Mark Crislip at Science-Based Medicine recently discussed Hill’s Criteria of Causation, but after looking at Dr. Hill’s original paper I felt obliged to examine the subject here as well because it is central to science-based medicine, and key in differentiating real medicine from quackery.

As I often discuss, a crucial issue in medicine is the question of epistemology; how we know what we know. Our therapies ought to be based on a real understanding of health and illness, and sound evaluation of the safety and efficacy of the interventions we undertake. The key difference between scientific and alternative medicine is in the criteria  for such evaluation. CAM proponents are often satisfied with theories of disease than are either made up out of whole cloth by individuals (e.g. homeopathy, chiropractic) or that are an agglomeration of folk beliefs (e.g. acupuncture, reiki and other energy therapies, TCM). Whether these theories are consistent with our general understanding of the universe, or with each other, is not a concern.

Even more damning, CAM practitioners are frequently satisfied that their personal impressions and experiences are adequate to validate the truth of the causal associations they see underlying disease or in the response to their treatments. Despite the manifold errors the human mind is known to exhibit in making causal associations, these people don’t see any need for a type of validation that compensates for these errors. They may lay claim to any scientific evidence that can be found for their approaches, for the aura of legitimacy it confers, but they will never reject the conclusions of their experience or intuition in light of any other kind of evidence.

In 1965, Dr. Sir Austin Bradford Hill gave a talk to the Royal society of medicine entitled The Environment and Disease: Association or Causation? In this address, he laid out nine criteria for concluding that an observed association was in fact representative of a causal relationship. His lucid and cogent presentation provides us with an excellent framework for making decisions about the causes of disease or the effects of treatments, all the more because he was so careful to emphasize that his criteria were guidelines which should support, not replace critical thought and judgment.

Here are Dr. Hill’s criteria, with a brief explication of each:

1. Strength– The strength of an association can be supportive of a true underlying causal relationship. If a proposed cause for a disease is associated with the disease itself only sporadically or unpredictably, this is weaker evidence for its causal role than if it is reliably present in conjunction with the disease. As always, Dr. Hill cautioned that “we must not be too ready to dismiss a cause and effect hypothesis merely on the grounds that the observed association appears to be slight,” but the strength of an association is a relevant factor in evaluating its significance.

2. Consistency– An association between cause and effect should be robust enough to be demonstrable in multiple studies by different investigators. This is key to understanding the fallacy of presenting a single study as definitive evidence for or against a disease etiology or treatment effect. The preponderance of the evidence as it accumulates is more meaningful than the results of particular studies, though the quality as well as quantity of the evidence must also be considered.

3. Specificity– If a putative cause is associated with a very specific set of symptoms, or a treatment with very specific effects, this supports a causal relationship. If the cause is present with a wide variety of different clinical presentations or the results following a treatment are highly variable, this argues against a causal relationship. As always, Dr. Hill correctly cautions against excessive rigidity in the application of this criterion, pointing out that many diseases are multifactorial and may not exhibit great specificity of association with a single causal factor. As he puts it, “if specificity exists we may be able to draw conclusions without hesitation; if it is not apparent, we are not thereby necessarily left sitting irresolutely on the fence.”

4. Temporality– Causes by definition precede their effects, so if a potential causal agent is observed after the condition it is speculated to be causing, this argues strongly against a true etiologic relationship. The obverse of this is, of course, the post hoc ergo propter hoc fallacy, perhaps the most intransigent and troublesome reasoning error in medicine. The observation that one thing precedes another is not in any way evidence for a causal connection because of the myriad of alternative explanations that often turn out to dictate the order of precedence. Unfortunately, precedence is very compelling as proof of causality despite being unreliable.

5. Biological Gradient– Also known as a dose-response curve, this relationship is common in biological systems and is strongly supportive of a causal/effect relationship. If the amount of a drug given or the intensity of an exposure to a potential cause of disease is correlated with the likelihood or severity of the resultant effect or the disease, this supports a conclusion of causation. If, however, a little bit is as good (or bad) as a lot, the hypothesis of causation should be questioned.

6. Plausibility– Dr. Hill was less convinced of the reliability of this criterion because, as he correctly observed, “What is biologically plausible depends upon the biological knowledge of the day.” However, as he explains in discussing his subsequent criterion, a proposed relationship which contradicts well-established understandings in biology or other areas of knowledge should be viewed as less likely to be correct, and less worthy of implementation or investigation, than a relationship consistent with such understandings.

7. Coherence– In contrast to his caution regarding the criterion of plausibility, Dr. Hill states, “On the other hand, the cause-and-effect interpretation of our data should not seriously conflict with the generally known facts of the natural history and biology of the disease.” A proposed mechanism, such as that underlying homeopathy, which requires overturning well-established principles in biology, chemistry, and physics must face a far greater burden of proof to be accepted as valid than a hypothesis consistent with established knowledge.

8. Experiment– Clearly, the results of controlled laboratory, animal model, or clinical trial studies are critical in drawing firm conclusions about the causation of disease or the effects of medical interventions. Contrary to the stereotype sometimes promulgated by CAM advocates, scientific medicine does not rely solely on this criterion, but it can be a very powerful tool for confirming or invalidating proposed relationships.

9. Analogy– This is perhaps the weakest of Hill’s criteria, though it is popular because of the simplicity and apparent clarity of arguments by analogy. While toxins may cause illness, for example, not all illness should be attributed to toxins. Likewise, while infection may cause a fever, not all fevers are due to infection. Analogies are most useful for suggesting possible relationships, which should then be confirmed or disproven by application of more rigorous criteria.

After discussing his criteria, Dr. Hill goes on to eloquently addresses two critical issues in the epistemology of medicine. First, he is very clear that conclusions about cause and effect relationships must be based on assessment of multiple criteria and application of sound reasoning, not on slavish adherence to one criterion or to any algorithmic model, including his:

“What I do not believe – and this has been suggested – that we can usefully lay down some hard-and-fast rules of evidence that must be obeyed before we can accept cause and effect. None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required as a sine qua non. What they can do, with greater or less strength, is to help us to make up our minds on the fundamental question – is there any other way of explaining the set of facts before us, is there any other answer equally, or more, likely than cause and effect?”

This shows a sophistication of reasoning inconsistent with the stereotype of science-based medicine advocates as obsessed with randomized clinical trials and blind to all other evidence for or against proposed causal relationships.

Dr. Hill also presciently addresses the proper role of statistical analysis in medical decision making. In dealing with questions of cause and effect, he argues that “no formal test of significance can answer those questions. Such tests can, and should, remind us of the effects that the play of chance can create, and they will instruct us in the likely magnitude of those effects. Beyond that they contribute nothing to the “proof” of our hypothesis.” He goes on to discuss how statistical analysis entered medical research in the 1920s and 1930s as a needed anodyne to the practice of basing firm conclusions and therapeutic practices on small, not representative case examples. However, he speaks strongly of the excessive role such methods were then coming to play in drawing conclusions from medical research, and the problems he describes have only worsened in the intervening time:

“I am told, some editors of journals will return an article because tests of significance have not been applied. Yet there are innumerable situations in which they are totally unnecessary – because the difference is grotesquely obvious, because it is negligible, or because, whether it be formally significant or not, it is too small to be of any practical importance. What is worse the glitter of the t table diverts attention from the inadequacies of the fare….Of course I exaggerate. Yet too often I suspect we waste a deal of time, we grasp the shadow and lose the substance, we weaken our capacity to interpret the data and to take reasonable decisions whatever the value of P. And far too often we deduce ‘no difference’ from ‘no significant difference.’ Like fire, the chi-squared test is an excellent servant and a bad master.”

Lastly, Dr. Hill answers definitively and in no uncertain terms those critics who falsely accuse practitioners of science-based medicine of passivity or helplessness in the absence of definitive clinical trial evidence:

“Finally, in passing from association to causation I believe in ‘real life’….In asking for very strong evidence I would, however, repeat emphatically that this does not imply crossing every ‘t’, and swords with every critic, before we act.

All scientific work is incomplete – whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time.

Who knows, asked Robert Browning, but the world may end tonight? True, but on available evidence most of us make ready to commute on 8:30 the next day.”

I really shouldn’t be giving this guy so much attention, but after our little tiff I’ve taken to checking in on his blog, and the vicious and self-serving marketing strategy is offensive enough to stimulate a response. Dr. Shaw Messonnier is continuing his tirade against veterinarians who stubbornly cling to science over faith-based medicine. His most recent blog post is still combining the blatantly unethical and deceitful mischaracterization of science-based veterinary medicine with the self-serving plugging of his own practices, and his book.

“Every day I see pets whose owners share with me the same tragic story. Their veterinarians have told them there is nothing they can do to help their pets. Many of these pets were seen by their veterinarians for routine checkups or what appeared to be minor problems. During the visit, a serious condition, often cancer, was diagnosed. As a result of the seriousness of the disease, the veterinarian offered no hope. Instead, the veterinarian told the owners that their pets had only a few weeks to live and recommended euthanasia when the pets’ condition declined.”

Of course, honestly discussing the inevitability of death is taboo in our culture, and while scientific medicine has much to offer in the treatment of cancer, and outperforms alternative methods whenever real tests are done (and this study), the reality is that some diseases cannot be cured and treatment must focus on maintaining comfort and a good quality of life. And the ultimate act of care for terminally ill pets is to let them die peacefully and without pain, rather than suffer the frequently awful and prolonged experience of an unaided death.

But Dr. Messonnier prefers confidently offering false, unsubstantiated claims of miraculous benefit from his methods (including diets free of supposed “toxins,” unproven or disproven nutritional supplements to “boost the immune system,” and of course avoiding “unnecessary” vaccinations). He makes wild and unsubstantiated claims about the success of his own methods, based solely on his opinion of what a great doctor he is. For example, “In general, pets treated with a combination of conventional medications plus natural therapies will usually live 2 to 3 times as long as those whose treatment does not include natural therapies.” This seems odd considering the evidence that in human cancer patients alternative medicine may actually be associated with shorter survival, either because of the effects of the CAM therapies themselves or because patients turn to CAM when they have diseases for which no real therapies exist. Still, he insists, “Integrative/holistic/natural/green therapies can offer “hope for the hopeless.” While I can’t always cure all of my patients, I can offer all of them hope and make them healthier. It is not uncommon for me to treat a pet who is given weeks to live by the previous veterinarian and have that pet live many months or even several years!”

In addition to such fanciful “clinical impressions,” and false hope, Dr. Messonnier bases his marketing strategy on mischaracterizing mainstream medicine, with all the cliches about real medicine only treating symptoms an CAM creating health, and so on: “The reason for my success? Unlike conventional doctors, I focus on HEALING the pet rather than TREATING the disease. This is a foreign concept to many doctors. When I was in veterinary school, I was taught to diagnose and treat disease. Our goal was never to improve the health of the pet but simply to win the battle against the disease. When that is not possible, the only other alternative is euthanasia.”

Not surprisingly, the rant ends with a plug for his new book: Unexpected Miracles-Hope and Holistic Healing for Pets. I have no doubt this will be a touching and emotion collection of anecdotes which create the impression, false though it is, that his methods can save those who we closed-minded and ineffectual science-based practitioners have given up on. Despicable and deceitful nonsense couched in the self-righteous language of the enlightened bringing hope and compassion to those abandoned by the cold and heartless practitioners of  mainstream medicine. Truly, if it were possible Dr. Messonier should feel ashamed.

I notice that Dr. Messonier has deleted  my response to his blog post defaming me. I guess polite, reasoned criticism is intolerable to him.

He has also written another post full of strawmen and cliches. He begins by trying to make his readers believe science-based veterinarians live in a fantasy world where nothing is done that is not validated by rigorous clinical trial evidence: “According to the skeptics, unless the therapy has been proven to work through numerous rigidly controlled scientific studies, they would be considered “alternative and unproven therapies” that should not be used in the practice of medicine.” Of course this is nonsense, and attacking a position your opponent doesn’t hold is vacuous rhetorical trickery.

A good definition of evidence-based medicine, which I have often quoted, 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.” Clearly, no one is arguing that we should never do anything unless it has been validated by good clinical trials. The point of evidence-based medicine is simply to organize the evidence in a hierarchy from least reliable (anecdote, personal impressions) to most reliable (replicated and well-designed clinical trials), and to weight most heavily the highest quality evidence available for a given intervention. Obviously, this is too complicated for Dr. Messonier, who prefers to paint an image of an imaginary bogeyman called the “The Skeptic,” which he then pastes over the face of anyone with the temerity to suggest his personal experiences might be mistaken.

He goes on to accuse conventional veterinarians of choosing to kill pets rather than admit their methods have failed and refer their patients to someone, like him, who has the power to help them. How’s this passage for self-aggrandizing, closed-minded, mean-spirited mischaracterization of those who disagree with him?

“I’m still bewildered by the fact that many conventional veterinarians choose euthanasia as a solution for failure of their conventional treatments, rather than simply opening their minds to the healing power that exists when using clinically proven, time-honored natural therapies. My hope is that more owners will continue to seek doctors, for themselves and their pets, who are open-minded to doing what is in the best interest of the patient regardless of which therapy ultimately proves successful, or which one has been “proven” to work by artificially designed controlled studies.”

Note the use of “clinically proven” to mean “I think it works.” And the use of “proven” in scare quotes to denigrate the conclusions of scientific evidence. Then there’s the usual meaningless cliché “time-honored natural” to describe blind faith in tradition combined with the naturalistic fallacy. And finally we have the blithe dismissal of clinical trials as “artificially designed controlled studies.”

This is a portrait of a mind closed to any suggestion of its own fallibility and blind to the history of medicine in the last 200 years, which has seen progress in well-being unlike the previous total of human history thanks to the “artificial” methods of science. This is a doctor so certain that he is right that disagreeing with him is intolerable and must be denounced, with all the self-righteousness of the religious fanatic, as a willful refusal to see the truth that he sees so clearly.

Of course, civil debate about the facts of specific medical interventions is impossible with such an attitude. He’s never once tried to convince me of anything, merely taken my suggestion that his epistemology is flawed as a personal affront and gone on a tirade against a cartoon image of me and other veterinarians who don’t placidly accept his view. The best one can hope for in such situations is that, as he suggests, pet owners will listen to the quite different approaches we represent and decide for themselves where the best hope for their pets lies. I have no doubt Dr. Messonier is genuinely convinced he is offering the best medicine, and I have very little doubt that he is mistaken. However, I agree with him at least so far as to believe pet owners can see through closed-minded nonsense. I just happen to believe that will lead them towards scientific, evidence-based medicine rather than “time-honored” woo.

Dr. Shawn Messonier, a highly visible alternative medicine veterinarian with a blog, radio program, and a couple of books, recently wrote an opinion piece for the online edition of USA Today claiming that changing vaccine recommendations were validation of his personal beliefs and clinical experiences about vaccines. Rather than recognizing that science is a process, not a fixed conclusion, and that such changes based on new evidence are exactly what good science and medicine are about, he prefers to interpret changes in vaccination practices as validation of his alternative medicine perspective, and he recommends we vaccinate even less (based, of course, on his clinical experience and intuition, not any specific evidence). I’ve investigated and written about veterinary vaccination in detail, and while there weren’t many specifics in his piece, I did feel he was too casual about implying that titer testing could be a wholesale replacement for vaccination and in citing his personal experiences as if they were a sound basis for a medical recommendation.

Rather than respond to my quite limited critique, Dr. Messonier chose to create and them attack a strawman with my name on it. He began by defending personal experience (though only of holistic doctors) as solid evidence and then referring vaguely to supposedly supportive studies:”I’m not surprised that “skeptvet” is skeptical of the recommendation for titer testing or other proven natural therapies. The “personal experience” of thousands of holistic doctors constitutes proof, as do controlled studies.”

He then raises some irrelevant uses of titers to test for infectious diseases and ends with the assertion that ” I’m all for scientific proof, but let’s not discount numerous cases of pets who improve with “natural” remedies simply because an admitted skeptic chooses not to “believe” in the facts.”

I responded trying to clarify his mischaracterization of my position and what my specific concerns were and left it at that. I then got an e-mail form Dr. Messonier asking me to appear on his radio program, chat a bit and take some calls from listeners. I got the impression that he was looking for a “sacrificial skeptic” rather than a substantive debate, so I declined. This concern has been confirmed by his recent blog post adding some features to his strawman version of me.

He starts by assuming my objections to CAM must be personal rather than principled and fact-based: “I’m not sure what his argument has to do with the fact that pets no longer need vaccines, but it’s obvious this anonymous person has some sort of grudge against alternative medicine and alternative doctors.” I’m not sure if he got carried away or really believes pets “no longer need vaccines,” but that is certainly a more radical position than he took in the USA Today article. As for having a “grudge” against alternative medicine providers, that is just an ad hominem to invalidate my points without actually addressing them.

He then tried to make hay out of suggesting there was something sinister in my not blogging under my real name: “I decided to check out skeptvet’s website. It was no surprise to find this person still does not identify himself on his website, which automatically raises a red flag for me. If you have a difference of opinion I respect that, but least don’t hide behind some anonymous moniker. In order to judge anyone’s credibility, it’s important we know who is making the statements. So from the outset skeptvet has one strike against him.”

What anonymity has to do with the substance of my positions I don’t know, but as I explained in my response to him, I blog under a nom de plume partly because the blog isn’t about me personally, it’s about the issues in veterinary medicine I am addressing. I don’t have any craving for the media spotlight, as he seems to. I also don’t wish to court unnecessarily the sort of pointless personal attacks he made in his post since adherents to alternative medicine seem to greatly resent criticism. If he is really interested in my identity, it would take about 5 seconds on Google to find it, so I don’t see that little bit of innuendo as meaningful.

He then went on to defend clinical experience as a form of evidence, with rather more passion than clarity of thought. Finally, he wrote me off as a closed-minded skeptic, thus dispensing with my arguments without so much as a glance in the direction of their substance or evidence:”Ultimately like many other skeptics, skeptvet will never be convinced that various therapies with which he does not agree may be helpful for people and pets. For those with an open mind, and the willingness to accept the time-honored tradition of clinical experience, a new world of healing awaits where true health can be obtained. An open mind is needed for change, and with change comes endless possibilities!”

Very convenient, and very consistent with the general world view that places personal faith above objective research in the hierarchy of evidence. Believe hard enough, click your heals together three times, and anything is possible! I’ve written about what real open-mindedness is before, but I doubt he took the time to read or consider that.

Though it was probably pointless, I responded on his blog, chiding him for personalizing his comments and attacking his imaginary image of me rather than dealing with what I actually say. Here’s part of what I said:

“I am quite open-minded to any therapy that is demonstrated to work in a reliable scientific way. I submit I am more open-minded than you are since I acknowledge that my personal intuition and experiences may be mistaken, while you stick by your own beliefs regardless of what the research evidence says. Pick something specific I have said doesn’t work, show me real evidence it works, and I will be happy to admit my error for all the world to see… If I am opposed to alternative medicine it is only because I am opposed to gambling and experimenting on our patients. The problem is not with my closed-mindedness or prejudice, it is with your standards of what constitutes reliable proof… Clinical experience is evidence, yes, but it is weak evidence and progress in medicine will not come from adhering blindly to tradition or simply trusting your gut, it will come from vigorously investigating new ideas to see if they are worthy of applying to our patients.”

This exchange is paradigmatic for the conflict between science-based medicine and faith-based medicine. Challenging a belief based on intuition, experience, faith in folk tradition, and so on automatically creates personal animosity and resentment. Since the basis for the belief is personal, any challenge to it must be taken personally as well. If my clinical practices are challenged and the evidence shows I am wrong, I may be embarrassed, but I will be grateful for the guidance, not resentful of it because the truth is more important than my feelings or my ego.

Sure, clinical experience and intuition form part of the basis for my beliefs just like anybody else. I am human, and I share in all the genius and all the stupidity of human nature. However, I accept that science is a set of tools that compensates for human cognitive flaws, and when the choice is between good science and intuition, I’d bloody well better abandon my intuition or I am valuing my ego above the truth and following in the venerable tradition that brought us therapeutic bloodletting, faith healing, homeopathy, and all manner of ineffectual or dangerous nonsense.

I’m happy to cordially discuss and disagree with Dr. Messonier about veterinary medical practices, and I’m open to the possibility that he knows things I don’t know and that he might be able to show me things I’m wrong about. But he seems more interested in demolishing strawmen, so it’s unlikely I’ll get the chance to learn anything he might have to teach me, and it’s certainly unlikely he’ll be able to learn anything from me.

For all that CAM proponents like to claim their methods are philosophically different from (and of course superior to) mainstream medicine, they also can never resist claiming scientific legitimacy or popularity among mainstream health care professionals. “Integrative medicine” is the buzzword for the effort to encourage doctors to mix unproven or outright disproven therapies in with real medicine and then give the woo the credit for any improvement and “allopathic” medicine the blame for any adverse effects.

A recent survey of medical students illustrates the agenda of integrative medicine nicely. One author, a CAM researcher at UCLA named Ryan Abbott, claims: “Complementary and alternative medicine is receiving increased attention in light of the global health crisis…Integrating CAM into mainstream health care is now a global phenomenon, with policy makers at the highest levels endorsing the importance of a historically marginalized form of health care.” These are big claims, and while there certainly has been encroachment of CAM into academic medicine and powerful figures in government are pushing the CAM agenda, I am not convinced that there is a wave of support for legitimizing unproven or nonsense therapies among practitioners, students, and teachers of scientific medicine.

This study claims to show high levels of support among medical students for integrating CAM methods into mainstream medical training and practice. As always with surveys, how the questions are asked says a lot about the reliability of the answers, but the full article is not yet available at the eCAM Journal site, so I can’t evaluate that. The authors do indicate, however, that the response rate to their survey was only 3%, which is extremely low. Response rates necessary to view a random population sample as representative are closer to 70%, so any generalization based on this data would be unjustified. Likely the only students who bothered to respond were those already predisposed to favor CAM, or perhaps those sufficiently motivated against it to take the survey, so it is doubtless a skewed sample. The response rate itself certainly does not suggest the level of interest in CAM that the authors seem to be trying to use the reslts to argue exists among medical students.

The authors also repeat the tired and inaccurate cliches about CAM being more “holistic” and “individualized” that scientific medicine. All-in-all, this “research” looks simply like an attempt to create the perception that the mainstream medicine is beginning to “see the light” and that doctors will soon be more open to spending more time and effort on placebo therapies. One can only hope the perception doesn’t become the reality.

There was a thoughtful and cogent essay on the Kevinmd Blog today about a key element in doctor/patient (or in the veterinary case doctor/client) relationships: what happens to the relationship when you say “No” to people. This is certainly a common challenge for veterinarians, and it set me to thinking about situations in which we are required, in my opinion, by ethics to tell our clients things they don’t want to hear, and things that will not endear us to them.

In America there are be two well-known rules:

1. Nothing is ever nobody’s fault.

2. There is never nothing to be done.
(I apologize for the grammar, but I feel the emphasis is more appropriate than the better-written versions of these statements)

As an advocate for science-based medicine, because I truly believe it leads to better health and well-being for patients than opinion and faith-based medicine, I have an ethical responsibility to own up to the limitations of scientific knowledge. I cannot claim one unifying cause for all disease (toxins, subluxations, unbalanced ch’i, dietary deficiencies, and on and on). And I cannot claim to always know why a particular clinical problem affects a particular pet. Philosophically and personally, I am comfortable with some degree of scientific indeterminism, and I believe it is possible that some things simply can never be predicted or fully understood. But even in the more pragmatic, practical world of applied medical science, the reality is that there is much we don’t know, and pretending that we have all the answers is misleading and wrong.

Unfortunately, people don’t like uncertainty, especially when it involved illness, and they tend to view the claim that something bad happened for reasons we don’t understand, or even possible just by chance and so for no good reason at all, as unacceptable and likely a cover for incompetence. Not being able to identify a clear and simple cause for something means we cannot control or prevent it, and this makes us afraid, and fear makes us angry. Facing this anger and dealing with it compassionately, and yet honestly, is a tough part of our job as veterinarians.

It is very difficult to tell a client that we do not know why their pet has a particular medical problem, and even more difficult to then deny them the comfort of the unproven, or even outright bogus theories they come up with or that others offer them. But part of our ethical responsibility to our clients, and the way we earn the trust they must ultimately have for us to do our jobs, is that we must be honest, even when dishonesty might provide some comfort or make us look better.

Along with admitting to the limitations of our knowledge, I believe we must be honest about the knowledge we do have. When we know that 98% of cats under 10 years of age who present with bloody urine do not have urinary tract infections, we must deny the client the antibiotics they may want from us even if we could make the client happy and get the credit for the pet’s subsequent improvement. We know they won’t help, and may even hurt the patient, and we have a responsibility to admit and make appropriate use of that knowledge. Giving antibiotics for infections that are likely viral and vitamins and other supplements that have no demonstrated value are common practice among physicians, and likely veterinarians as well. They serve our need to do something, and the clients’ need to get something for the trouble and expense of coming to see us. However, they are illusions, not medicine, and ultimately I don’t believe they benefit our patients, clients, or profession.

The same holds true for any implausible or outright unproven medical approach. While our clients are likely to perceive improvement, at least in the short term, with almost anything we do (thanks to a placebo effect by proxy), giving a placebo is a form of lying and is essentially unethical and contrary to the principles of a legitimate veterinarian/client relationship. This is especially true for vets as the placebo is more likely to benefit our clients than our patients, who are better served by real therapies.

CAM therapies can have an advantage over science-based medicine in that they frequently offer direct and simple (though false) explanations and treatment protocols. CAM providers seem rarely at a loss for an explanation or a treatment, and though I am sure it must sometimes happen, it seems very rare that a CAM provider will admit that they don’t know why something bad has happened and that they do not have anything but comfort and support to offer. Part of the mythology that CAM  treats causes rather than symptoms, and part of the reality that CAM often makes clients more satisfied with their care than mainstream medicine, has to do with the sense of confidence and certainty (however unjustified) that allows CAM providers to avoid admitting helplessness or uncertainty when we who are dedicated to dealing in evidence and truth cannot avoid it.

There are many other examples of situations in which we are obliged by ethics to say no to clients or tell them something they don’t want to hear. Denying requests for tests, medications, or procedures that are not appropriate for the patient, recommending tests and procedures which are appropriate even if we fear the client may object to the costs, honestly (though gently) explaining their own responsibility for some medical problems and the actions they need to take (overfeeding and obesity, poor medication compliance, etc), and admitting our mistakes are all painful but necessary elements to a veterinarian/client relationship.

It is understandable that we may be tempted to shirk such painful communication, and it is certainly easier in the short run to do so. I have even met veterinarians who based long, financially successful careers on the routine practice of giving clients want they want regardless of what is medically appropriate or best for the pet, and of routinely lying to clients. However, I believe the ethics of our profession, the dictum to do no harm if we are not certain the need or benefit justifies it, and the principle of trust based on honesty in our relationships with clients often requires us to say “No” and to tell clients things they would rather not hear from us In the long run, I also believe we provide better care for our patients if we act this way, and that the short term advantages of false hope and even outright dishonesty cannot compete with the benefits of sticking with the truth, even if it may not always be what we wish it were.

Just to let all readers know, on January 28th, I will be hosting the 129th Skeptics’ Circle, a biweekly blog carnival collecting and presenting articles applying the skeptical point of view to a wide variety of issues. I’ve had a few of my own articles included in past Circles, and I’m very excited to have a chance to host!

Check out the recent 127th Circle, and remeber to check back for some ggreat skeptic writing January 28th! Or even better, contribute a blog post of your own!

The question of whether the electromagnetic radiation from cell phones is a risk factor for human disease, especially brain cancer, has been debated and studied at length. There are committed partisans on both sides, but the research is inconsistent and incomplete. A couple of nice summaries and discussion of the issue and the research can be found at the National Cancer Institute and The Skeptics Dictionary. Overall, it seems unlikely to me that cell phone usage represents a significant risk, but the issue has not been decided beyond all reasonable doubt.

However, a recent study has added a bit of fun to the discussion by claiming cell phone radiation may prevent or reverse Alzheimer’s disease! According to news articles about the study:

“The results showed that:

Exposure started when they were young adults, ie before showing signs of memory impairment, appeared to protect the Alzheimer’s mice from becoming cognitively impaired.

Exposed older Alzheimer’s mice performed as well on tests measuring memory and thinking skills as normal older mice without dementia.

When older, previously unexposed Alzheimer’s mice already showing memory problems were exposed to the electromagnetic field, their memory impairment vanished.

Normal mice exposed to the electromagnetic waves for several months showed above normal memory performance.”

The authors seem quite optimistic about the applicability of the results to human disease:

“Since we selected electromagnetic parameters that were identical to human cell phone use and tested mice in a task closely analogous to a human memory test, we believe our findings could have considerable relevance to humans.”

“Arendash and colleagues concluded that electromagnetic field exposure could be an effective, drug-free, non-invasive way to prevent and treat Alzheimer’s disease in humans.”

“The cognitive benefits of long-term electromagnetic exposure are real, because we saw them in both protection- and treatment-based experiments involving Alzheimer’s mice, as well as in normal mice.”

It should come as no surprise that I don’t share this enthusiasm. The results are certainly interesting, but this is precisely the sort of small, animal model study that the media loves to extrapolate wildly from, contributing to the public perception that science is constantly finding phony “miracle cures” and that scientific research results cannot be trusted. The problem, as I’ve argued before, is not with science but with individuals, scientists and others, who treat such curious and preliminary results with excessive enthusiasm.

Talking about a “effective, drug-free, non-invasive way to prevent and treat Alzheimer’s disease” based on exposing mice to EM in the lab and then looking at their behavior and their brains is indefensible. Replication in other laboratories, further elucidation of possible mechanisms, study of safety concerns, and the whole labyrinth of procedures in human subjects to assess safety and efficacy are needed, years of work, before such speculations ought to be publically entertained. I’ve often pointed out that being part of mainstream science and medicine does not, alas, immunize one against some of the lapses in critical thinking often associated with CAM, and this provides another example.

Still, it will be interesting, though, to see what reaction this study generates in the alternative medicine community. I suspect those enamored of “natural” medicine will reject as unholy any such technological methods regardless of whether they ultimately prove useful. I also suspect that if the exact same study came out only “electromagnetic radiation” was replaced throughout with the name of an herb or traditional energy therapy, such a study would be nearly universally proclaimed as justification for immediate use of the agent or procedure in  human clinical practice. This is, after all, exactly the sort of evidence proponents of “Evidence-Based Alternative Medicine” routinely rely on.