A colleague recently received the following statement, as part of a follow-up report from a board-certified specialist to whom she had referred a case. The pet received a number of alternative medical therapies as well as conventional treatment for its condition.

“Integrative medicine can increase the variety of many different treatment plans and has the opportunity to reach a more successful health plateau for your patient. Invariably, integrative medicine acts as a adjunct protocol and offers more than a healthy body. Integrative medicine also provides a healthy sense of well being. As we progress towards newer and more extensive technology we lose the art of the basic touch and hands on treatment. In this day and age with our society relying heavily on technology and invasive sciences we must not look to holistic care as an alternative but as a way back to our soul.”

There are a number of elements to both the concepts and the logic of this statement which I find disturbing, especially coming from a specialty center to which I sometimes refer patients, and in which I must have confidence in order to keep doing so. It also illustrates one of the biggest problem in defending science-based medicine: overcoming the conflation of unproven or ineffective CAM treatments with a warm and caring therapeutic relationship.

1. “Integrative medicine can increase the variety of many different treatment plans”

This seems a variety of the bogus “health care choice” argument. Yes, adding unproven or implausible therapies to what we do gives us more things to do, but if these interventions aren’t shown to have a benefit, and might even be harmful, then so what? Variety is not itself a good thing, especially if it only serves our psychological need to do something without truly benefitting our patients.

2. “has the opportunity to reach a more successful health plateau for your patient”

This statement is meaningless without evidence to show it is true. CAM proponents freely claim better health through their methods, but shampoo makers freely claim their product is “New and Improved” every few months too. Should we believe it just because they say so?

3. “Invariably, integrative medicine acts as a adjunct protocol and offers more than a healthy body.”

Same problem. The assumption is made that adding this stuff helps, but I expect any doctor, especially a second-tier specialist, to have more than anecdote and faith to back up their claim that their treatments can help my patient. This statement suggests any and all CAM interventions added to conventional therapy will “invariably” bring benefit. No side effects? No interference with conventional therapies? No possibility of failure? If it sounds too good to be true that’s because it is.

4. “Integrative medicine also provides a healthy sense of well being”

Here we begin to get into the underlying philosophical position that will fully emerge later. These added interventions aren’t really about making the patient better in terms of their disease but about making them feel better. Of course, since we can’t access our pets inner feelings in any detail (well, except for pet psychics, of course), we have to decide if they get a sense of “well being” from CAM therapies. And given that both as doctors and owners we desperately want them to be and feel better, there is great risk of our projecting our needs and feelings onto them. CAM placebo effects certainly have an impact of people’s perceptions of their own disease, and they have an impact on their perceptions of how their animals feel (as the recent guest post illustrated), but I have yet to see anything more convincing than testimonial to show that they really affect our pets’ feelings as this statement presumes they do.

5. “As we progress towards newer and more extensive technology we lose the art of the basic touch and hands on treatment.”

Ah, we begin to see the cliché New Age notion that modern medicine is all about technology and that in the mythical Golden Age medicine was about caring and healing the whole person. There is no question the dramatic proliferation of knowledge and the subsequent necessary division of doctors into ever narrower specialties has affected the patient/client-doctor relationship, and this is part of why people are driven to the often warmer and more personal ethos of CAM. Scientific medicine must address this problem to protect our patients from turning to physically ineffective but more psychologically appealing methods.

However, the fact remains we live longer, suffer less, lose fewer of our children, and overall enjoy a far better quality of life and health than any humans who have ever lived, largely thanks to technology. We now have the luxury to indulge our search for meaning and fulfillment because most of us aren’t always battling to feed ourselves or struggling with an endless stream of physical ailments. I for one see no reason we can’t enjoy the opportunity for “self-actualization” technology has provided, and improve on the gains we’ve made, without jettisoning the very technology that has given us the opportunity to do so. I would love to have a close, supportive relationship with my health care provider. But I see no reason why that should require I also accept a host of implausible, vitalistic, and ultimately often ineffective therapeutic interventions too.

Finally, one must ask again if we are projecting our needs onto our pets. I believe I am as gentle, caring, and empathetic as any vet, and I generally have good success interacting with my patients. But frankly, many of my patients don’t appear to take comfort from being handled, however caringly, by strangers. The acupuncture and chiropractic sessions I’ve seen often involve a great deal of supportive, caring treatment of the client, who then feels their pet must enjoy the relationship as much as they do. However, judging from the behavior of the animals themselves, I remain unconvinced. They generally seem no more nor less distressed when receiving chiropractic or acupuncture than they do during my physical examination or vaccination procedures. Yet somehow, everyone involved believes the animals share their owners’ feelings the “spiritual” aspects of these encounters.

6. “In this day and age with our society relying heavily on technology and invasive sciences we must not look to holistic care as an alternative but as a way back to our soul.”

It isn’t entirely clear from the passage (especially given the awkwardness of some of the language which suggests to me it might have been written by someone not a native speaker of English) whether or not the use of “soul” here is intended literally or  is just a way of referring emphatically to feelings and emotions. It wouldn’t surprise me if it is meant literally since the notion that disease is fundamentally a spiritual rather than physical phenomenon is widespread in alternative medicine. Either way, however, the sentence echoes the theme of the statement as a whole, which seems to be that scientific medicine is cold and machinelike and that we need some “old-fashioned” psychological support from our doctors.

There is an element of truth to this, certainly for humans, though I think it is sometimes debatable whether what our pets need or desire in terms of a therapeutic relationship is the same as what we think they want. However, once again there is no reason this needs to be connected to alternative, unconventional medical treatments. The answer to a more supporting, warmer health care environment and better human relationships between health care providers and patients/clients isn’t to give up scientific medical therapies that work, or even to add unproven therapies to them. It is to change the economics and structure of the health care system to provide both the highest quality, most effective physical care and meet the emotional needs of patients/clients. This won’t be easy, and it will likely be more expensive, but turning to CAM isn’t the answer.

Linking CAM to the perception that modern medicine is cold and uncaring is a marketing triumph, but it doesn’t make the specific methods any more likely to be effective. This is why so much CAM is used by people with complex, chronic diseases, often for which scientific medicine has not yet found effective treatment. When choosing care for discrete, acute, critical illnesses few people choose CAM methods of questionable effectiveness. People want medicine that works, and though they want to feel cared for also, they shouldn’t have to accept bogus treatments along with emotional support.

One of the most common responses I get when I point out the lack of evidence for particular CAM therapies is, “So what? If it doesn’t do any harm and if people feel better, even just because of a placebo effect, then why do you want to convince them this stuff doesn’t work?”

Of course, the first answer to this has to be challenging the assumption of safety which seems to adhere to most CAM therapies, and I have done that at length. However, beyond that issue, it seems to me a fair question whether the truth matters when it takes away something benign that people want to believe and which might offer some relief from symptoms via a psychological mechanism, if not by way of actually changing the underlying disease process. I have several answers to this question, some personal and philosophical, others more pragmatic and directly relevant to medicine.

On a personal level, I share the sentiments of R. Barker Bausell, author of Snake Oil Science. He sees investigating the truth about the claims of alternative medicine as part of the larger project of science, and his research and writing are motivated at least “partly [by] a common professional objective for a scientist: to be able to claim a personal victory in one small skirmish in the perpetual struggle between knowledge and ignorance.” Though I understand that many, perhaps most, people don’t share the sentiment, a lot of us in science are driven by a visceral sense that truth matters, and that even unpleasant truths are to be embraced and comforting untruths disdained. I don’t see imparting this sense to others as a core goal, or justification, for challenging bogus medical claims, though I do hope my passion for what is true may resonate with some readers. But I must be honest and confess that this feeling is a large part of why I engage in my various projects promoting science-based medicine.

On a more practical level, there is clear evidence that the comfort taken from untrue beliefs in medicine does harm beyond the direct damage particular medical therapies may cause. While some turn to CAM only when they have exhausted the options provided by science-based medicine, CAM therapies are often promoted as an alternative to scientific medicine. However, when CAM is used in lieu of the more effective, better understood therapies of scientific medicine, people suffer and sometimes die unnecessarily. We see this happen in the asthma patients who have poorer compliance with drug therapy, and poorer quality of life scores, then they substitute herbs for medicine, and in the cancer patients who eschew effective mainstream treatment or palliation in favor of alternative therapies, leading to greater suffering and earlier death. What is more, because CAM therapies are so amenable to placebo effects and to false assessments of real efficacy, even casual experimental use in conjunction with conventional therapies can lead to a belief in not only the efficacy of the alternative interventions but create sympathy with the philosophical underpinnings of these interventions and skepticism of the underlying foundations of science.

CAM proponents frequently emphasizes supposed philosophical differences between alternative medicine and science. Some of these are marketing points rather than true differences, such as the nonsense about CAM treating the whole patient rather than just the disease, or scientific medicine treating only symptoms while CAM treats root causes of illness. However, there are some genuine philosophical differences between science as an epistemological approach and the world view of many CAM adherents. CAM often rests on a foundation of vitalism, the notion that invisible spiritual or “energy” forces are the true source of animation for living beings, and that disease is not a manifestation of disorders in the physical body but in these mystical forces. Vitalists claim to be able to sense and manipulate such forces, but these claims are never demonstrable by any objective means and must be accepted on the basis of faith alone.

This is in contrast to the position of methodological naturalism, in which scientists agree to put aside any personal intuition or revelation of a spiritual nature when investigating and treating the causes of disease, and focus solely on mechanisms and causes which can be objectively and repeatedly demonstrated to anyone. The claims of some CAM advocates that this approach is doomed to failure because it ignores the “real” nature of life and health are belied by the astounding success of the technology and medicine it has generated. Millennia of vitalist approaches to medicine failed to achieve the improvements in health and longevity a naturalistic approach has accomplished in only a couple of centuries. There’s a reason why mystical health care theories have had more success being adopted in the treatment of chronic diseases, particularly involving subjective symptoms like pain, and have failed to be widely accepted in acute, life-threatening situations. Homeopathic birth control hasn’t caught on too well either, so perhaps there is more to be said for “reductionism” than CAM proponents often credit.

Yet vitalist philosophies have an emotional and aesthetic appeal, and I understand the historical and psychological reasons they are so attractive and widespread. Nevertheless, I feel the evidence of history conclusively demonstrates naturalism to be a more accurate and successful model of reality, and there are real dangers in choosing to ignore this reality and adhere to comforting but unsuccessful paradigms when dealing with health and disease.

Similarly, many CAM advocates hold to an extreme relativism born of the post-modernist philosophical movement. This sees all models of reality as purely social constructs with no sound basis to give preference to one over another. Any attempt to assert one model is more faithful to an objective physical reality than another is dismissed as merely an attempt to justify a particular social and political power structure, to the advantage of one cultural group over others. Thus, even claiming objective reality exists and can be described is denounced as a form of political and cultural oppression. All points of view are held to be equally valid, and no truth claims are defensible.

This philosophy has had much success in the rarefied air of academe, though even there it is beginning to fray. It is buttressed by the reality that all of our models of reality are in fact  influenced by cultural factors, and that oppression is often justified by its intellectual apologists through the promulgation of scientific and pseudoscientific theories. However, postmodernism throws the baby out with the bathwater, and in an attempt to eliminate xenophobia and ethnocentrism it eliminates any hope of understanding the universe or improving our lives. Again, the history of science, technology, and medicine clearly and forcefully demolish the notion that there is no objective reality and that we can have no true knowledge of it. Such a perspective has no usefulness, and should have no place in medicine.

On a more practical level, one reason to care about the efficacy of CAM methods is simple economics. A 2009 study from the NCCAM found Americans spent $33.9 billion on “alternative” therapies (though the definition used in the study was quite loose). This is a lot of money to put into treatments of dubious effectiveness, and even if they have some positive effects in terms of subjective symptoms like pain or nausea, I think it is fair to wonder whether such resources could be better spent discovering more effective therapies or making health care more available to those who cannot afford even basic care.

Finally, Simon Singh and Edzard Ernst make the case in Trick or Treatment: The Truth about Alternative Medicine that it is nearly impossible to benefit from the placebo effect of a medical therapy without either lying to the patient or at a minimum deliberately ignoring the evidence against the placebo therapy. Most CAM practitioners obviously genuinely believe their methods work. However, maintaining this belief requires ignoring the principles and practice of science and evidence-based medicine. In today’s world, with the knowledge that scientific research has accumulated in the last few hundred years, sticking with such an attitude requires a kind of deliberate ignorance. CAM practitioners who utilize clearly disproven methods or concepts, such as homeopathy, the vertebral subluxation, and so on, must reject the very principles of science and the most basic, and well-established scientific understanding of the world. This is an act of faith that makes their approach more of a religion than a medical science.

There are those who honestly try to apply the principles of science and evidence to CAM. Unfortunately,  there are few CAM therapies that one can honestly justify in this way. Acupuncture for pain and nausea, chiropractic for idiopathic back pain, and a few well-studied herbal remedies and nutritional supplements are about all CAM can justly claim to be supportable by any sort of real research evidence, and even some of these claims amount to a primarily psychological, rather than disease-modifying, set of effects. There are important ethical questions associated with the use of placebo therapies, whether in mainstream medicine (where antibiotics and vitamins are often used to this end) or in CAM (where arguably the majority of the benefits seen are placebo-based). As I’ve argued before (here and here), the benefits may well be outweighed by the harm done to the caregiver/patient or client relationship by introducing deliberate deception, or even more the more subtly disingenuousness in sticking with what one’s experiences and intuition say and ignoring robust evidence against one’s approach, into this relationship. Though it is a philosophical point, and as such not provable in any objective way, I cannot help but feel that we are better served by honesty and a commitment to the truth than by accepting the short-term benefits associated with deceiving others or even ourselves.

Though it’s certainly not an original observation, I’ve begun to see some repeating patterns of behavior associated with unreliable and unscientific medical claims, and I think it might be useful to review some possible warning signs that one is dealing with quackery or nonsense. Certainly, not all of these markers will be found in the claims or marketing of every unsubstantiated medical approach, and some of them may well be found attached to legitimate or correct claims. However, viewing hem as risk factors or red flags can help one to separate the pseudoscientific from the scientific and the truly helpful from the nonsense.

1. The Galileo Complex-

Most idiosyncratic ideas that conflict with the mainstream understanding of reality turn out to be wrong. As Michael Shermer puts it: “History is replete with tales of the lone scientist working in spite of his peers and flying in the face of the doctrines of his or her own field of study. Most of them turned out to be wrong and we do not remember their names…The person making the extraordinary claim has the burden of proving to the experts and to the community at large that his or her belief has more validity than the one almost everyone else accepts.”

The exceptions stand out precisely because they are exceptions. People with questionable ideas like to compare themselves to Galileo or other historical figures who were widely doubted and whose ideas were vilified and suppressed in their own era but who were later vindicated by science and history. This is a neat little bit of self-aggrandizing spin that is a lovely example of the availability heuristic and cherry picking fallacies. Because such cases are unusual, they stand out in our minds, which makes us likely to see them as more common or representative of the norm than they are, and because we wish to validate our own ideas we tend to notice and cite only those examples which support our claims and ignore those which do not. So any book, web site, or lecture which makes comparisons to Galileo or other such figures should be suspect in terms of the soundness of the reasoning and the intellectual honesty and humility of the author.

A lovely example of this is a book by a lawyer who often defends alternative medicine providers against government regulation, Richard Jaffe, who titled his own book about his work Galileo’s Lawyer.

2. The Dan Brown Gambit-

Despite some worrisome signs of growth and the lax oversight by government thanks to effective legislative lobbying, alternative medicine is a fairly small, largely marginal element of healthcare overall. It tends to serve primarily affluent clients with chronic complaints, often involving largely subjective symptoms such as pain or fatigue, and people with philosophical predilections towards it such as postmodernist liberals, some varieties of libertarians, and those generally suspicious of modernity, materialism, and methodological naturalism. Mainstream science-based medicine has earned the confidence of people by producing unequivocal results, it is generally preferred by most people unless they have one of these philosophical objections to it or a condition which science does not yet have clearly effective treatments for.

Unable to accept this fact, many CAM advocates argue that their methods are better but have failed to replace scientific medicine due to a conspiracy of suppression by the medical-industrial complex. A nice example of this comes from one of the more extreme alternative medicine sites, Shirley’s Wellness Café:

“Dr. Guylaine Lanctot, M.D. – The medical establishment works closely with the drug multinationals whose main objective is profits, and whose worst nightmare would be an epidemic of good health. Lots of drugs MUST be sold. In order to achieve this, anything goes: lies, fraud, and kickbacks. Doctors are the principal salespeople of the drug companies. They are rewarded with research grants, gifts, and lavish perks. The principal buyers are the public – from infants to the elderly – who MUST be thoroughly medicated and vaccinated…at any cost! Why do the authorities forbid alternative medicine? Because they are serving the industry, and the industry cannot make money with herbs, vitamins, and homeopathy. They cannot patent natural remedies. That is why they push synthetics. They control medicine, and that is why they are able to tell medical schools what they can and cannot teach. They have their own sets of laws, and they force people into them. That is a mafia. This sensational expose’ also uncovers the truth behind vaccines, AIDS, cancer, the World Health Organization, the Rockefeller Foundation, the World Bank, and more. Dr. Lanctot, M.D is the author of The Medical Mafia  How To Get Out of It Alive and Take Back Our Health and Wealth.”

These arguments resemble those found in many Dan Brown novels, in which thin threads of evidence are used to claim that venal cabals of robber barons collude with doctors to maintain people in a state of constant illness, despite the availability of cheap, natural cures for all diseases, solely because of their devotion to profit and power. This is closely related to both the Galileo Complex and what I have elsewhere called the David and Goliath Myth. As in most every other human endeavor, claims of shadowing conspiracies to silence the truth ought to be viewed skeptically, as they are often a cover for the simpler fact that vacuous and mistaken ideas fail to find acceptance because people simply aren’t fooled by them.

3. Deep Secrets-

Difficult to disentangle from the phenomena already cited is the slightly twist on the underlying theme I call Deep Secrets. Many advocates of alternative medicine will claim they have found simple and obvious knowledge that has been hidden from the rest of us, either by our own slavish acceptance of the propaganda of the Medical-Industrial Complex or because the secrets have been actively suppressed. A couple of examples of this are Dr. Andrew Jones book The Veterinary Secret, Kevin Trudeau’s Natural Cures “They” Don’t Want You to Know About, but there are many others. Claims of secret wisdom uncovered by lone geniuses and available to you free (as long as you buy their book, DVD, etc), should always raise one’s suspicions.

4. The One True Cause of All Disease-

Harriett Hall at Science-Based Medicine has written eloquently about this phenomenon. Many CAM proponents claim their method is based on understanding the “true underlying cause of disease,” while scientific medicine is merely treating symptoms. Most times, this “true cause” is some sort of perturbation of a vitalist energy detectable only by the intuition of the practitioner. While people prefer the simple and definitive to the complex and ambiguous, reality is under no obligation to conform to our wishes for it, and reality is often complex and ambiguous. If there were one simple and obvious true cause for all illness, I cannot imagine that it would not have been found and manipulated at some point in human history with such great success as to eliminate all disease and displace all other models of health and well-being. The failure of this to happen is one of the better bit of evidence against the claim. And I have wondered aloud before how CAM proponents rationalize the use of multiple therapies concurrently each of which is based on totally incompatible One True Causes of disease. A cause for doubt if ever there was one.

5. If It Sounds Too Good To Be True, It Is-

An old maxim, but a sound one. People will often investigate with a sharp, critical inquiry the details of a new electronics or automotive purchase looking for solid evidence on which to make a choice, and yet the same people will throw common sense and skepticism away when fed an appealing line of pseudoscientific sales patter by an alternative medicine advocate. Practitioners of scientific medicine are often at the public relations disadvantage of having to be truthful with our patients and clients, including admitting to the limitations of our knowledge an ability to solve their medical problems. Anyone who claims dramatic and unprecedented success with no risks should be pressed to produce more than their word or the testimonials of fellow believers to back up such claims, because such claims so often prove false in every area of human endeavor and medicine is no exception.

My recent brush with the “healthcare choice” concept, as well as a podcast interview I listened to with Dr. Paul Offit on Point of Inquiry put me in mind of an interesting and challenging puzzle in the philosophy of medical practice; the question of the tension between the role of health care providers as experts and the autonomy of patients of veterinary clients. I subsequently ran across an articulate and cogent discussion of this problem from the Annals of Internal Medicine, Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice, which I highly recommend to anyone interested in understanding the complexities of the relationship between healthcare providers and patients.

Briefly, human medicine has traditionally followed the paternalistic model, in which the doctor is viewed as an expert with knowledge and skills the patient does not have. The doctor is expected to determine what is best for the patient and make the treatment decisions, which the patient is expected to accept. The disadvantages of this approach are obvious. As the authors of the article from the Annals put it, “it can be difficult to determine what a patient’s best interests are; inappropriate biases caused by sex, race and socioeconomic status can affect decision making; and patients can be deprived of the opportunity to make decisions that reflect the reality of their conditions.” The paternalistic model ultimate fails to give appropriate respect to the rights of patients to control their bodies and lives.

Many decisions made in the context of health care are not truly medical decisions so much as decisions about values. Quality of life, physical and emotional suffering, tolerance for risk, and many other factors affect the appropriateness of a given treatment plan that are subjective and truly accessible only to the patient. It is widely understood now that the paternalistic model is not ideal, and for at least 30 years most physicians have been trained in a more patient-centered model in which patient autonomy is properly valued.

What is less well-recognized, however, is that there are strengths and benefits associated with the paternalistic mindset. The reality is that despite the easy availability of large quantities of raw information, a deep and accurate understanding of medicine and the basic scientific principles underlying it is not readily available without the years of study and training health care providers undergo. The Internet has convinced us that we can quickly be experts in any area regardless of our personal abilities, skills, and experiences, but this is an illusion. Knowledge without understanding is dangerous because it leads us to confidently make poor decisions. The reality is that in the complex world of modern medicine even professional physicians can easily be overwhelmed by the required and ever-growing knowledge they need to make sound decisions, and lay people will only do poorer in judging the potential risks and benefits of particular interventions, no matter how much time they spend Googling the issue.

The alternative patient-centered or independent choice model of medicine has the obvious strength of giving proper respect to the autonomy of the patient and their feelings and values. However, in its extreme form it explicitly prohibits the doctor from offering recommendations or counsel, and limits the role of the provider to a neutral recitation of the statistical and technical features of various options among which the patient must choose entirely independently. This abdicates any responsibility for the welfare of the patient so long as autonomy is preserved.

There are some differences between human and veterinary medicine in how this tension between reliance on doctor expertise and authority and the autonomy of veterinary clients plays out. The paternalistic model was never fully realized in veterinary medicine due, in part, to the role of the animal patient in the lives of the clients. Traditionally dominated by agricultural applications, veterinary medical decision-making was long constrained by the need to focus on the utilitarian or economic value of the patient. Even non-agricultural animals were often viewed in a more utilitarian way than is now the rule, and the dominant model of companion animal medicine was not unlike that of auto mechanics. People would bring their dysfunctional pets to be repaired or, if this was not possible or the economic cost was too high, to be destroyed.

The profession has changed greatly, and now companion animal medicine is far larger a domain than agricultural practice, at least in terms of the number of veterinarians if not the total economic value of the industry. The prevailing model is much closer to that of pediatric human medicine than auto repair. Pets are commonly seen as individual family members, and the focus is on their health and well-being rather than their utility in most cases. Of course, economic limitations are still far more stringent than in human medicine, and the resources available are less, but very similar principles apply. The decisions made affect the patient directly, but the patient cannot themselves make decisions or even express their wishes. The interests of clients and patients sometimes conflict, and the veterinarian must attempt to serve both while maintaining acceptable professional and ethical standards and an economically viable practice.

The issues discussed in the Annals paper often arise in companion animal medicine. Many decisions, especially involving quality and end of life as well as economics, are value decisions rather than medical decisions, and so the autonomy and independence of the client must be respected. However, the doctor does have knowledge and understanding not available to most clients, and so ought to be able to offer guidance as well as factual information to assist in decision-making. What is more, the veterinarian has a duty to the patient, and protecting the patient’s interests sometimes requires working against the desires of the client.

How, then, do we negotiate the complexities of the veterinarian-patient-client relationship in a way that safeguards the interests of the patient, respects the values and autonomy of the client, makes optimal use of the expertise of the veterinarian, and is economically tenable for all parties? I cannot claim to have a comprehensive answer, but as always I have a  few thoughts.

To begin with, veterinarians should be trained to explicitly acknowledge the questions and issues involved. Very little time in vet school is spent discussing these concerns or how they might be addressed, and most veterinarians end up stumbling into an approach that seems to work for them with little or no guidance. As a consequence, practice styles range from those veterinarians who only discuss options they wish the client to pursue and who freely tell clients what they ought and ought not to do, to veterinarians who try to practice a strictly “independent choice” model and never make an explicit recommendation or voice any personal opinions in the consultation room. As is so often the case, the best solution seems to be between the extremes, and it is likely to be an ever-evolving, self-aware process rather than a rigidly fixed formula or algorithm.

The Annals paper discusses at length what the authors call the “enhanced autonomy” approach. Essentially, this involves trying to integrate the factual details of the medical situation with the values, feelings, and interests of the doctor and the patient through open and careful communication. While the patient must ultimately make the final decision about their own care, the doctor is not obligated to ignore the medical facts as they understand them, nor their own judgment. The authors describe the advantages of their model in this way:

“The independent choice model reflects a limited conceptualization of autonomy. Under this model, it is thought that an independent choice is best made with no external influence, even when one’s competence to make the choice is limited. However, autonomous medical choices are usually enhanced rather than undermined by the input and support of a well-informed physician. Only after a dialogue in which physician and patient aim to influence each other might the patient fully appreciate the medical possibilities…Enhancing patient autonomy requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient’s values and their own, and then offer recommendations that consider both sets of values and experiences. This model is “relationship-centered”….rather than exclusively patient-centered. It denies neither the potential imbalance of power in the relationship nor the fact that some patients might be inappropriately manipulated or coerced by an overzealous physician. It assumes that an open dialogue, in which the physician frankly admits his or her biases, is ultimately a better protector of the patient’s right to autonomous choice than artificial neutrality would be. Because the biases of a physician will probably subtly infiltrate the conversation even if he or she tries hard to remain neutral, it may be better to explicitly label these values than to leave them outside of the conscious control of either participant.”

Such a model is well-suited to companion animal medicine as well. It requires first and foremost open acknowledgement of the roles both client and veterinarian play in making decisions for the patient. The veterinarian has knowledge and competence the client does not. They are able to appreciate the complexities of the medical situation, and they have the emotional objectivity to view potential outcomes realistically. The veterinarian also has a responsibility to advocate for the interests of the patient and to adhere to their own ethical and professional standards. Finally, the veterinarian has a fiduciary responsibility to the client.

The client has the ultimate responsibility for caring for their pet in a way consistent with their own values and resources. They understand the pet and their interests in a direct and personal way not available to the veterinarian. Therefore, the client must be the ultimate decision-maker regarding their pet’s care. However, part of their responsibility to the pet is to be aware of and attempt to compensate for the interference of their own interests with those of the pet. And as part of the duty to give the best care possible, the client should understand and acknowledge the need for the guidance the veterinarian can offer out of their deeper understanding of the medical questions at issue.

Interestingly, this model for the veterinary-client-patient relationship shares some features with the principles of evidence-based veterinary medicine. One widely used definition of EBVM, which I have cited before, is “the integration of the best research evidence available with clinical expertise as well as the unique needs or wishes of each client in clinical practice.” Balancing the best available information, which of course is primarily the province of the veterinarian, with the needs and wishes of the client requires both the client and the veterinarian to accept the limitations of their own knowledge. The client should defer in matters of medical fact to the veterinarian, who is in a better position to understand the medical issues in a deep and meaningful way. The veterinarian, in turn, should acknowledge the limitations of their own knowledge and experience and rely on the best and highest level evidence available to guide their recommendations. The doctor must also defer to the client in areas where the core issues are those of values rather than medicine, while of course still staying true to their own ethics and understanding of appropriate standards of care.

These negotiations between the interests and competencies of the parties involved are complex and situational, and they require explicit, clear communication, thoughtful self-reflection, and a willingness to consider and integrate factual information with sometimes contrary interests, values, and perspectives. This all makes the activity both difficult and sometimes frustrating and also richly rewarding.