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An Age of Endarkenment? The American Veterinary Medical Association and Homeopathy

It can be frustrating, and sometimes even a little depressing, to be a skeptic. Promoting reason and science-based medicine often feels like a Sisyphean effort that garners lots of hostility and ad hominem attacks from proponents of pseudoscience and few concrete victories. But once in a while, something happens to give a little hope and inspiration.

In 2010, for example, the House of Commons Science and Technology Committee report on homeopathy came out, clearly unmasking homeopathy for the vitalist 18th century relic it is (though, sadly, politics is complicated and often unmoved by mere scientific truth, and the government didn’t eagerly embrace the findings or recommendations of the committee). About the same time, the British Medical Association called homeopathy “witchcraft,” and recommended it no longer be supported by the National Health Service. More recently, the Chief Medical Officer in Britain openly acknowledged homeopathy is “rubbish.” Perhaps there has been a shift in the winds? Maybe there is hope that the institutions of government and organized mainstream medicine here in the U.S. might be willing to start taking a stand against pseudoscience in the way they used to in the days before Wilk vs American Medical Association?

As a veterinarian, I was particularly delighted and inspired in March, 2012 when the Australian Veterinary Association (AVA) joined in this movement and took  a firm and public stand on unscientific therapies, in particular washing its hands of homeopathy:

Australian Veterinary Association (AVA) resources will not be used to promote therapies that, in the Board’s opinion, are not compatible with current understanding of physiology and pathophysiology and have been demonstrated to be ineffective by the current accumulated body of knowledge.

That the Board agreed that the veterinary therapies of homeopathy and homotoxicology are considered ineffective therapies in accordance with the AVA promotion of ineffective therapies Board resolution.

This echoed the policies of the British Veterinary Association, and other national veterinary groups in Sweden, Denmark, and elsewhere in Europe. The idea that the central player in organized veterinary medicine in the U.S., the American Veterinary Medical Association (AVMA), which has as members more than 80% of the licensed veterinarians in the country, could be moved to take a similar stand started to seem like a realistic possibility.

The existing AVMA policy on Complementary and Alternative Veterinary Medicine (CAVM) has some nice sentiments in it.

The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method… Practices and philosophies that are ineffective or unsafe should be discarded…

However, in the roughly 11 years since that policy was adopted, not a single practice or philosophy actual has been discarded, or identified as inconsistent with the scientific method or established scientific knowledge. It has become merely institutional cover for veterinarians practicing alternative therapies to claim that these are recognized and compatible with scientific medicine despite the lack of meaningful supporting evidence.

So a group of veterinarians from the Connecticut Veterinary Medical Association (CVMA) and the Evidence-Based Veterinary Medicine Association (EBVMA; of which I am currently president), decided to submit a resolution to the AVMA governing body (the House of Delegates), re-affirming that veterinary medicine should be science based and finally identifying homeopathy as the pseudoscientific nonsense it is.

The full text of the resolution can be found here, but the core of it is in these statements:

RESOLVED, that the American Veterinary Medical Association (AVMA) affirms that—

  1. Safety and efficacy of veterinary therapies should be determined by scientific investigation.
  2. When sound and widely accepted scientific evidence demonstrates a given practice as ineffective or that it poses risks greater than its possible benefits, such ineffective or unsafe philosophies and therapies should be discarded.
  3. In keeping with AVMA policy on Complementary and Alternative Veterinary Medicine, AVMA discourages the use of therapies identified as unsafe or ineffective, and encourages the use of the therapies based upon sound, accepted principles of science and veterinary medicine.
  4. Homeopathy has been conclusively demonstrated to be ineffective.

There is nothing here that ought to be remotely controversial for the vast majority of veterinarians who practice conventional medicine. And while proponents of all pseudoscience like to pretend their practices are scientifically legitimate, the evidence that homeopathy is both inconsistent with established science (should not work) and demonstrably ineffective (does not work) is overwhelming. The CVMA and EBVMA accompanied the resolution with a white paper, The Case Against Homeopathy, which illustrated in detail the following points:

  • It is generally accepted in veterinary and human medicine that the safety and efficacy of medical therapies is best determined by scientific investigation and scientific evidence.
  • The principles of homeopathy are incompatible with well-established scientific knowledge.
  • There is abundant pre-clinical research showing most homeopathic remedies (those that are highly diluted) have no biological effects.
  • There is abundant clinical research in humans showing homeopathy to be no more effective than placebo.
  • The limited veterinary research available is consistent with the research done in humans in showing that homeopathy has only placebo effects, not specific therapeutic treatment effects.

The resolution had support among a wide range of veterinarians working in different fields. Official endorsements came from the American College of Veterinary Clinical Pharmacology, the American Academy of Veterinary Pharmacology and Therapeutics, and the American Society of Laboratory Animal Practitioners. A number of individual veterinarians also publically supported the measure.

A particularly compelling letter of support came from Dr. Narda Robinson at Colorado State University. Though supportive of some forms of complementary and alternative treatment, Dr. Robinson was concerned about both the evidence against any real benefit from homeopathy and the official policy of the Academy of Veterinary Homeopathy (AVH) to discourage conventional medical care. The presence of such allies added to the sense that the times were a-changing, and at last we might be able to do something about this ridiculous bit of vitalism.

There was also, however, a conspicuous silence from many organizations whose members aren’t usually practitioners of homeopathy but who, for various reasons, were unwilling to acknowledge publically that it is nonsense. There was hope, for example, that the American College of Veterinary Internal Medicine (ACVIM) would endorse the resolution. One of the most respected specialty colleges in veterinary medicine, this group could have significant influence on the acceptability of pseudoscience like homeopathy.

The ACVIM declined to endorse the resolution despite the fact that most of its members do not accept the scientific legitimacy of homeopathy. The reasoning and individual comments offered in their explanation of this decision exemplifies the flaws in the philosophy of evidence-based medicine that have led the group founding SBM to take on the cause of science-based medicine instead:

It should be stated outright that the BOR believes that evidenced-based medicine should be the foundation of the practice of veterinary medicine as much as possible. Realistically, however, we all recognize that many treatment and diagnostic decisions applied to veterinary patients, both by general practitioners and veterinary specialists are made in the absence of evidence…

If I tried to say that I believe all therapy must be based on scientific evidence and clinical trial data, I would be an absolute hypocrite, and I would be reduced to being able to treat a handful of diseases.

This is the argument that says, in essence, that EBM requires optimal evidence before a judgment can be made, and in the absence of near perfect, gold standard RCT evidence, everyone should be free to do whatever they like based on any theoretical reasoning or personal intuition or experience. This approach, which ignores the vast knowledge we have already accumulated which makes some hypothesis far more likely to be true than others, reduces EBM to an intellectual curiosity with no practical value. If we cannot distinguish between homeopathy and conventional medicine after 200 years of scientific research, then we might as well give up entirely on the notion that science is of any use in informing clinical decision making.

Fifty years ago, we had no clue that genes could be normal, but silenced. We had no mechanism for how non-mutating substances cause cancer. We now know they do. I cannot feel comfortable speaking with strong certainty that an entire form of medicine does not work when it is practiced in many parts of the world, journals describing it are indexed in Pubmed, and many are equally convinced of its efficacy.

This is the familiar fallacy that because unexpected or improbable things have turned out to be true in the past, and because our knowledge is inevitable flawed and incomplete, we must refrain from ever judging anything to be untrue, with dash of the argumentum ad populum fallacy for seasoning.

There are too many shades of grey surrounding what we each do on a day-to-day basis to comfortably single out a particular therapy for condemnation because of a lack of evidence. There are many forms of “unconventional” or “alternative” therapy with no more evidence of efficacy than homeopathy. And even when using “conventional” therapy in an empiric manner, problems with the resolution arise. Every patient empirically treated without a definitive diagnosis is, in essence (in my opinion), a violation of at least the spirit of the resolution (and with as much potential for harm from delayed diagnosis as any non-traditional therapy). Every time I reach for certain dangerous drugs (eg, chemotherapy drugs, glucocorticoids) because I have nothing else to offer, I violate the spirit of the resolution (and arguably in a more severe manner in that my non-evidenced-based therapy has a greater likelihood of causing harm than the homeopathic treatment). Where would/should the lines be drawn then?

Given the necessity in many cases to make decisions with only scant, poor quality or even conflicting evidence an alternative wording to the resolution that many BOR members seemed comfortable with is offered:

  1. Safety and efficacy of veterinary therapies should be determined whenever possible by scientific investigation.
  2. When sound and widely accepted scientific evidence demonstrates a given practice as ineffective, or that it poses risks greater than its benefits, such ineffective and unsafe philosophies and therapies should be discouraged.
  3. Veterinarians may legally employ any therapy not proscribed by applicable laws and regulations governing the practice of veterinary medicine. However, veterinarians have an ethical duty to society, and to their patients and clients, to ignore their biases and instead base their judgments and recommendations as often as possible on the best available scientific evidence.

This statement seems to me to be saying, “We believe science is the best way to validate medical therapies, but we aren’t willing to say that anything is ever invalidated unless nothing we do involves any evidentiary uncertainty.” To suggest that empirical use of chemotherapeutics is roughly equivalent to treating cancer with water is clearly ridiculous. Yet there is a component of humility and a sense of fairness that makes this sort of reasoning very appealing to the majority of veterinarians who don’t believe in homeopathy but are reluctant to criticize their colleagues who do.

 

While I applaud the recognition of our individual and collective ignorance and limitations, I believe it does no service to our patients and clients if we mistake post-modernism for humility. The evidence against therapeutic bloodletting was no better than that against homeopathy, and it was no less plausible. Should we revive that practice because we have not definitively demonstrated it is useless in all circumstances by extensive and perfect RCTs? Lines should, indeed, be drawn, and while they may not always be perfectly drawn and immutable, they can be based on a thoughtful and reasonable assessment of the available evidence.

As I see it, all conclusions in science are, of course, provisional and subject to revision as new evidence is developed. And our confidence in our conclusions should be proportional to the evidence available to support them. So it is possible evidence could be developed to validate homeopathy as a clinical intervention. Personally, I see this as about as likely as the emergence of evidence that the Earth does not, in fact, revolve around the Sun, but in some theoretical sense at least it is possible. And the evidence concerning homeopathy is not impervious to criticism, especially given the generally low level and poor quality of it. However, if we cannot draw conclusions about a therapy until near perfect evidence is available, then EBM is useless as a decision-making tool.

My own approach is that we must critically evaluate and rank the evidence according to EBM methods, then integrate this with other relevant information, such as biologic plausibility, and make a pragmatic decision based on the evidence that exists. Accepting the provisional nature of such decisions, we must be willing to re-evaluate them as necessary, but it does no good to simply refrain from making them at all if the evidence is less than ideal. We don’t entirely understand the mechanisms of gravity, but we refrain from leaping out of windows all the same.

In the case of homeopathy, the absence of evidence seems very much to be evidence of absence given the implausible foundations and the failure of numerous attempts to validate the method over two centuries. If even this is not sufficient to declare the therapy ineffective (with, of course, the very small caveat that allows for new evidence to someday emerge), then I cannot see how any therapy can ever be discarded or how EBM can provide effective guidance for clinicians in selecting interventions.

Less surprising and disappointing than the failure of support from the reasonable mainstream of veterinary medicine was the opposition from the expected sources. The AVH and the American Holistic Veterinary Medical Association (AHVMA) both opposed it. The AVH attempted to muddy the waters in the usual way by producing a white paper of their own, The Evidence for Homeopathy, which claims to show that homeopathy is based on legitimate, validated scientific principles and has abundant evidence of clinical benefit.

This paper illustrates exactly the points made and demonstrated in The Case Against Homeopathy. Low-quality studies with poor control for bias, confounding, and other sources of error are cited to justify claims that the evidence does not support. Sometimes, even studies which find no effect are cited to support claims of an effect. Bits of legitimate science are misinterpreted to generate the false impression that they validate the implausible theoretical foundations of homeopathy. Clear publication bias in support of homeopathy is ignored whereas negative evidence is dismissed on the basis of presumed individual bias regardless of the methodological controls used to account for this. This document was a transparent attempt to select and distort the evidence in favor of their pre-exiting beliefs.

Though tedious, I thought it might be useful to go through the AVH document point by point, including critically appraising each of the references cited. The result is The Evidence for Homeopathy-A Close Look, which deconstructs the bogus arguments of the AVH in exhaustive detail (for this, I want to specifically give my thanks to the other authors at SBM, to Orac of Respectful Insolence, and to the folks at Rational Veterinary Medicine, where I found invaluable information about some of the research cited in the AVH paper).

Apart from the AVH attempt to manufacture scientific legitimacy for their approach, there was the usual hue and cry of a less academic nature. The folks at Mercola.com offered some of the usual hysteria and hyperbole about “health freedom” and the right to peddle and procure whatever medical interventions anyone wants, regardless of evidence concerning safety or efficacy. And one leading opponent of the resolution, a homeopath involved in the AVH and often seen lecturing on homeopathy at mainstream veterinary continuing education meetings, went so far as to compare this resolution to the Holocaust: “She felt that this was her personal Kristallnacht, that the walls came down around her and that she was being marginalized from within her own AVMA.” The AVH submitted a letter full of smoke and mirrors and outright error commenting on specific statements in The Case Against Homeopathy, which I have responded to point by point. And apparently, individual veterinarians worried about losing their freedom to employ imaginary therapies contacted the AVMA to protest the shocking and outrageous idea of admitting homeopathy doesn’t work. About 700 emails and 250 phone calls were apparently received by the AVMA condemning the resolution. It goes almost without saying that the AVMA did not hear from nearly as many skeptics willing to openly speak against homeopathy.

So with pseudoscience and outrage pitted against a mountain of scientific evidence, any guesses as to the outcome?

Well, technically it wasn’t a defeat. The House of Delegates voted by about 3:1 not to vote on the content of the resolution but to refer it for evaluation to the committee that wrote the current CAVM policy quoted above. The same policy which made reasonable noises about the importance of science 11 years ago and has been rather quiet since in the face of apparently growing infiltration of homeopathy and other pseudoscientific practices into the mainstream. I’m not directly involved in the politics or the process, but my guess is the resolution will die quietly in committee, or perhaps be replaced by more vague noises about science and research without any clear statements about the validity of any specific intervention.

So are we slipping into a medical Age of Endarkenment in the U.S.? We still pay lip service to science evidence and reason, but even the best educated and trained among us accept shoddy science and postmodernist rationalizations as reasons to refrain from declaring even such egregious nonsense as homeopathy as out of bounds. It’s true, there are only about 130 members in the AVH, so homeopaths are a tiny minority within the veterinary profession. But with the complicity of the majority, unwilling to criticize anything our colleagues do, this minority can continue to sell pseudoscience and placebos to their clients.

And the AHVMA, which represents CAVM in general, is much larger and more influential than the AVH. They have recently raised about $400,000 to promote “integrative medicine” at mainstream veterinary schools, with an ultimate goal of $20 million and multiple academic centers promoting alternative therapies, positioning themselves as the Bravewell Collaboration of veterinary medicine. And despite their claims to respect science and support rigorous research, they have thrown their lot in decisively with the magic water that is homeopathy. What can skeptics use to combat those resources, other than mere facts and evidence, which seem less persuasive to our otherwise mainstream colleagues than we might hope?

The passionate few who are believers cannot, of course, make homeopathy anything other than a marginal practice, in most cases just added on to real medicine in true “integrative” fashion. After all, it doesn’t actually work. But the hope that we might actually see the death of it alltogether seems distant indeed. Like the proponents of intelligent design, homeopaths seem to be having some success generating a maufacturoversy, suggesting there is some legitimate scientific dispute concerning the plausibility and efficacy of homeopathy. And few of my colleagues in veterinary medicine seem inclined to look at the evidence critically and in depth themselves to see that there is, in fact, no real doubt or legitimate dispute. Money, popularity, and the voice of the passionate minority of believers seem unlikely to yield to mere reason and evidence, especially when shielded by the apathy or post-modern neutrality of the majority. Perhaps “Age of Endarkenment” is going a bit far, but some days the victories of the Age of Enlightenment seem evanescent, and it is clear we shall have to keep rolling the same old boulders up that hill for the forseeable future.

 

Posted in: Homeopathy, Veterinary medicine

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37 thoughts on “An Age of Endarkenment? The American Veterinary Medical Association and Homeopathy

  1. Guy Chapman says:

    There are only three problems with homeopathy. First, there is no reason to suppose it should work. Second, there is no way it can work. Third, there is no proof it does work.

    There’s no reason to think it should work because like does not cure like, diseases are not caused by miasms, and the supposed vital force lacks any evident basis in fact.

    There’s no way it can work because it’s predicated on the assumption that matter is infinitely divisible, which we know it is not.

    There’s no proof it does work because every single observation is fully consistent with the null hypothesis, and no test yet proposed by homeopaths is capable of refuting the null hypothesis.

    Apparently these three problems, which underlying the scientific consensus that homeopathy is bunk, are all part of the evil skeptic suppression of natural cures. And that’s why, out of stubbornness, homeopaths refuse to provide the clinching proof they know to exist. Or something.

  2. art malernee dvm says:

    The big problem with homeopathy is that its legal. Doctors should not be allowed to sell medicine with nothing but water in the bottle.
    Art Malernee dvm

  3. Badly Shaved Monkey says:

    I think Brennen hits a nail very squarely on the head when he points out that if an organisation applying the principles of EBM to homeopathy cannot reject that useless therapy then there really is not purpose in the EBM project.

    However, might I suggest that perhaps the proposed resolution was too wordy and allowed too much scope for shruggies to carefully miss the point. If it had skipped the motherhood and apple-pie of the first three clauses and just proposed a slightly expanded fourth version so the whole thing was specifically and only intended at skewering homeopathy I wonder whether you might have had more success. Would the ACVIM really want to be seen specifically defending homeopathy instead of being able to make a rather vague defence of clinical freedom?

    Is it too late to suggest a more targeted version? It must be disheartening to have put in this much work building a high-explosive rocket only for the detonation to get soaked up by the cottonwool numbness of wishy-washy committee people.

    A well-known senior UK vet once said to me of a certain veterinary regulator that “I really don’t understand it. Good people get elected then they turn into sh*ts.”

  4. Ed Whitney says:

    Yeah, guys, if you eradicate homeopathy, whatever will become of the classic old TEETH (tried everything else, try homeopathy) acronym on medical charts?

  5. pmoran says:

    While I applaud the recognition of our individual and collective ignorance and limitations, I believe it does no service to our patients and clients if we mistake post-modernism for humility.

    Humility and awareness of of certain limitations to the “universal standard” that we aspire to within our practices is not post-modernism. But you may not have meant that to be taken literally.

    Local vets routinely perform Caslicks in pregnant mares (partially stitching up the vulva). That is an invasive, distressing, and expensive practice, which has to be undone later, and which almost certainly does not prevent miscarriage. I have not seen good evidence for any other benefit.

    In my country there are also early indications that laparoscopic debridement for ostearthritis of the knee, another invasive and expensive procedure, is continuing to be performed in humans in very large numbers despite evidence that it works no better than a sham procedure in the usual case.

    This is not intended to echo the CAM plea ‘clean up your own act and then worry about ours”. It is a plea for a little introspection.

    Our zeal in trying to winkle out the least detectable whiff of any tolerance of a pretty harmless placebo like homeopathy, is considerably greater than that with which we address egregious disregard for the “Gold Standard” of evidence in our own practices.

    And I’ll tell you why. Homeopathy is an affront to Science with a capital S. That is why we go on about it so much. It gives us an irresistible. addictive sense of self-righteousness to be crusading against it, as an (only deceptively) low-hanging fruit of CAM. What rewards are there in drawing attention to substandard medical and veterinary practice?

    In contrast, those medical procedures are in most or all cases an actual assault on the patient. This should be seen to be concerning us at least as much as the occasional use of homeopathy when we have nothing better in our medicine cabinets. We otherwise seem to be placing science on a considerably higher pedestal than patients welfare, especially if the practice of homeopathy can induce placebo and other non-specific benefits, as a lot of evidence suggests.

    “Homeopathy doesn’t work” is technically correct, in one limited sense, but where medical and veterinary practice is concerned “other than as placebo” should be added. The main message is that if it is to be tried for any reason it should not be used as a substitute for evidence-based medicine, where that is available and safe.

  6. BSM,

    The ACVIM specifically stated they would be happy to endorse the first three points if the fourth was removed. It was ONLY the specific identification of homeopathy as ineffective that they objected to, so I don’t think the rest was a problem.

  7. BillyJoe says:

    pmoran,

    Brennen: “While I applaud the recognition of our individual and collective ignorance and limitations, I believe it does no service to our patients and clients if we mistake post-modernism for humility.”
    Peter: “Humility and awareness of of certain limitations to the “universal standard” that we aspire to within our practices is not post-modernism. But you may not have meant that to be taken literally.”

    Perhaps it might have helped if Brennen had put a period instead of comma in the middle of his sentence. In any case, it was clear to me that he was referring to two separate things here. in other words, that the part after the comma did not relate to the part before the comma. Meaning that he individually and separately applauds the first attribute but not the second attribute.

    “laparoscopic debridement for ostearthritis of the knee”

    That seems an unnecessarily roundabout way of getting into the knee joint! ;)
    On a more serious note, most orthopaedic surgeons here are declining to do these procedures to the chagrin of their patients, but some persist in doing so to the delight of their patients. So annoying.

    ” a pretty harmless placebo like homeopathy”

    I’m not going to start up yet another discussion about the falsity of this claim. Others have been there and done that much better than I could. But you must know by now that, for many reasons, this claim is patently false unless severely qualified (which you haven’t done).

    “It gives us an irresistible, addictive sense of self-righteousness to be crusading against [homoeopathy]”

    You are impugning motive here that may not even exist.
    How about: reducing to a subsistence level the practice of patent nonsense which can have all the harmful effects I didn’t mention above but of which you are well aware, having been exposed to them numerous times on this very blog.

    ” those medical procedures are in most or all cases an actual assault on the patient

    OTOH, laparoscopic debridement of the knee would classify as actual assault and BATTERY of the patient! :)

    ““Homeopathy doesn’t work” is technically correct, in one limited sense, but where medical and veterinary practice is concerned “other than as placebo” should be added.”

    Again, been there and done that by others better than I could. But to repeat:
    “homoeopathy works only as a placebo” = “homoeopathy doesn’t work”
    “Homoeopathy works as well as sham homoeopathy” = “homoeopathy doesn’t work”
    Anything else is just doublethink. We must at least start with being honest about the facts, whatever we may subsequently think about the virtues or otherwise of actually using the damn thing as a placebo (with all the dishonesty and lies that entails, to make my position clear!)

  8. pmoran,

    My point was simply that while it is clearly appropriate to recognize the insufficiency of the evidence for many of our practices, and to proportion the confidence with which we recommend them to th level if evidence we have, the fact this is not a reason to refrain from rejecting those interventions which clearly don’t have benefit. The mentality that allows one to utilize or defend homeopathy supports all manner of dangerous and worthless practices, and challenging . both that mentality and specific practices that deserve to be abandoned is a necessary part of the continual effort to improve veterinary medicine. I understand why this annoys homeopathy, but I am . continuously perplexed at why it annoys others or why so much energy is expended trying to identify a motive other tHan the obvious one of eliminating as much nonsense as possible from medicine.

  9. Badly Shaved Monkey says:

    The ACVIM specifically stated they would be happy to endorse the first three points if the fourth was removed. It was ONLY the specific identification of homeopathy as ineffective that they objected to, so I don’t think the rest was a problem.

    Oh, OK.

    Is it likely that the sane but shrugging majority of the ACVIM really want to support homeopathy itself? I don’t think that’s specifically evident from the comments you posted. Their approach looks more like an attempt to deflect what they characterise as the thin end of a wedge. I think you and I welcome the insertion of that wedge trying to split the profession from useless interventions.

    Somewhere they’ve misunderstood the cleavage point.

    We have a spectrum of evidence for what we (and doctors) do. At one end there is the thoroughly well-proven. At the other end there is the explicitly disproven. The grey zone in the middle is huge. We want to cut off the disproven extreme end. The wet willies of the ACVIM seem to think that the whole grey zone is placed under immediate threat. That is just paranoid and ridiculous. Time and again I make the point to owners and colleagues that we have to make the best decisions we can with weak evidence. Ours is a small profession and we can never hope to match human medicine’s evidence-base and its grey-zone is very large anyway. But if we have any pretence of practising a disciplined medicine we should find it possible to reject nonsense.

    pmoran’s tolerance of homeopathy is equally a plea to tolerate exactly the kind of poor thinking that led to the MMR scandal. The anecdote-based, special way of ‘knowing’ that sustains SCAM therapies is a contagious meme that is infecting and damaging many aspects of medical practice. The only motivation for tolerating homeopathy is to retain access to a placebo effect. I am persuaded that properly defined placebo effects are mostly trivial and in veterinary medicine they will be even smaller.

    Is there any mileage in cutting your losses now? Cut out the mention of homeopathy to reaffirm the AVMA’s acceptance of the other principles with the backing of ACVIM. Then later, propose a specific resolution to cite homeopathy as being in breach of those principles that have just so recently reaffirmed. Politically that would make it much easier for you to point out that they risk being identified as defenders of one specific nonsense rather than as trying to preserve a vague notion of clinical freedom.

    My efforts with the RCVS in 2006 ran up against the same problems, but I was not nearly so well organised as you have been and was more casually dismissed. I found it a sickening irony that the RCVS president who brushed it all off in the defence of supposed clinical freedom counted the letters MBA in her list of qualifications. She assured us that the normal processes of scientific investigation as reported in the peer-reviewed literature would deal efficiently with the problem. The difficulties inherent in that are too numerous to list as part of this post, but the rise of quackademic medicine shows us that this is a misplaced hope and citing it is just an excuse that is made to avoid having to deal with the issue.

  10. Badly Shaved Monkey says:

    That seems an unnecessarily roundabout way of getting into the knee joint!>/blockquote>

    You beat me to it!

    :)

  11. ConspicuousCarl says:

    pmoran on 26 Jan 2013 at 5:20 pm

    the least detectable whiff of any tolerance

    Allowing the sale and prescription of homeopathy isn’t a “whiff” of tolerance, it’s a complete trashing of any standard of evidence.

    Tolerance for unscientific treatments would be the use of something with UNKNOWN efficacy when nothing good is available. Homeopathy isn’t even a guess, it’s known fraud.

    It’s really weird that pmoran accuses us of “zeal” and “self-righteousness”, but then he is always throwing up his dramatic defenses of nonsense and hides behind pseudo-humble BS like “I’m just a messenger” while also suggesting that lying to patients to give them placebo effects is somehow the opposite of ivory-tower snobbery.

  12. rmgw says:

    It’s getting ever more difficult to avoid homeopathy and similar quackery: vets will recommend this stuff without in any way pointing out its defects whilst the whole point of employing a vet is that they are supposed to be curing your charges’ problems with their superior knowledge of veterinary medicine: they might, at least, point out that when they pass on anecdotal evidence about their own successes with quackery (“it’s completely natural, no chemicals, he never looked back” direct quote from a horse vet about treating her own horse) that they are departing from receive medical wisdom into realms that any loonie can google for themselves without the tedium of six years’ study.

    On an even darker note: “Local vets routinely perform Caslicks in pregnant mares (partially stitching up the vulva). That is an invasive, distressing, and expensive practice, which has to be undone later, and which almost certainly does not prevent miscarriage. I have not seen good evidence for any other benefit. ” I am shocked to hear that this wretched business is still going on: I wrote a paper myself about it more than ten years ago after finding out that Caslick’s is carried out on mares to make them perform better (zero evidence, of course) in all sorts of “sporting” events: if this doesn’t look like a bit of money-spinning to the detriment of the patient, what does?

    In both cases, the remedy has got to be more efficient ruling from a professional body: after all, human doctors are involved in, say, execution duties, just as vets are employed in slaughterhouses, bull rings (and rodeos?) etc and still manage to maintain the professional norm that their actions are for the good of the patient exclusively: cannot this principle be further introjected into veterinary medicine, precluding advice given to owners solely to further the latter’s entertainments (e.g. in “sports” involving nonhumans), the pushing of nonsensical quackeries and supplements and the carrying out of unnecessary and prejudicial procedures?

  13. Alia says:

    Well, a few years ago my cat was dying of renal failure. Her blood test results were awful, kidney ultrasound left no hope really, but since the cat was pretty much alive and even bit through the vet’s finger, she said we should try to save the cat. And she proposed a treatment that, while science-based, was rather experimental. And you know what? My cat is still alive, behaves just like a healthy cat her age, her blood test results are only slightly above the norm – all thanks to our vet, who decided on experimental treatment. Although the vet herself keeps repeating “It was a miracle”.

  14. art malernee dvm says:

    The internal medicine veterinarians must go along with the avma because the avma must recognize their speciality. The government state veterinary regulatory boards do not allow vets to promote they are specialist unless the avma recognises the speciality. The avma also provides accreditation to veterinary schools for the government and state board/ malpractice insurance for avma members. I have been a member of the AVMA 47 years. It’s difficult to compete with the avma without also obtaining their corporate funding. I think the avma is controlled by those who promote quackery but I still send in my dues every year. The state avma has a member who is present at the state veterinary board meetings. A lot of money is now being funded by alternative medicine groups to fund teaching of alternative medicine to students. The vet school in Florida list acupuncture as one efficacious treatments offered to pet owners.
    Art Malernee Dvm
    Fla Lic 1820

  15. BSM,

    It might be possible to eliminate the policy on CAVM entirely. The policy already states that all veterinary therapies should be validated scientifically and that ineffective treatments should be discarded. The problem is that such general statements don’t lead to any action. So it might be possible politicaly to simply say all our interventions should be judged by the same standards and leave it at that, bnut I think it unlikely that any specific intervention can be singled out regardless of the evidence against it if even homeopathy doesn’t qualify for this.

  16. Alia,

    I’m glad things worked out for your cat, but I would point out two things:

    1. Such anecdotes don’t tell us anything sueful about whether or not a therapy actually works, for many reasons: http://skeptvet.com/Blog/2012/07/medical-miracles-should-we-believe/

    2. There is a huge difference between trying a plausible but untested therapy with full informed consent and offering magic water as a powerful medicine.

  17. Alia says:

    @Brennen McKenzie
    That was exactly my message, probably should have stressed it more – that this experimental treatment it was science-based and plausible, even though not mainstream. And that’s why we decided to try it. I would never, ever give my pets homeopathy and I would look for another vet if they proposed it as a treatment. So while in addition to proven, researched and mainstream treatments there is a lot of room for other, experimental treatments, homeopathy is certainly not one of them.
    I am also a member of a cat owner’s forum and sadly, a lot of people out there believe in homeopathy and other stuff like Bach essences and claim it helps their cats with various issues. I stopped trying to tell them otherwise, they are so much into woo that they won’t listen to me anyway.
    As for my cat’s recovery being a miracle – well, she had end-stage renal failure, but I personally believe it wasn’t a miracle – possibly she’s just very strong and vital. And we did everything we could to save her.

  18. pmoran says:

    My point was simply that while it is clearly appropriate to recognize the insufficiency of the evidence for many of our practices, and to proportion the confidence with which we recommend them to th level if evidence we have, the fact this is not a reason to refrain from rejecting those interventions which clearly don’t have benefit. The mentality that allows one to utilize or defend homeopathy supports all manner of dangerous and worthless practices, and challenging . both that mentality and specific practices that deserve to be abandoned is a necessary part of the continual effort to improve veterinary medicine. I understand why this annoys homeopathy, but I am . continuously perplexed at why it annoys others or why so much energy is expended trying to identify a motive other tHan the obvious one of eliminating as much nonsense as possible from medicine.

    I understand all this, and have at times said the same, but in the long run the fate of CAM depends upon the mainstream having a near-complete portfolio of safe and truly effective methods for everything, a point that is nowhere near yet reached, and also the public having faith that this is so. At the moment we and our various processes have only grudging and easily shaken public trust, and perhaps rightly so. Anything that damages public trust further is therefore of critical importance.

    From such different perceptions as to why people resort to CAM, the role of placebo influences and compulsive consumption of medicine, and other realities that we face, even allowing a little for the oft-demonstrated contrariness and rebelliousness of human nature, one can develop subtlely different approaches to “the problem of CAM”, even defining the problem differently. “Don’t allow/use CAM — it doesn’t work” may evoke a very different response to “if you are thinking of using it, don’t use it alone for serious illnesses”.

    This states up front the major practical concern from CAM use and one that the public can more easily understand. Expressing concern for their welfare will evoke a different public response to brow-beating them about “the science” and leaving them with conflicted impulses (although the scientific background is also needed).

    I am not saying that any of the views expressed here are wrong, merely that they are not secure enough to justify the degree of contempt often expressed for those who favour a slightly more relaxed (and possibly instinctively more mature and politically savvy) attitude towards the use of these agents (not “support”, BSM).

    Partly I am seeking a position that more obviously puts us by the side of the patient in the battle against the common enemy of disease, rather than sets us against certain of his primeval instincts. In the long run it will come down to trust.

  19. weing says:

    “I understand all this, and have at times said the same, but in the long run the fate of CAM depends upon the mainstream having a near-complete portfolio of safe and truly effective methods for everything, a point that is nowhere near yet reached, and also the public having faith that this is so.”

    If that is the case, that the public has this unwarranted faith that we have a near-complete portfolio of safe and truly effective methods for everything, then we should quickly disabuse them of this belief. We should also impress upon them that CAM is even further from this laudable goal and no more time and resources should be wasted upon CAM. It is definitely not where the answer lies.

  20. BillyJoe says:

    Alia,

    ” I personally believe it wasn’t a miracle”

    Well, did your cat have end stage renal failure due to a reversible or limited cause which just managed to reverse or stop before your cat actually died of renal failure, or did one of those gods, that I assume neither you nor your cat believe in, decide to intervene and save its life.

    |:

  21. BillyJoe says:

    ““Don’t allow/use CAM — it doesn’t work” may evoke a very different response to “if you are thinking of using it, don’t use it alone for serious illnesses”.”

    Or perhaps an even more mature, but perhaps a little less relaxed but at least more inclusively honest message:
    “If you are thinking of using acupuncture, please take into account that there is no evidence that it actually works apart from making you feel better because something is being done; and please continue to use the treatments that have been shown to work”.

    Also, I would be surprised if any medicos here would say to a patient contemplating using acupuncture:
    “Don’t use it. It doesn’t work”.

  22. Narad says:

    And she proposed a treatment that, while science-based, was rather experimental.

    Alia, would you mind sharing what it was? (No snark; I know CRF in cats up close and personal.)

  23. Alia says:

    Narad, the problem is, English is not my first language, and while I’m fluent with it, I’m not so sure about medical and pharma terminology. But I’ll try.
    So, we gave our cat drips. Under skin on her neck, because we had to do it at home, she wouldn’t allow any vet to do it without sedation and sedating her every day just to give her an IV drip would make no sense. About 100ml of physiological saline once a day, with furosemidum. And also one of B group vitamins (don’t remember which one) and a few steroid injections to improve the cat’s appetite and help fight gum inflammation. After about two weeks the cat got much better and since then the improvement was steady. Now, over two years after the initial diagnosis, we give her a very small dose of Enalaprili maleas every day and a drip once a week. And of course she’s on a special renal support diet.

  24. pmoran says:

    BJ:Or perhaps an even more mature, but perhaps a little less relaxed but at least more inclusively honest message:
    “If you are thinking of using acupuncture, please take into account that there is no evidence that it actually works apart from making you feel better because something is being done; and please continue to use the treatments that have been shown to work”.

    I have little objection to that. Few patients would not already know that the method is “dubious” — even from the simple fact that I had not previously recommended it myself?

    Also, I would be surprised if any medicos here would say to a patient contemplating using acupuncture:
    “Don’t use it. It doesn’t work”.

    I am sure of that. Yet that is definitely the message that these pages are sending in spades, and that is what I am talking about. Who would ever know from our public face that we are so “soft on CAM’ when forced to be so in privacy of our own consulting rooms? I’d like to get away from that inconsistency, too.

  25. Scott says:

    Few patients would not already know that the method is “dubious” — even from the simple fact that I had not previously recommended it myself?

    Good grief. News flash – the overall perception of acupuncture in society is NOT that it is “dubious.” If you’re assuming that people know the least bit about how grossly out-of-touch with reality it is, well, with most people you’re (yet again) dead wrong.

    It’s astounding how you so often just Make Stuff Up in order to support your ideological commitment to legitimizing quackery.

  26. mousethatroared says:

    BillyJoe “or did one of those gods, that I assume neither you nor your cat believe in, decide to intervene and save its life.”

    Why do you assume that a cat doesn’t believe in a god? Cat’s seem extremely religious to me – They just happen to be religious from the perspective of the deity rather than that of the lowly worshipper. :)

  27. pmoran says:

    If that is the case, that the public has this unwarranted faith that we have a near-complete portfolio of safe and truly effective methods for everything, then we should quickly disabuse them of this belief.

    I was actually suggesting that this was the “final solution” to “the CAM problem”, at some very distant point in the future. Who would believe that we have those answers right now?

    Until that point is reached there will always be some demand for other treatments to try. Trying to stamp it all out before then, an end-point that you and many others hint at within these pages, involves too much interference in individual freedoms, some small risk of useful measures being overlooked, and a much greater risk of some being deprived of useful medical support of some kinds.

    Certainly most skeptics don’t sufficiently acknowledge the role of unmet medical needs within 95% of CAM. I have had to defend that pretty obvious fact here. Some skeptics may not say as much but they convey the message that the mainstream should be enough for anyone and that there is no real need to looking elsewhere. This is an insult to both the intelligence and the suffering of many who use CAM.

    We should also impress upon them that CAM is even further from this laudable goal and no more time and resources should be wasted upon CAM. It is definitely not where the answer lies.

    I agree. Yet who is to make that judgment, when it is at the patient’s own expense and risk? What became of our new-found desire for less authoritarianism and paternalism in medicine?

    Our role is an advisory one, but even in that we need to acknowledge the complexity of the needs that people bring into medical interactions and in how they respond to them.

  28. Alia says:

    Well, I remember one Sandman story (you know, the graphic novel by Gaiman), in which a cat owner prayed to Basted. And the goddess helped – bringing the cat painless death, because that was the only thing she could do, she was so powerless. So I certainly wouldn’t pray to Bastet, asking for a miracle. ;-)

  29. pmoran says:

    It’s astounding how you so often just Make Stuff Up in order to support your ideological commitment to legitimizing quackery.

    This has nothing to do with ideology. Any time you wish to take me up on the scientific background to anything I say, let’s be having you. My positions are based upon what I believe to be a more accurate understanding of why people use CAM and what they might get out of it despite its content of fraud and nonsense.

    I am supporting an as yet still tentative re-examination of a “scientific ideology” that cannot see beyond (or does so only dimly, selectively, inconsistently and self-servingly) the “working better than placebo” model of medical practice. Sometimes that model defines everything that is important in a medical interaction, yet, given the complexities of illness and of human nature, all too often it does not.

    To be a little more permissive is also not the same thing as “legitimizing”. Did you miss where I said there remain grounds why the mainstream should not fully endorse acupuncture for its own use?

  30. Narad says:

    So, we gave our cat drips. Under skin on her neck, because we had to do it at home, she wouldn’t allow any vet to do it without sedation and sedating her every day just to give her an IV drip would make no sense.

    OK, yah, sub-Q fluids are totally standard. I’m surprised the vet had trouble with it, unless there’s some confusion with actual IV fluids, where you have to shave the cat and so forth.

    About 100ml of physiological saline once a day, with furosemidum.

    So the cat wasn’t urinating. That sounds like acute kidney failure.

    And also one of B group vitamins (don’t remember which one) and a few steroid injections to improve the cat’s appetite and help fight gum inflammation. After about two weeks the cat got much better and since then the improvement was steady. Now, over two years after the initial diagnosis, we give her a very small dose of Enalaprili maleas every day and a drip once a week. And of course she’s on a special renal support diet.

    OK, treating for hypertension is a very good idea in CRF (particularly if you want to keep the retinas attached). I guess I’m not clear on whether this was preexisting CRF that hadn’t been detected and turned into a crisis, or whether there was some insult that provoked things. But anyway, the treatment doesn’t really sound experimental at all.

    Thanks for the description, though; I can very much empathize with dealing with this stuff.

  31. Scott says:

    Any time you wish to take me up on the scientific background to anything I say, let’s be having you. My positions are based upon what I believe to be a more accurate understanding of why people use CAM and what they might get out of it despite its content of fraud and nonsense.

    Oh please. You just claimed that people know acupuncture is “dubious.” Which the slightest bit of examination of how the general public talks about it clearly shows that to be false.

    To be a little more permissive is also not the same thing as “legitimizing”. Did you miss where I said there remain grounds why the mainstream should not fully endorse acupuncture for its own use?

    Pure smoke screen on your part. You make it VERY clear that you want nothing less than for quackery to be fully accepted and embraced.

  32. @pmoran

    I think there are many reasons people seek CAM, and the failure of conventional therapies to solve their particular clinical problem is only one of them. It seems pretty unlikely to me that we are ever going to have perfect, all-encompassing medical care, but even if we did I suspect CAM would remain since there are ideological, esthetic, and cultural reasons for choosing it as well.

    However, I think you’re mistaking the condemnation of useless therapies for condemnation of those who seek them out. The only reason I see to challenge these practices is that I believe they are ultimately bad for my patients. Few people, at least in my experience, use a CAM therapy while being fully cognizant that is nothing more than a placebo. They use it because they believe, or at the very least hope, that it will make them better in a meaningful way, not simply trick them into feeling a bit better while their disease goes merrily on. So there is inevitably some deception involved in offering these therapies to patients, and that seems more disrespectful of their autonomy than criticizing useless treatments.

    And in my field, where the patients cannot speak for themselves, I see real suffering that goes unrelieved because of the mistaken belief, on the part of pet caretakers and vets, that something like homoepathy is helping. There is no abstract moral or ideological crusade involved in wanting to reduce the danger of this sort of thing by discouraging the use of such therapies. And while I am pleasant and respectful to my clients, and continue to have clients who appreciate my care for their pets while not always following my guidance, I am always clear that since they are paying for my advice and my judgment, I am obliged to give it to them. They are not obliged to take it, but I have an ethical duty to say, “Homeopathy is nothing more than a placebo for you and does not help your pet in any way.”

    So I think your concerns about criticism of CAM interfering with individual freedom is misguided. True freedom involves making not only a free, but an informed choice, so offering accurate information can only facilitate truly free helthcare choices.

  33. Alia says:

    @Narad – the cat was urinating. A lot. Drinking and urinating, drinking and urinating – her kidneys stopped filtering and the water just went through her, so to say. That’s why furosemidum was in this case an experiment. I know it’s standard when the cat has stopped urinating.
    Also, the kidney ultrasound has shown that our cat’s kidneys are abnormally small and with cirrhosis (not sure about this word, though, got it from a dictionary).

  34. pmoran says:

    Brennen: So I think your concerns about criticism of CAM interfering with individual freedom is misguided. True freedom involves making not only a free, but an informed choice, so offering accurate information can only facilitate truly free helthcare choices.

    I have no great argument with you. “Homeopathy is nothing more than a placebo for you and does not help your pet in any way.” is a fairly accurate representation of the state of the science concerning veterinary practice. This is less clear within human medicine, wherein it is the patient who may be very placebo responsive and who also brings a panel of other human needs into medical interactions, ones that may not be fully dealt with by mainstream care, for a variety of likely reasons.

    It was not criticism of CAM that I suggested risked personal freedoms, it was the processes involved in “Trying to stamp it all out —, the explicit intent of some of the commenters here and the clear implication of some of common rhetoric, to the alarm of some of those we wish to influence.

    We are obliged to state what we know, but even that requires more qualifications than we normally allow for when it comes to complex interventions like acupuncture (in humans).

  35. BillyJoe says:

    Pmoran,

    “Who would ever know from our public face that we are so “soft on CAM’ when forced to be so in privacy of our own consulting rooms?”

    I’m sure that language between professionals (of any type) is much more explicit that that used by them amongst the public that they serve (example: the leaked emails from the CRU of the UEA). But if, in the case of the medicos posting here, that can indeed be characterised as “soft on CAM”, that would amount to hypocracy. I would hope that is not the case. I would hope it would be more accurately characterised as ” telling the truth about CAM, softly”.

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