving Traditional Chinese Medicine (TCM) was recently discussed by Edzard Ernst, one of few, and most productive researchers in the CAM field applying an evidence-based approach.
Matthias Lechner, MD, Iva Steirer, MD, Benno Brinkhaus, MD, Yun Chen, CMD, Claudia Krist-Dungl, MS, Alexandra Koschier, MS, Martina Gantschacher, MA, Kurt Neumann, MS, and Andrea Zauner-Dungl, MD. Efficacy of Individualized Chinese Herbal Medication in Osteoarthrosis of Hip and Knee: A Double-Blind,Randomized-Controlled Clinical Study. The Journal of Alternative and Complementary Medicine. 2011;17(6): 539–547.
First, why is the notion that CAM is somehow more individualized than conventional care total nonsense? Well, to begin with, any good doctor considers the particular history, physical examination findings, diagnostic test results, known medical problems, and concurrent therapies of each patient. If individualized treatment simply means considering the unique circumstances and values of the particular patient you are treating, then all good medicine is individualized. That concept is even built into the common definitions of evidence-based medicine:
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett)
[EBM is] the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances.(Strauss)
However, when CAM practitioners claim that formal scientific research and science-based medicine ignore individual variation, they are usually referring to the practice of studying groups of patients under controlled conditions and then applying lessons learned from those studies to the care of individuals. They claim that since we are all snowflakes, utterly unique, what is learned from groups cannot tell us anything useful about individuals.
This argument fails most dramatically on the simple evidence of the tremendous effectiveness of science-based medicine. Tens of thousands of years of looking at patients one by one and trying to figure out based on those experiences what to do for the next patient failed to control or eliminate any common diseases or meaningfully improve the length and quality of human life and health. A couple of centuries of gradually relying on formal scientific research instead of such haphazard individual experiences has wiped out or dramatically reduced many common and deadly diseases, nearly doubled average life expectancy (at least for those who can afford to use science-based medicine), and in many other ways unequivocally improved our health. It requires deep self-delusion to deny that science works better than prescientific, unstructured ways of figuring out how to preserve and restore health.
On a more theoretical level, however, consider this. Statistics can indicate the probability of winning or losing a game of chance very precisely, on the group level. As an individual, of course, you can’t know with certainty whether you will win or lose if you go to Las Vegas and play these games because these statistics only describe what happens over the course of many trials, that is what will happen on average when large numbers of people play. They don’t predict for you, as a unique individual, what your results at blackjack or roulette will be. This is very much like the situation in science, where controlled studies look at outcomes on the level of the group but can’t precisely predict the results of a therapy in an individual patient.
And yet, casinos make enormous sums of money by playing the odds and expecting that most people will lose. This is a successful strategy for them. And many people lose, some with disastrous personal consequences, by imagining that they are exempt from the statistical rules that apply to groups and that some special individual factor will allow them to beat the odds. Choosing to believe that general statistical principles don’t apply to them because they are special and unique ruins people’s lives in Vegas, and in medicine. Choosing to play with or against the odds, as defined by formal research, is no guarantee, but it is much more likely to lead to a good outcome than imagining the odds don’t matter because each of us is unique.
Finally, when a CAM practitioner claims they treat every individual patient based on that patient’s unique characteristics and that science-based medicine treats all patients as if they were the same because it bases treatment guidelines on research done on groups, they are simply mistaken. If a series of controlled studies indicates that Treatment X is better than Treatment Y for a certain diseases, and if I use this to support giving patients with that disease Treatment X most of the time, then yes I am applying information gained from population research to individuals. I am playing the odds.
However, if a CAM practitioner looks at a patient and evaluates their particular characteristics and then decides on a specific treatment, where do they come up with the connection between the patient’s characteristics and the treatment? They use their personal experience, gained from seeing what happens with prior patients, or they use rules laid down by other practitioners based of their own experiences, or they rely on general rules based on the theoretical ideas behind the style of therapy they use. In other words, they extrapolate from observations made on other patients to the individual they are currently treating.
This is exactly the same as what a science-based practitioner does with one important difference: the generalizations that scientific medicine applies to individual patients come from formal, controlled research designed to compensate for the unreliability of individual observations and judgments, whereas the generalizations used by CAM come from informal, unstructured observations with no control for bias or the many common errors that mislead us when we study disease. CAM practitioners are using generalizations based on the study of groups to decide how to treat each new case, they are just relying on poorer quality group evidence.
Ok, so how does this apply to the clinical study that looked at supposedly individualized TCM herbal therapy for arthritis of the knee? Well, the study started by randomly assigning patients to either receive individualized herbal treatment based on the judgment of experienced practitioners in each case, or a standard herbal mixture believed, again based on past experience with groups of patients, not to have any benefits for arthritis. The experimental formula consisted of a number of herbs selected in advanced based on TCM theory which the investigators expected might be useful for the kind of disease they were studying. However, individual patients received particular combinations of these ingredients based on the judgment or practitioners at the time they were evaluated.
The control treatment (not really a placebo since it contained chemicals which might or might not have real physiological effects, since none have been thoroughly evaluated in scientific studies) was a collection of herbs not believed to have benefit for arthritis based on prior experience and TCM theory It was made to taste similar to the herbs pre-selected for the experimental treatment to help make it harder for patients to know which they were receiving. I can already hear the complaints of some herbalists that this makes it an inappropriate control since taste is one of the guiding principles for the use of herbs in some approaches to herbal medicine. I’ll leave that pseudoscientific objection aside for now since it’s not directly relevant to the point here.
Baseline characteristics were similar between the two groups of patients, and randomization and blinding appeared to be properly conducted. Overall the study was well-done methodologically, with a formal accounting of patients lost to follow-up and a reasonable effort to use standard and predefined outcome measures.
So what were the results? Well, as is usual in a study looking at a subjective measure like pain, all patients improved. There was, however, no difference between those who received individualized treatment and a random herbal concoction not expected to have any effect on arthritis. This most likely indicates nothing happening here other than nonspecific effects associated with participating in a trial, including placebo, regression to the mean, the Hawthorne effect, and all the usual suspects that fool us in clinical trials, and in real life.
This study nicely illustrates several of the issues associated with supposed individualization of CAM treatment. First, it shows that such treatment is not, in any meaningful sense, any more individualized than good quality science-based medical treatment. Choosing a selection of herbs based on previous experience, historical use, tradition, and the unscientific theories of Traditional Chinese Medicine, and then selecting which of these herbs to give each patient based on the same prior experience and unscientific theory, is still applying generalizations based on groups to individuals. It simply uses generalizations based on unreliable sources of data.
The study also illustrates that individualizing therapy in this way doesn’t add any efficacy to the treatment. Not surprisingly, the study showed, as the others mentioned early have as well, that tailoring treatment to individuals based on generalizations derived from biased and unreliable sources of information leads to a therapy no more effective than randomly picking herbs out of a hat.
The difference between effective science-based medicine and ineffective medicine of any kind, conventional or alternative, is that the general principles used to guide therapy are derived from formal, controlled research that compensates for the weaknesses in our individual, informal, and unstructured judgment. If individualized medicine is just a code for using informal group observations instead of structured scientific ones to guide therapy, than it is not surprising that it doesn’t work any better than just making up a treatment haphazardly with no guiding principles at all.
I am always on the lookout for research studies concerning raw diets for dogs and cats. A lot of claims are made about the health benefits of raw diets, but there is no substantive body of evidence to justify these claims. In particular, claims that raw diets are healthier than commercial dry or canned pet foods are common, despite no clinical studies making this comparison. I hope eventually such studies will be done, and while I am skeptical raw diets will prove superior, I will be happy to start recommending them if they prove to have benefits that outweigh their risks.
Unfortunately, a recent study of raw diets doesn’t add much information directly relevant to the debate.
Beloshapka, AN. et al. Effects of inulin or yeast cell-wall extract on nutrient digestibility, fecal fermentative end-product concentrations, and blood metabolite concentrations in adult dogs fed raw meat-based diets. American Journal of Veterinary Research 2012;73(12):1016-1023.
The study compared raw beef and chicken-based diets with or without a couple of prebiotics (not probiotics) in research dogs. All dogs were fed each of the diets, and measurements were made of body weight, fecal consistency, nutrient digestibility, and fecal chemicals associated with the presence of prebiotics.
The short version of the results is:
It is not clear from this report whether or not the diets were formulated to be nutritionally adequate as defined by AAFCO standards, though levels of calcium and phosphorus were reported to be within acceptable limits (though variable based on the specific ingredients in each of the diets). Obviously, nutritional adequacy would be an important issue in evaluating the quality of any diet.
So overall, this study shows that raw diets are highly digestible (which is not surprising, but of questionable importance), that short-term feeding of them under controlled circumstances doesn’t seem to have any negative effects or any benefits unless one considers less poop an important benefit or buys into the still unproven health benefits of prebiotics. There is nothing wrong with studying the variables this project looked at, of course, but it doesn’t have much direct bearing on the controversy over feeding dogs and cats raw diets.
Despite the possibility that some dietary supplements could have real health benefits, there are many reasons to be skeptical of the safety and value of most supplements on the market. Most have not been tested scientifically to an extent that marketing claims made about them are truly legitimate. Unfortunately the legal framework for regulating these products almost guarantees that most never will be adequately tested. Thanks to the politicking that has led to the Dietary Supplement Health and Education Act (DSHEA), this “travesty of a mockery of a sham” masquerading as public health regulation makes it possible for the multibillion dollar industry that is Big Supplement to profit from selling supplements without ever having to prove they do what the companies claims, so long as the claims are sufficiently vague and the Quack Miranda Warning is appended I small print at the bottom of the page. As a consequence, the supplement industry can make a sizeable sum of money without having to turn around and invest much of that in research or quality control.
The supplement industry is known to spend a far smaller share of its profits on research that the larger, and much more closely watched, pharmaceutical industry, since the law requires little evidence of safety and efficacy for its products. However, even DSHEA requires some minimal quality control standards for herbal remedies and dietary supplements as well as placing some limits on the marketing claims that can be made. The GAO has previously reported that, despite this, contamination with dangerous substances and illegal marketing practices are common in the herbal medicine industry.
And now FDA inspection reports have shown that the dietary supplement industry also has serious and widespread problems with quality control, safety, and regulatory compliance.
The Chicago Tribune has published an article detailing the failings of the supplement industry to meet even its minimal obligations under DSHEA. Here are some examples:
There is a huge body of evidence showing that inadequately tested supplements and an insufficiently regulated supplement industry can not only fail to help but can actively harm people (see below). And the limited evidence from the veterinary field is certainly no better than that for the human supplement market.
There is a dangerous double standard that requires chemicals called drugs to be extensively and expensively tested (which isn’t always sufficient to prevent harm even with great efforts) and yet chemicals called “herbs” or “supplements” can essentially avoid any testing of safety or efficacy. Even attempts to require basic accuracy in labeling, quality control in manufacturing, or honesty in advertising are routinely ignored by this industry. Without more serious efforts to control the supplement companies, people will continue to waste their money, and even sometimes damage their health, by using these unproven and uncontrolled products.
Some of the Harm Caused by Vitamins, Supplements, and Herbal Remedies
Vitamin C can interfere with chemotherapy.
Vitamin E can increase cancer risk
Vitamin E supplements increase risk of hemorrhagic stroke
Vitamin E supplements may increase risk of heart attacks and stroke
Vitamin E increases risk of prostate cancer
Omega-3 Fatty Acids may increase risk in ventilator patients with acute lung injury
Mursu J, et al. Dietary supplements and mortality rate in older women: The Iowa Women’s Health Study. Archives of Internal Medicine. 2011;17(18):1625-33.
Widespread Failures in Quality Control of Dietary Supplements Herbal Preparations, Including Ayurvedic and Traditional Chinese Medicine (TCM) Herbs:
Aliye Uc, MD, Warren P. Bishop, MD, and Kathleen D. Sanders, MD, Camphor hepatoxicity. South Med J 93(6):596-598, 2000,
Angers RC, Seward TS, Napier D, Green M, Hoover E, Spraker T, O’Rourke K, Balachandran A, Telling GC. Chronic wasting disease prions in elk antler velvet. Emerg Infect Dis. 2009 May;15(5):696-703.
Angkana R, Lurslurcharchai L, Halm E, Xiu-Min L, Leventhal H, et al. Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients. Annal Allerg Asthma Immunol 2010:104(2);132-138.
Berberine. Inbaraj JJ, Kukielczak BM, Bilski P, Sandvik SL, Chignell CF. Photochemistry and photocytotoxicity of alkaloids from Goldenseal (Hydrastis canadensis L.) Chem Res Toxicol 2001 Nov;14(11):1529-34
Booth JN 3rd, McGwin G. The association between self-reported cataracts and St. John’s Wort. Curr Eye Res. 2009 Oct;34(10):863-6.
Burkhard PR, Burkhardt K, Haenggeli CA, Landis T.Plant-induced seizures: reappearance of an old problem. J Neurol 1999 Aug;246(8):667-70
Chung-Hsin Chen,Kathleen G. Dickman,Masaaki Moriya, Jiri Zavadil, Viktoriya S. Sidorenko, Karen L. Edwards,Dmitri V. Gnatenko, Lin Wu, Robert J. Turesky, Xue-Ru Wu, Yeong-Shiau Pu, Arthur P. Grollman. Aristolochic acid-associated urothelial cancer in Taiwan. Proceedings National Academy of Sciences, April 2012.
Panax ginseng: A Systematic Review of Adverse Effects and Drug Interactions. Drug Saf 2002;25(5):323-44 Drug Saf 2002;25(5):323-44
Cupp MJ Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999 Mar 1;59(5):1239-45
Debelle FD, Vanherweghem JL, Nortier JL.Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008 Jul;74(2):158-69. Epub 2008 Apr 16.
Emery DP, Corban JG Camphor toxicity. J Paediatr Child Health 1999 Feb;35(1):105-6
Ernst E Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000 Nov;143(5):923-
Fugh-Berman A Herb-drug interactions. Lancet 2000 Jan 8;355(9198):134-8
Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997 Apr;37(4):344-50
Kutz GD. Herbal dietary supplements: Examples of Deceptive or questionable marketing practices and potentially dangerous advice. General Accounting Office. May 26, 2010.
Lai MN, Lai JN, Chen PC, Tseng WL, Chen YY, Hwang JS, Wang JD. Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrology (Carlton). 2009 Apr;14(2):227-34.
Lawrence JD. Potentiation of warfarin by dong quai. Page RL 2nd, Pharmacotherapy 1999 Jul;19(7):870-6
Means C. Selected herbal hazards.Vet Clin North Am Small Anim Pract 2002 Mar;32(2):367-82
Nizsly N, Grizlak B, Zimmerman M, Wallace R. Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem? eCAM 2010 7(1):107-113
Norred CL, Finlayson CA Hemorrhage after the preoperative use of complementary and alternative medicines. AANA J 2000 Jun;68(3):217-20
O’Connor A, Horsley CA. Yates, KM “Herbal Ecstasy”: a case series of adverse reactions. N Z Med J 2000 Jul 28;113(1114):315-7
Pittler MH. Ernst, E Risks associated with herbal medicinal products. Wien Med Wochenschr 2002;152(7-8):183-9
Poppenga RH.Risks associated with the use of herbs and other dietary supplements. Vet Clin North Am Equine Pract. 2001 Dec;17(3):455-77, vi-vii
Pies R Adverse neuropsychiatric reactions to herbal and over-the-counter “antidepressants”. J Clin Psychiatry 2000 Nov;61(11):815-20
Prakash S, Hernandez GT, Dujaili I, Bhalla V. Lead poisoning from an Ayurvedic herbal medicine in a patient with chronic kidney disease. Nat Rev Nephrol. 2009 May;5(5):297-300.
Raman P, Patino LC, Nair MG. Evaluation of metal and microbial contamination in botanical supplements. J Agric Food Chem. 2004 Dec 29;52(26):7822-7
Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll G Acute heart transplant rejection due to Saint John’s wort. Lancet 2000 Feb 12;355(9203):548-9
Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet.JAMA. 2008 Aug 27;300(8):915-23.
Shad JA, Chinn CG, Brann OS Acute hepatitis after ingestion of herbs. South Med J 1999 Nov;92(11):1095-7
Smolinske SC J Am Med Womens Assoc 1999 Fall;54(4):191-2Dietary supplement-drug interactions.
Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular disease. J. Am. Coll. Cardiol. 2010 55: A32
Wang JD, Lo TC, Chen PC. Increased mortality risk for cancers of the kidney and other urinary organs among Chinese herbalists. J Epidemiol. 2009;19(1):17-23. Epub 2009 Jan 22.
Zhang SY, Robertson D. A study of tea tree oil ototoxicity. Audiol Neurootol 2000 Mar-Apr;5(2):64-8
Kidney failure from aristolochia in TCM herbals preparations.Lead, mercury and arsenic in herbal preparations.
Lead in ayurvedic preparations.
Tea Tree Oil Can be toxic to cats.
Toxic metals in Brazilian herbal preparations.
Contamination of herbal products with undisclosed pharmaceuticals.
Widespread contamination of supplements with undisclosed toxins and parmaceuticals
Like the subject of pet psychics, the subject of dowsing is one I never thought it would be necessary to write about. This form of divination, like casting rune stones or knuckle bones and examining the entrails of sacrificial animals, is so clearly superstitious nonsense incompatible with science that it is hard to imagine even the most extreme advocates of alternative medicine taking it seriously.
Sadly, my ability to imagine the credulity of others has proven insufficient. A recent article in the Journal of the Royal Society of Medicine has chosen to treat dowsing, as employed by practitioners of another bit of folk magic, homeopathy, as a proper subject for serious scientific inquiry. (The paper is in the April issue, so I still secretly hope it was intended as an April Fool’s joke)
R McCarney, P Fisher, F Spink, G Flint, R van Haselen. Can homeopaths detect homeopathic medicines by dowsing? A randomized, double-blind, placebo-controlled trial. J R Soc Med 2002;95(4):189-191.
The authors describe dowsing this way.
Dowsing is a method of problem-solving that uses a motor automatism, amplified through a pendulum or similar device. In a homeopathic context, it is used as an aid to prescribing and as a tool to identify miasm or toxin load….Dowsing, also known as divining, water witching or rhabdomancy, has been defined as a ‘problem solving technique which apparently utilizes a motor automatism in conjunction with a mechanical instrument to obtain information otherwise unknown to the dowser’
I prefer this definition, from the Skeptic’s Dictionary:
Dowsing is the action of a person–called the dowser–using a rod, stick or other device–called a dowsing rod, dowsing stick, doodlebug (when used to locate oil), or divining rod–to locate such things as underground water, hidden metal, buried treasure, oil, lost persons or golf balls, etc. Since dowsing is not based upon any known scientific or empirical laws or forces of nature, it should be considered a type of divination and an example of magical thinking.
The authors of the dowsing study list several theories for how dowsing “works:”
Theories on dowsing come into three categories. Normal inference theory suggests that the dowser processes a large amount of information pertinent to the scenario at a subconscious level and moves the instrument accordingly. The physical theory sees the movement in the device being due to the amplification of minute reactions in the human body, with the precise nature of the reaction being unclear. It could be an electromagnetic field, or some form of vibrational energy.
According to the theory of psionic medicine, every living thing and inanimate object is continuously vibrating at a molecular level. This vibration is sensed subconsciously by the dowser, and it is then amplified through the pendulum or other dowsing device. Some proponents of this explanation suggest that this sense originally developed as a survival tool because it enabled individuals to find water. As the vibrational pattern can change with disease, it is purported to be a useful tool for clinical practice.
Finally there is the psychical theory which suggests the dowser employs some form of extrasensory perception.
They have, however, omitted one very important theory:
The ideomotor effect refers to the influence of suggestion or expectation on involuntary and unconscious motor behavior. The movement of pointers on Ouija boards, of a facilitator’s hands in facilitated communication, of hands and arms in applied kinesiology, and of some behaviors attributed to hypnotic suggestion, are due to ideomotor action… The term “ideomotor action” was coined by William B. Carpenter in 1852 in his explanation for the movements of rods and pendulums by dowsers, and some table turning or lifting by spirit mediums (the ones that weren’t accomplished by cheating). Carpenter argued that muscular movement can be initiated by the mind independently of volition or emotions. We may not be aware of it, but suggestions can be made to the mind by others or by observations. Those suggestions can influence the mind and affect motor behavior.
In other words, dowsing is yet another example of people fooling themselves into believing that outside forces are accomplishing actions which, in fact, they are generating through their own unconscious need to see what they want and expect to see.
Dowsing has been studied a number of times, in as scientific a way as it is possible to study magic. The studies have pretty consistently shown that with any reasonable controls for bias (such as blinding of the dowsers), dowsing doesn’t work. Dowsers have not demonstrated the ability to find anything with an accuracy better than chance if they don’t know in advance where it is.
Naturally, dowsers often complain that this failure is due to the effects of the testing situation, which in some undefinable way muddies the psychic waters so they can’t perform. In the current study, this concern was accommodated.
In discussions before the study began, dowsers expressed concern that the pressure of an experimental situation might be detrimental to the dowsing sense. For this reason the study packs were mailed to the volunteers for evaluation in their own time in relaxed conditions…there was generally a high level of confidence in the responses (n=99, 63.5%), which suggests that we were successful in making the dowsers feel relaxed about the study.
So how was the study conducted? Well, six registered homeopaths with experience in the medical applications of dowsing were sent 26 pairs of unlabeled bottles containing either a homeopathic solution (a 12C preparation of Bryonia which, as the authors put it, “is ‘ultramolecular’…a dilution of 10-24…very unlikely to contain any molecule of the starting material”) and a placebo (prepared in an identical way except from distilled water instead of the Bryonia mother tincture).
In other words, they received two bottles of water one with magic powers and one without. They also received a pair of labeled bottles to practice on. They were then instructed to identify the magic water (I mean the homeopathic remedy) by magic (I mean dowsing).
And how did they do? Of 156 selections between pairs of bottles,
48.1% responded correctly (n=156; 95% confidence interval 40.2%, 56.0%; P=0.689)….percentage of correct responses ranged from 34.6% (n=26; 95% CI 15.77%, 53.4%; P=0.170) to 61.5% (n=26; 95% CI 42.4%, 80.6%; P=0.327). Of responses given with high confidence, 45.0% were correct (n=99; 95% CI 35.6%, 55.3%; P=0.421).
So, almost eerily close to perfect chance levels, with performance no better for those who were confident in their choices versus those who knew they were guessing. In fact, “High confidence was slightly more associated with an incorrect response.”
Since this is science, the authors made some comments about the potentially inappropriate application of statistics (using a method which assumes independent samples for samples that are actually associated), but as they put it,
The data were in fact so far from showing any type of effect of dowsing that the assumption of independence was probably met, so the more appropriate clustered analysis is unlikely to show a different effect.
So does this close the book on “medical dowsing?” Undoubtedly not. It does serve, however, as an excellent illustration of the premise of this blog. The application of scientific study to the highly implausible only seems justifiable if resources are unlimited or if the results, when negative, will influence peoples belief in implausible practices. Neither of these conditions is met in the real world.
In an ideal world, it might make sense to study every idea no matter how unlikely to be truth based on established knowledge, since once in a great while crazy ideas actually turn out to be right. But in the real world, they usually don’t. Since we have to conserve our resources and use them as efficiently as possible in investigating potential therapies, and since scientific evidence against magic does little to reduce people’s belief in magic, conducting and publishing studies like this seems a pointless and unconscionable waste of time and effort which only conveys an inappropriate sense of legitimacy to the hypotheses being studied. On the other hand, it is entertaining.
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