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.

I am often struck by what I consider one of the great mysteries of CAM: how theories and approaches that are mutually inconsistent and incompatible are unified under the CAM umbrella without any apparent notice being taken of their mutually exclusive dogmas. The American Holistic Veterinary Medical Association (AAVMA), which I’ve written about before, is the paragon of this phenomenon. The organization supports and publishes “research” articles about almost any quack therapy without discrimination, so long as it cannot be said to be solidly based on scientific research evidence. The siege mentality seems to blind members of the CAM community to their internal differences.

Chiropractic is based on the theory that a mystical energy called innate intelligence travels through the spine and that subtle misalignments of the vertebrae (subluxations) block the normal flow of this energy, which leads to all disease. Granted, some chiropractors treat these ideas much like many Christians treat the Bible, as metaphors rather than literal truth, but the idea is still the foundation of the method and still widely invoked, especially since those chiropractors who have renounced it are left rather lamely claiming that their method works because people say it works even if no one can say why.

Traditional acupuncture, insofar as it has any consistent theoretical foundation, relies on the similarly vitalistic concept of qi which gets blocked or unbalanced to cause all disease. Manipulation of the qi as it flows through meridians by penetration with needles is the key element of acupuncture therapy. Again, some acupuncturists have attempted to jettison the vitalism underlying the tradition of their approach, though they haven’t come up with a demonstrable, consistent alternative explanation of how acupuncture might work, but many still employ the traditional concepts and language.

Homeopathy is based on another vitalist force gone awry, only this time the key to treatment of all disease is identifying a natural substance that induces the same symptoms as a particular disorder (Law of Similars) and then making it into a potent medicine by diluting and shaking it (Law of Infinitesimals and succussion). The contortions of homeopaths to try and rationalize this nonsense by bizarre interpretations of quantum mechanics are especially entertaining.

Many less popular CAM approaches rely on similar vitalist concepts, and yet many, many of them claim a unitary cause of disease and a single method for treatment, and no one seems to notice that all of these theories and all of these treatments cannot all be the one true cause/treatment of disease. Yet it is quite common for practitioners and patients alike to combine methods and recommend several or all of them. Clearly, the reality is that whatever unites these folks, it is not a particular theory nor even a commitment to their various one true answers. So what is it?

Well, epistemologically of course it is the belief that personal experience and intuition are reliable and sufficient to confirm the truth of an idea or the efficacy of a therapy. There is a strong tendency to a post-modernist relativism that suggests multiple incompatible truths can all be true for someone somewhere since there is no single physical reality out there waiting to be understood, as methodological naturalism and most scientific epistemology assumes.

Politically, CAM practitioners share a sense of being bold and unconventional thinkers surrounded by an oppressive and unimaginative orthodoxy marching in lockstep and suppressing all dissent. The reality is quite different, as CAM has become a well-financed and politically powerful lobby, but the image still persists in the minds of many practitioners and users.

CAM proponents often view the world as “toxic” and see the benefits of technology and science as hiding malign and poisonous underbellies. They tend to view history as a decline from a romanticized golden age in which humans lived in a state of nature and were healthier and happier to a time of decay in which science serves only to abuse and oppress the earth and the body.

There are undoubtedly other philosophical and aesthetic commonalities to the CAM movement, and I think it would be a fascinating topic for detailed study. Unfortunately, the general distrust of the very notion that there is a single objective reality that exists for everyone everywhere and that isn’t influenced at all by our beliefs or feelings makes possible a kind of doublethink in which mutually inconsistent medical theories can all be true. This makes it possible to suggest with a straight face that CAM might really be “complementary” even to scientific medical practice while still rejecting the very philosophical and epistemological premises that underlie science-based medicine. It would be nice if pointing out the logical inconsistency here had an impact on the beliefs of CAM followers, but they are well-protected against such reasoning.