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- Herausgeber: WS
- Kategorie: Fachliteratur
- Sprache: Englisch
Whether online or in the local pet store, there are a bewildering variety of pet healthcare products and services to choose from. Diets and supplements, ancient herbs and folk remedies, and even high-tech treatments like hyperbaric oxygen tanks and laser therapy. Everything promises to give your pet better health and a longer life, and isn’t that what every pet owner wants?
But how do you know if all of these products do what they claim? Are they safe? If they really are miraculous cures, why are so many offered only on the Internet or by a few veterinarians specializing in “alternative medicine?”
Brennen McKenzie, a vet with twenty years of experience and the former president of the Evidence-based Veterinary Medicine Association, helps pet owners and veterinary professionals understand the claims and the evidence, allowing them to make better choices for their companions and patients.
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Seitenzahl: 642
Veröffentlichungsjahr: 2022
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Placebos for Pets?
The Truth About Alternative Medicine in Animals
Brennen McKenzie, VMD, MSc
Copyright © 2019 Brennen McKenzie
All rights reserved. No part of this publication may be reproduced, stored in or introduced into a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission from the publisher.
Published in 2019 by Ockham Publishing in the United Kingdom
ISBN 978-1-912701-37-7
Cover design by Claire Wood
www.ockham-publishing.com
About the Author
Dr. McKenzie has been in small animal general practice for eighteen years. After completing a bachelor’s degree with majors in English Literature and Biology at the University of California at Santa Cruz, he followed his dream of becoming a primatologist. He obtained a master’s degree in Animal Behavior and worked for several years in environmental enrichment and primate behavior.
Switching gears, Dr. McKenzie attended the School of Veterinary Medicine at the University of Pennsylvania and began working as a vet in private practice. He has served as President of the Evidence-Based Veterinary Medicine Association and taught veterinary students as a clinical instructor for the College of Veterinary Medicine at Western University of Health Sciences. In 2015 he completed his MSc in Epidemiology at the London School of Hygiene and Tropical Medicine.
Dr. McKenzie has shared his expertise through lectures at numerous veterinary conferences and in a monthly column in Veterinary Practice News magazine. He runs the SkeptVet Blog and contributes to the Science-Based Medicine Blog.
In his sparse free time, he enjoys playing his mandolin, traveling with his family, and sitting on the couch with his dogs watching the hummingbirds and woodpeckers outside his living-room window.
Contents
Introduction
1| What is Complementary and Alternative Medicine?
Words, Words, Words
Medicine and Philosophy
The Politics of CAM
Defining CAM by Example
Bottom Line
2| How to Evaluate Medical Therapies for our Pets
Missy’s Story
Anecdotal Evidence: Is Seeing Believing?
What Can We Learn From History?
Is there a Placebo Effect for Animals?
How Science Helps us to Find the Best Medicine
How Does Science Work?
Now What?
3| Homeopathy
What is It?
Does It Work?
Is it Safe?
Bottom Line
4| Acupuncture
Acupuncture. What’s the Point?
What Is It?
Is It Safe?
My Acupuncture Experience
Bottom Line
5| Manual Therapies
Hands-on Treatment: Chiropractic, Massage, and Physiotherapy
Chiropractic
Massage
Physiotherapy, Physical Therapy, and Rehabilitation
Plausible but Unproven Physiotherapy
Scientifically Dubious Physiotherapy
Bottom Line
Handling Manual Therapies for Pets
6| Herbal Medicine
What Is It?
Common Concepts in Herbal Medicine
Varieties of Herbal Medicine
Other Herbal Traditions
Does It Work?
Cannabis
Ginkgo biloba
Is It Safe?
Bottom Line
7| Dietary Supplements
Introduction
What Is It?
General Concepts in Dietary Supplement Use
Does It Work?
Examples of Dietary Supplements
Glucosamine
Probiotics
Is It Safe?
8| Alternative Nutrition
Food is Love
The Basics of Nutrition
Myths and Misconceptions about Pet Nutrition
Organic Foods
Homemade Pet Food
Raw Diets
So How Do I Decide What to Feed My Pets?
9| A Quick Guide to Other CAM Practices
Introduction
Animal Communicators/Pet Psychics
Aromatherapy and Essential Oils
Cold/Low-Level Laser Therapy
Colloidal Silver
Cranberry
Cupping
Fish Oils
Lysine
Music Therapy
Naturopathy
Neutering
Orthomolecular Medicine
Pheromones
Prolotherapy
Pulsed Electromagnetic Field Therapy (PEMF)
Reiki
Yunnan Baiyao
Conclusions
10| A Prescription for Science-based Pet Care
What’s It All About?
Our Core Questions
General Principles
Watch Out for Red Flags
Further reading
Introduction
As a veterinarian, I get to spend much of my day interacting with animals. This is one of the great pleasures of my work. However, some people are surprised to learn that vets spend as much, or more, time interacting with people as with animals. Talking with the owners and caretakers of my patients is critical to helping the animals I treat. Listening to my clients’ concerns and observations, asking questions about their animals, and educating them about how to best care for their pets is a critical part of my job. While most vets enter the field eager to help animals, it turns out we get to help people too, and that is also quite rewarding!
A very important part of talking with my clients involves answering their questions and helping them make informed and effective decisions about the care of their animal companions. In order to do this I have to be informed myself, about many different kinds of medical problems and the bewildering variety of options for preventing or treating them. Many of the treatments I use are things I learned about in veterinary school. But in the eighteen years I have been in practice, much has changed in veterinary medicine. New therapies have been developed, and research has shown us that some treatments we used to rely on are not as safe or effective as we once thought. An important part of my responsibility is to keep up with the progress and research in medicine so I can give current and accurate information to my clients.
There are also many products and procedures available to animal patients that are not part of the mainstream medicine typically taught to veterinary students. These are sometimes collectively referred to as “complementary and alternative medicine” or CAM (though we will see a bit later that it is not at all clear or simple to determine exactly what that means). Even though these methods may not be part of the veterinary curriculum, it is important for me to know as much as possible about these options so I can counsel my clients and help my patients.
I have put a great deal of time and energy over my career into learning about such alternative therapies. I have asked questions of those offering these treatments; read the literature produced by CAM practitioners and the scientific research regarding these practices; considered the work of skeptics and critics of CAM; I have even been certified in one CAM method (acupuncture). In doing this, I discovered that figuring out what works and what doesn’t in medicine is itself a fascinating and complicated business. This realization led me to completing a master’s degree in epidemiology, the science of how we study health and disease and the medical treatments we use. Throughout my career I have tried to approach all the questions my clients ask, and all the treatments they ask about, with both an open mind and a commitment to providing the highest quality of scientific, evidence-based medicine to my patients.
I have been happy to discover that in the veterinary profession the learning never stops! I will never reach a place where I know all there is to know, about CAM or anything else. However, I have learned a lot over the years, both from my clients and patients, and from the time and effort I have put into studying and investigating all of the treatment options available. I share that knowledge individually with my clients every day. My hope is to share it with you in this book and to help you answer some of your questions about how to care for your own animal companions or, if you are also a veterinarian or veterinary nurse, how to give the best care to your patients.
Perhaps the best way to learn is to begin by asking questions. For each of the practices I discuss in this book, I will ask three basic questions:
1. What is it?
2. Does it work?
3. Is it safe?
These are the questions I always ask of any therapy I might use or recommend to my clients. One goal in this book is to answer these questions for some of the most common CAM practices my clients ask me about. Hopefully, you will find useful information about many of the products or techniques you might be interested in using to help your own pets or your patients.
However, another, and perhaps even more important, goal is to empower you to ask and answer these questions for yourself. As well as sharing what I have learned about specific alternative practices, I want to share what I have learned about how to evaluate new and unfamiliar treatment options. It turns out that the way we go about answering these questions has a huge impact on the reliability of the answers we come up with.
It is an exciting time in veterinary medicine, with new discoveries and improvements in our diagnostic and treatment abilities appearing all the time. No one can be an expert in every aspect of medicine, and both vets and pet owners can sometimes feel overwhelmed by the sheer number of choices and options available. A reliance on the best evidence available and a thoughtful, careful approach to evaluating claims about pet care products and medical treatments can help us make good choices. I hope you will find both the information and the strategies I present here useful and that they will help you to critically evaluate all the options you encounter in caring for your pets and patients.
Brennen McKenzie, MA, MSc, VMD, cVMA
1|
What is Complementary and Alternative Medicine?
There cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted.
- Marcia Angell and Jerome Kassirer
A book about complementary and alternative medicine has to begin by at least trying to explain what that means. It turns out that isn’t as simple as it might sound. This label is applied to a huge variety of very different practices. Proponents of CAM therapies often disagree with each other about what to call their approaches, about the theories behind them, about the details of how they should be used, and about the extent to which they are compatible or incompatible with mainstream scientific medicine. No one definition or description will satisfy everyone. However, to talk about CAM we have to have at least some sense of what we mean, so I will try to give some pragmatic definitions of commonly used terms.
In each chapter of this book, I have provided references for scientific journal articles, books, websites, and other resources that provide more detailed information about specific topics. I have also created a bibliography at the end of the book suggesting other resources which discuss CAM, evidence-based medicine, psychology, and other related subjects. My hope is that these sources will be useful to you in exploring all of these topics.
Words, Words, Words
Alternative Medicine
This is an older term less commonly used alone today, though it is still often included as part of the phrase “complementary and alternative medicine.” This label originally identified practices fundamentally incompatible with scientific medicine and intended to replace it.
For example, some practitioners of homeopathy don’t believe infectious organisms, such as viruses or bacteria, directly cause infectious diseases. They propose the alternative explanation that an imbalance in the nonphysical or spiritual energy they call the Vital Force underlies all disease, and that infectious organisms merely contribute to such an imbalance or are symptoms rather than causes of disease. This alternative theory leads to rejection of many medical practices based on conventional germ theory, such as the use of vaccines or antibiotics.[1]
Many other alternative therapies, such as Traditional Chinese Medicine, Indian Ayurvedic medicine, and Reiki or other types of “energy medicine,” also reject the conventional explanations of disease as primarily physical, with roots in the sciences of chemistry, anatomy, physiology, and so on. Instead, these approaches have entirely separate explanations for how disease develops, often centered on spiritual forces that cannot be examined or manipulated through traditional scientific methods. This view is called “vitalism,” and it is part of many alternative medical approaches.[2],[3]
These alternative practices were often intended to replace mainstream medical care. However, because of the many apparent successes of scientific medicine in the twentieth century, few people have been willing to entirely abandon conventional scientific explanations for disease and scientific medical therapies, so truly alternative approaches are less commonly recommended these days. This has led to the development of the category of “complementary medicine.”
Complementary Medicine
Many of the therapies initially promoted under the label “alternative medicine” are now more often identified as “complementary,” or “complementary and alternative medicine,” abbreviated for convenience as CAM (or CAVM for complementary and alternative veterinary medicine). This label suggests that the therapies under this umbrella can be used along with conventional scientific medicine and that they provide some additional benefits that complement mainstream treatment. The therapies themselves, and the theories behind them, however, are typically the same as those identified by the earlier label.
Integrative Medicine
Even the term “complementary” is disliked by some CAM practitioners however, because it implies that conventional medicine is the main treatment and alternative therapies simply “complement” or add something to it. This gives CAM the appearance of a subordinate or second-class status. To better convey their belief that alternative therapies should be viewed as equal to, or in some cases better than, conventional medicine, many of these practitioners now prefer the term “integrative medicine.” The underlying idea here is that both conventional and alternative therapies are simply different but equally useful tools available to veterinarians, and they should each be chosen and employed when appropriate without any distinctions based on their underlying rationales of history. The alternative therapies themselves, however, are the same regardless of whether they are used under the banner of alterative, complementary, or integrative medicine.
Integrative medicine is, perhaps, the trickiest label for CAM because it obscures important differences between alternative and science-based therapies. The term suggests we can seamlessly blend alternative and conventional therapies, that they are equally useful and reliable tools we can select from for the medical job at hand. However, the reality is that there are practical and philosophical differences between how alternative and conventional therapies are developed, tested, and employed, and sometimes these differences matter.
There are several ways in which CAM approaches commonly differ from conventional medicine: they often rely on a theoretical foundation that is incompatible with established scientific knowledge; they usually lack substantial supporting scientific evidence; and they are frequently promoted by a committed group of supporters who believe a particular therapy is safe and effective based on anecdotal experience or historical and cultural tradition despite the absence of supporting scientific evidence.
There is no reason to integrate a plausible and scientifically proven therapy into mainstream medicine and still preserve for it a separate identity as “alternative.” If we treat all proposed therapies equally, evaluating their mechanisms and clinical effects at every level through rigorous research, then we can simply accept those that prove their value and abandon the rest. As the editors of the Journal of the American Medical Association have put it: “There is no alternative medicine, only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.”[4] The only use for a special category of integrative medicine is to present some therapies as equal in legitimacy to others before they have been properly tested and proven their worth. This is a subject I will discuss in more detail shortly.
Holistic Medicine
Holistic is an interesting term since its typical meaning in the area of CAM differs quite a bit from its strict definition. Formally defined, “holistic” simply means viewing things as complete, integrated wholes rather than collections of individual parts. It is often contrasted with “reductionism,” which in its most extreme forms views complex systems such as living beings as only the sum of their separate parts. In medicine, a holistic approach means treating a patient as a complete individual, with attention to all relevant aspects of the patient’s body, mind, and context or environment.
This is, of course, an approach every doctor should take. Imagine one of my patients comes in with a nosebleed. If I look only at the patient’s nose and ignore the rest of the body and how the patient is feeling generally, or if I don’t consider systemic diseases, genetic factors, or environmental causes that might be behind the problem, then I am practicing an extreme and ridiculous kind of reductionist medicine. Despite the suggestion that scientific medicine works this way, conventional doctors are taught to look at all relevant aspects of their patients’ condition and context and to practice holistically in the strictest sense.
The tricky part of the concept of holism, though, is the question of what is relevant. It is impossible, and pointless, to consider everything in the universe when trying to understand and treat an individual’s health problem. Some things are more relevant than others, and we often have good reason to know the difference. If I suddenly start vomiting profusely, the fact that I recently ate a piece of spoiled fish is likely quite relevant! The fact that I was wearing a blue shirt that day, on the other hand, is almost certainly not. The problem with the term holistic is that in most cases it is not used to suggest that understanding health and disease require a comprehensive evaluation of all relevant factors but to imply some specific factors are relevant which scientific medicine doesn’t generally consider to be so.
Holistic medicine is often defined, for example, as including the influence of spiritual factors or other nonphysical energy forces among the most important variables in determining health or illness. As one CAM veterinarian and author has said: “Holistic practitioners believe that vital life energy is the most important factor in the health of the patient…Because medical science has defined itself on a strictly physical basis, it is true that vitalism is unscientific. By definition, vitalism embraces a concept about a nonphysical force that can never be understood within the current scientific, medical paradigm.”[5]
Other CAM vets have somewhat different definitions of what must be considered to practice “holistically.” Some may view all disease as caused by dietary factors; others may feel that many chronic diseases can be traced to the use of vaccines or antibiotics in a patient many years before; and still others may believe that electromagnetic radiation from modern electronic devices is a crucial factor in illness. These are all real claims I have heard from CAVM practitioners. Each individual would then say that a holistic approach must consider the particular factor he or she believes is relevant, and that any approach which does not is “reductionistic” and deficient.
In practice, “holistic” is most often a code for the use of alternative theories of disease and alternative therapies, intended to signal a distinction from conventional scientific medicine. The specific difference in what is considered relevant to health varies with the particular alternative theory or approach employed. I believe that all good vets should practice holistically in the sense of considering all likely relevant factors and treating every patient as a whole individual in a unique context. However, I think the specific factors that are relevant within this holistic approach have to be demonstrated through research and a sound scientific understanding of health and disease. The concept is legitimate, but the term should not be misused as a mere code for an alternative medical ideology.
Natural
This is one of the terms most commonly used to market and promote CAM approaches, yet it is surprisingly difficult to define consistently. A natural remedy, one would think, would be something found in nature in its original and final form, requiring no processing or alteration by humans to be useful. The opposite, then, would be a remedy that is artificially created and could not exist without human efforts. Yet it turns out that the boundary between the natural and artificial is more of a blurry region with no clear or sharp dividing line. And even when such a distinction can be made, it is often not meaningful.
Certainly, it is fair to consider many modern medical therapies as artificial in the sense that they could not exist without extensive human effort. Anesthesia and surgery, pharmaceuticals, artificial joints, and many other medical technologies are clearly not natural in any obvious sense. On the other hand, what therapies might be considered natural?
Perhaps feeding an animal raw plant leaves believed to have medicinal properties is using a natural therapy? What if those leaves are dried and combined with leaves from several other plants? How about if the leaves are powdered and placed into capsules or mixed into a liquid for injection? If a specific chemical compound is identified in a plant, isolated in a laboratory and then packaged into pills, is it still natural? What about manufacturing the exact same chemical, down to the last atom, in a laboratory rather than extracting it from a plant? Would it somehow not be safe or effective if made this way when it was before?
Can a herbal remedy be natural if it is identified and prescribed according to a complex set of theoretical principles and rules developed by humans over centuries? Can piercing the body with needles, as in acupuncture, be considered a natural therapy? How about extracting chemicals from natural substances, diluting them repeatedly until no actual molecules of the original substance remain, as is done in homeopathy? Is this a natural therapy? Is feeding raw meat to our pets natural while feeding cooked meat isn’t? What if vitamins and minerals are added to the meat and it is frozen or canned?
As you can see, there is virtually nothing in medicine that doesn’t involve some effort or alteration of natural materials by humans. It is not obvious what degree of human activity renders something no longer natural. Even more problematic, however, is the issue of why a natural treatment should be better than an artificial one.
Saying that something is natural is usually a way of implying it is inherently healthy and benign. Calling something artificial, by contrast, conveys a much more negative impression, implying it is unhealthy or even false and deceptive. However, it is easy to find examples that belie these connotations. Nothing could be more natural than E. coli or Salmonella, bacterial organisms in raw foods that cause diarrhea and vomiting. Intestinal worms and malnutrition are ubiquitous among animals in nature. Even toxins such as radioactive uranium, asbestos, and cyanide are found, complete and functional, in nature. Yet all of these natural things are harmful to us and our pets.
In contrast, the vaccines which have eliminated smallpox and polio and greatly reduced the suffering once caused by many infectious diseases are clearly artificial, in the sense of being created by humans out of natural materials. Antibiotics, which have rendered many routinely fatal diseases curable, and vitamin supplementation of foods, which have eliminated dreadful and once common maladies like scurvy and rickets, do not exist in nature. Blood transfusions, organ transplants, prosthetic limbs, insulin for diabetics, and even such simple and unheralded public health technologies as indoor plumbing and toilet paper, have saved lives and reduced suffering for millions. Yet these could not be described as natural in the usual sense.
The term “natural” is ill-defined and largely meaningless when applied to medicine. It doesn’t help us decide whether a therapy is safe or beneficial for our animals. It doesn’t even reliably distinguish between conventional scientific and alternative approaches. Every day I remind my clients of the importance of providing plenty of exercise, healthy food and water, and appropriate social interaction for their pets. These are all beneficial, natural, and completely science-based healthcare recommendations.
The idea that something natural must automatically be good is so widespread and consistently mistaken that philosophers have given it its own name: The Appeal to Nature Fallacy. While things that are “natural,” insofar as we can even define that, may be good, the fact that they are natural doesn’t prove or predict their good qualities. This is an idea that will come up again and again in our discussions of alternative medicine, and it is pernicious because it is both intuitively appealing and completely unreliable.
Medicine and Philosophy
When I first began to investigate CAM, I had the rather naïve view that all I needed to do to effectively help my clients was find the appropriate published research showing which therapies worked and which didn’t. I initially saw CAM as just a set of medical treatments that, for some reason, got a special label but could otherwise be considered, tested, and then accepted or rejected in the same way as conventional treatments. It took some time for me to understand that much of the reason the category of complementary and alternative medicine exists at all is rooted in basic ideas about the world that are very different from those behind science-based medicine.
Some CAM therapies can be studied and used scientifically, of course, and I will talk about these when I get into specific CAM treatments. However, CAM in general is an ideological category, not merely a collection of individual treatments. It is a collection of different, sometimes even mutually incompatible, ideas and practices united by their status as outside the mainstream, and often by a few general philosophical concepts (though even these are not uniformly accepted by all practitioners of alternative therapies). Therefore, I think it will be useful to briefly introduce here some of the differences in the core philosophies of alternative and science-based medicine. This will help us a lot later when we come to evaluating the claims and evidence behind CAM practices and comparing them with conventional medicine.
Do Our Thoughts Make Our Reality?
One key idea taken as a given in the scientific view is that the world exists independent of what we humans think or believe about it. I may not understand how the world works all the time, but my beliefs about it don’t change how it works. I would be surprised if many people seriously question this assumption, but there are some strains of CAM that don’t accept that the natural world is independent of human beliefs.
Some CAM vets, for example, rely on the idea that we can influence the physical world directly with our thoughts, and that we can cause disease in our pets with our thoughts and feelings.
…the major influence that directs your pets’ health and well being [sic] is your perceived state of being…. what my years of observation have taught me is that when our pet develops a chronic or fatal disease, the form of that disease often reflects our perspective on life…. the emotions we are experiencing, when we think about our pet’s health condition, are likely the emotions that participated in the development of the problem in the first place. If I am frustrated with life and this perception persists long enough, the energy that is created will influence my reality.
When I see a person who is chronically frustrated with their job, or relationships, it does not surprise me when their pet develops a chronic illness.[6]
Similarly, some CAM therapists believe that the key to curing disease is in how we direct our mental, emotional, and spiritual energies, and that the physical aspects of illness are secondary, if they matter at all.
Our energy field creates our reality, and if we can learn to take control of our energy, we change our lives. The concepts of resonance and entrainment form the basis for energy medicine modalities such as Healing Touch, Healing Touch for Animals, Therapeutic Touch, Reiki, Pranic and Reconnective Healing. The practitioner’s energy field entrains the patient’s energy field and changes its vibration, allowing the body’s instinctive healing mechanisms to work more efficiently… So in order to be an effective practitioner of any type, we must create a healing state with our own energy field.[7]
It is nearly impossible to prove or disprove the existence of nonphysical energies or effects of our thoughts on the physical world. There is no good scientific evidence that such beliefs are true, but many people who believe in them claim this is because science simply doesn’t have the ability to detect or understand such forces. The supernatural, by definition, transcends the natural world and so cannot be consistently controlled, manipulated or predicted. Whatever the truth may be about the existence of supernatural forces, science as a system for understanding the world only applies to aspects of the physical world—things that can be detected, measured, and that manifest regular, consistent behavior. Anything else must be accepted or rejected on faith alone.
Science assumes the physical world exists independent of the beliefs, or even the existence, of human beings. This means that for some CAM practices, especially those that rely on a belief in nonphysical energies or spiritual forces, it isn’t very useful to study them scientifically. Individuals who believe in the importance of such metaphysical forces are unlikely to give up those beliefs regardless of the outcome of scientific research. These practices are fundamentally faith-based.
While I have no objection to personal faith or spiritual beliefs in general, I think they are an unreliable foundation for medicine. Historically, we based our medicine on personal experience and belief for thousands of years. This approach failed spectacularly, not producing in several millennia even a fraction of the improvements in our health and life expectancy science has given us in only a couple of centuries. Furthermore, if the foundation for how we treat our pets’ illness is the personal belief of each individual doctor, then there is no shared understanding, no common ground to define veterinary medicine, just individual vets each making up their own system of healthcare. How, then, are pet owners to decide which of these varieties of faith-based medicine is most likely to help their pets? For reasons I will explore throughout this book, I think science is the best tool for deciding which treatments will really help our animal companions and which won’t. Any method that excludes itself from scientific evaluation should be treated very skeptically indeed!
Can We Know Anything?
In addition to the view that the world has a real, physical nature that is independent of human beliefs, the scientific approach to understanding health and disease also relies on the assumption that we can develop practical, useful knowledge about how the natural world works and that we can use this knowledge to change things, including to influence health and disease. Just as the world is real, the knowledge we get through scientific investigation is real.
Sure, science makes mistakes all the time. It eventually corrects these given enough time and effort, but clearly our knowledge at any given moment is incomplete and imperfect. In the scientific view, however, there are such things as facts, and we can know some things with a pretty high degree of confidence. We may still have some tinkering to do with the theory of gravity, for example, but it is vanishingly unlikely that we will one day realize it was wrong all along and that we actually can fly using the power of our minds, just by thinking differently about our relationship to the ground.
While advocates of alternative approaches to health also often claim to have practical knowledge, to understand the causes of disease and how to prevent or treat them, some subscribe to a very different philosophy of knowledge than that of scientific medicine. CAM practitioners sometimes reject scientific facts that conflict with their beliefs by claiming that all human understanding of nature is just a collection of ideas in our heads, metaphors that don’t have any objective reality. This means that any set of metaphors we choose to use is equally valid, and no approach to knowledge, scientific or otherwise, can claim superiority over other approaches.
This is an appealing notion in some ways. It is useful in other fields, such as art, politics, religion, and so on, in preventing ethnocentrism, the conviction that one’s own cultural beliefs are inherently true and the beliefs of other cultures are false. Such ethnocentric views have caused no end of trouble in the world, and it is worthwhile trying to minimize them. Unfortunately, applied to medicine and other aspects of the natural world, this kind of relativism can quickly lead to absurdity. One defender of Traditional Chinese Medicine provides a good illustration of this:
If no paradigm [meaning a model of reality] does have absolute value, there is no absolute basis with which to judge another paradigm. Any paradigm will appear limited or incorrect from the perspective of a different paradigm, so Chinese medicine will seem incorrect from a biomedical point of view, and vice versa.
The invocation of a saint can cure intractable cancer; a voodoo curse can kill.…A shaman applying a curse does not consider it to be a placebo, nor does his victim. To them, real magic is involved. To interpret it otherwise is to make a culturally, paradigmatically biased judgment. We can never prove the shaman wrong, only offer an alternative explanation.[8]
Clearly, relativism carried to this extreme rejects the possibility of any real knowledge and progress, in medicine or any other field.
The Politics of CAM
As we have seen, the question of what complementary and alternative medicine really is, and what distinguishes it from conventional medicine, is not a simple one. CAM is a diverse collection of beliefs and practices, some of which are compatible with scientific views of health and disease and some of which are not. Many of the specific CAM theories about what causes illness and how we should prevent or treat it conflict not only with a scientific understanding of the natural world but with each other. Accepting the core principles of homeopathy, for example, must mean Traditional Chinese Medicine is completely wrong, at least if we are to be intellectually consistent.
The category of complementary and alternative veterinary medicine, then, is not a set of beliefs about health and disease so much as an ideological construct. It links ideas and practices primarily through a shared status as outside the medical mainstream. And though there are some common philosophical themes that appear in many CAM approaches, these are by no means universal in the CAM community. Advocates of alternative therapies often disagree as vociferously with each other as with proponents of science-based medicine about the nature of health and the value of specific therapies. However, the CAM label provides a useful tool for joining together disparate approaches outside the scientific mainstream in advocacy, lobbying, and marketing efforts to obtain recognition and a larger role in veterinary medicine.
Part of the challenge of defining complementary and alternative medicine is that in some sense there really is no such thing. In terms of what matters most, whether a specific treatment is safe and works for patients, calling something CAM is meaningless. We don’t distinguish treatments in scientific medicine on the basis of what country or historical period they originated in, because this tells us nothing useful about them. And we don’t judge the safety and effectiveness of conventional treatments by different standards based on the theory of how they work, how old they are, how popular they are, and so on. These factors may matter in the marketing or promotion of a practice, but not in terms of judging whether that practice is useful to patients.
Ideally, all medical therapies we apply to our pets should have a plausible theory for how they might work that is consistent with well-established scientific principles. Our treatments should also be supported by a variety of forms of scientific evidence, from test tube and laboratory studies to trials with patients in the real world, showing they have benefits greater than their risks. If we can demonstrate a particular therapy is safe and effective using appropriate scientific testing, why does it require a separate category, such as “alternative” or “integrative,” to be utilized as part of our overall treatment approach? If we test a therapy, show it works, and begin using it, how is it not simply another tool of conventional or science-based medicine?
Defining CAM by Example
Because of the complexity and inconsistency of CAM terminology, listing specific practices that are typically considered part of CAM is sometimes used as a substitute for defining the general category. This too is an imperfect strategy which often fails to achieve the truly important distinction vets and pet owners need, between safe and effective therapies and those which are ineffective or do more harm than good.
Confusion is also created when some conventional therapies are claimed as alternative by CAM practitioners because they are popular or well-supported scientifically and this makes the category as a whole seem more legitimate. In human medicine, for example, alternative practitioners often claim that recommending healthy nutrition, regular exercise, and attention to one’s emotional and social needs as well as physical symptoms are features of CAM, even though these are established, routine practices in conventional medicine as well. And, as I’ve already argued, there really isn’t much need for a list of alternative therapies if we simply apply the same standards of evidence to every practice and then accept the useful and reject the useless or harmful.
Nevertheless, some practices are consistently identified as alternative, for historical reasons or because of philosophical differences from science-based medicine such as I’ve discussed already. And since this book will be most useful to pet owners if I am able to select and discuss those alternative therapies that are most likely to be offered to them, it is worthwhile to make at least a rough list of the most common CAM practices. More detailed discussion of each approach and the theory and evidence concerning it can be found in the chapters addressing individual practices.
The approaches that almost everyone would agree are part of complementary and alternative medicine include homeopathy, herbal remedies, acupuncture, historical systems of folk medicine—such as Traditional Chinese Medicine or the Indian system of Ayurvedic Medicine—and any therapy that claims to work primarily by detecting and manipulating nonphysical “energy” of some kind or spiritual forces.
There is less agreement about the wide variety of practices often called “manual therapy” or “physical medicine.” Certainly, direct extrapolation of human chiropractic to veterinary patients is an alternative practice. However, massage and many rehabilitative or physical therapy modalities, including hydrotherapy, cold laser therapy, therapies involving the use of electricity or ultrasound to treat musculoskeletal disease, and many others are in a grey area. Some are clearly incompatible in theory with scientific principles and have no real evidence to support claims that they work. Others, however, often offered by the same practitioners, have at least some plausible theoretical rationale or even some research evidence in humans or animals to suggest they may be effective for some problems.
In these unclear cases, the distinction between not yet tested or proven conventional therapy and alternative medicine is, once again, often more in the philosophical foundations than in the specific treatment itself. A science-based practitioner will make limited claims proportional to the available evidence and not rely primarily on anecdotes or speculate wildly about the effects of their therapies. If someone says a massage might make your pet feel better or that laser therapy is a possible, but not entirely proven, way to encourage wound healing, these claims are perfectly compatible with scientific veterinary medicine. It is not a form of alternative or integrative medicine to offer a plausible but unproven therapy, so long as the nature of the evidence is honestly disclosed.
However, if someone claims a massage will “release toxins” or slow the progression of cancer in your dog, or that laser therapy can reverse aging or adjust your pet’s energy field, this person is promoting alternative medicine. Even if the specific treatments they use are nearly identical to those offered by a conventional veterinarian, this view of what these treatments do and how they do it is vastly different from, and incompatible with, the view of scientific medicine.
This may not seem an important distinction at first. Surely a massage is a massage regardless of whether one thinks it increases blood flow or removes “toxins?” And if cold laser therapy improves healing, who cares whether the vet offering it believes it works by stimulating cell regeneration or balancing Qi (a mystical spiritual energy important in Traditional Chinese Medicine)? However, these differences really do matter when deciding who to trust with the care of your pet.
Dramatic unsubstantiated claims and theories that conflict with established scientific knowledge, even when employed to justify a benign or even potentially useful therapy, are a warning sign. Practitioners who don’t rely on science and evidence-based medicine are unlikely to distinguish between promising but unproven treatments and completely ineffective ones. If you believe one can balance Qi using laser light, you are likely to also believe unbalanced Qi is a cause of illness. When this is true, you may be less interested in identifying and treating real causes of illness, such as infectious agents or cancer. And if wild and unlikely claims for massage are acceptable without good evidence, why wouldn’t such claims for homeopathy or “energy medicine” or any other ineffective method be just as acceptable?
Bottom Line
Ultimately, calling a specific practice alternative or holistic, natural or integrative, tells us very little about whether that practice is safe or whether it will be beneficial for our pets. As usual, the devil is in the details, and most of this book will be about exploring the details. To determine which claims about CAM are likely true, which are false, and which we don’t yet have enough information to judge, we need to look closely at specific practices and claims made for them.
But what’s the best way to figure out if such claims are true or if a CAM treatment really works? Should we ask a conventional vet or one who practices alternative therapies? Should we ask other pet owners who have tried CAM treatments? Or do we have to try each one for ourselves to really know whether or not it works?
As you likely already suspect, my approach to evaluating CAM is to look to science. Though science can produce facts, bits of knowledge in which we can have a pretty high degree of confidence, science is not primarily a collection of facts. Science is a method for testing what we guess or think we know about the world. In the next chapter, I’ll introduce you to some of the ways science can help us understand alternative therapies, and how it can help us make the best decisions possible in caring for our animal friends.
By definition…complementary and alternative medicine…has either not been proved to work or been proved not to work. Do you know what they call alternative medicine that’s been proved to work? Medicine.
- Tim Minchin
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How to Evaluate Medical Therapies for our Pets
Another source of fallacy is the vicious circle of illusions which consist on the one hand of believing what we see and on the other seeing what we believe.
- Sir Clifford Allbutt
Missy’s Story
Missy was a perfect golden retriever, with beautiful red-gold hair and a friendly, joyful demeanor. She seemed the picture of health when I walked into the exam room. Her owner, though, was worried and had brought her to see me because she was concerned that Missy might have leukemia.
Leukemia is a relatively rare blood cancer, but golden retrievers are more prone to a variety of cancers than some breeds, and at eight years old, Missy was old enough for cancer to be a potential concern. Usually, however, dogs with leukemia are sick: not eating, losing weight, with a listless, sad demeanor. Missy looked nothing like a dog with cancer.
When I asked her owner about her behavior at home, she told me Missy was eating well, playful, energetic, and showing no symptoms. Puzzled, I asked the owner why she thought Missy might have leukemia. The answer was that an energy healer had told her that Missy had this disease.
I briefly mentioned energy medicine in the last chapter, and I will evaluate the concept in more detail later. The vague term “energy” is used to refer to everything from the chemical reactions in cells that fuel normal metabolism, to nonphysical spiritual forces some CAM practitioners believe are responsible for health and disease. Such forces cannot be objectively detected or measured, so there is no scientific evidence for their existence or their role in health. This means that any claim about them has to be taken on faith since it cannot be tested in any objective way.
Though I was skeptical of the idea that Missy might have such a serious illness that had created no symptoms but could only be detected by subjective or intuitive methods, I certainly took her owner’s concern seriously. Leukemia is a cancer of blood cells, and it is usually diagnosed by taking a blood sample and looking for abnormal cells. So I ran a number of blood tests on Missy to check for leukemia and other possible diseases. Fortunately, all the test results were normal.
I expected Missy’s owner would be relieved to hear that there was no evidence her companion had cancer, but she still seemed uneasy, not satisfied by the good news. Believing Missy had a specific illness gave her owner a focus for her fears about her pet’s well-being and an opportunity to take action to help her beloved companion. Being told there was nothing wrong, especially when she did not necessarily understand why the blood test should be more reliable than her energy healer’s methods, left Missy’s owner anxious and unsure about what she could do to take control and ensure her pet’s welfare.
I checked in on Missy from time to time after her visit, and the owner always reported she was doing well. Then about a year later, Missy came back to the hospital again. This time, she had a cough, and her energy practitioner had determined she most likely had a lung tumor.
As before, Missy was joyful and energetic. She was eating well, breathing comfortably, and seemed overall in perfect condition. Her cough and other symptoms were typical for an upper respiratory infection, something which is rarely serious and is easily treated. Still, I did not wish to overlook the possibility of something more serious, so I took an X-ray of her chest to look for possible causes of Missy’s cough.
Happily, her chest X-rays showed no tumor, and after a few days of antibiotics her cough went away. I couldn’t help asking Missy’s owner what her energy practitioner had said about the failure of any sign of leukemia to develop after her previous visit, thinking that perhaps two mistaken diagnoses of life-threatening illness might have shaken the client’s confidence in the practitioner’s methods. How naïve I was! Missy’s owner informed me, without any hint of doubt, that not only had her energy healer detected the leukemia even before it was possible to see it in the blood, but that she had cured it using homeopathy!
Missy’s story illustrates a number of the ways in which people can develop and maintain dubious beliefs about health and disease, and how alternative medicine for pets often appears to work even when it really has no effect. We are all naturally worried about the possibility our pets may become ill, and we want to be able to do something to prevent this. Though there is reason to believe that our pets, like us, are living longer and healthier lives than ever before, it is hard not to fear the inevitable loss of our companions, and we naturally want to do everything we can to keep them well and put off that loss.
Unfortunately, this desire for control over our pets’ fate can lead us to believing in the power of alternative therapies even when there is little reason to believe they actually work. Humans readily see what we want or expect to see in the world around us, and this tendency can be dangerously misleading. Things are all too often not what they seem.
The purpose of this chapter is to address some of the ways we typically judge claims about medical therapies, and how we can improve the process to make better decisions for our pets. Some kinds of evidence are more trustworthy than others. And while all information should be viewed critically and skeptically, some sources are more reliable than others. By understanding how our own thoughts and perceptions can fool us, and which methods are most effective at guarding against these errors, we can make the best healthcare choices for our pets.
Anecdotal Evidence: Is Seeing Believing?
Can you tell which of these two people is a woman and which a man?
Image from Russell R. Perception. 2009;38(8):1211-1219.[9]) © R. Russell
Would you be surprised to be told these are both pictures of the same person? The apparent gender difference is just a trick created by changing the level of contrast in the photos.1 You shouldn’t feel bad if you guessed wrong because most people do. But more importantly, you shouldn’t feel too confident if you guessed right, since you had a 50/50 chance! This image illustrates how easily our judgement can be mistaken, even about something as basic as identifying the sex of another human.
Most people are familiar with the large variety of optical illusions and how our vision can fool us. However, every aspect of our processes for perceiving and evaluating the world, from our senses to our reasoning and memory, has quirks and weaknesses like those that make us susceptible to optical illusions. This means that for all our talents as a species, and all our intelligence, education, and experience as individuals, we can still come to the wrong conclusion in an astounding number of ways!
Despite the abundant evidence from the fields of psychology and neuroscience that our direct experiences often can’t be trusted, much of what we believe about the world still comes from such experiences.[10]-[14]Anyone who has ever been stung by a bee or burned their hand on a hot stove has a compelling set of beliefs about bees and stoves, and these beliefs don’t seem to require any scientific data or the opinions of experts on entomology or thermodynamics to validate them. Beliefs founded in direct experience are deeply compelling and often seem incontrovertible. The problem is that our sense of certainty about such beliefs doesn’t have anything to do with how likely they are to be correct.[15]
In the world of medicine, personal narratives used to support claims about medical practices are called anecdotes. By far the most common response I get when I question a claim about an alternative therapy is an anecdote supposedly proving that the therapy really does work. If you have ever had a sick pet and tried a number of different treatments without success, and then seen your pet get better following a particular treatment, you almost certainly believe that final therapy worked. What else could any reasonable person conclude?
You have probably heard the term “anecdotal evidence,” and you may know that doctors and scientists don’t put a lot of stock in it. So why don’t scientists or your vet always agree with what seems the obvious conclusion from personal experience?
Well, the frustrating truth is that such experiences tell us very little about what works and what doesn’t in medicine. After all, it is possible to find positive anecdotes, often quite a few, for every treatment anyone has ever tried. You can find stories of miraculous cures for everything from herbal remedies to homeopathy, from raw diets to prayer and even, of course, for the therapies of science-based medicine. Do they all work? Are they all the same? If a test always shows everything works, perhaps it’s not a very reliable test? Anecdotes are a test no therapy has ever failed.
2018 By Paul Ingraham, used with permission
Unfortunately, because of their emotionally compelling nature, anecdotes sway us far more than dry, cold statistics, even if the numbers are more trustworthy. This is as true for doctors as it is for pet owners, which is why a story told by someone with lots of academic degrees or clinical experience isn’t necessarily any more reliable than one told by anyone else.
Obviously, not every story is wrong. Quite often, anecdotes may illustrate the truth, even though they cannot prove it. And expertise and experience can reduce the chances of our falling into error, but not by as much as we like to think. I will certainly tell stories in this book because they are an efficient and enjoyable way to illustrate ideas. But I will repeatedly caution you not to imagine that stories alone, mine or anyone else’s, can prove an idea true or false.
What Can We Learn From History?
In addition to anecdotes and testimonials, another common way in which proponents of alternative therapies support their claims is by referring to historical tradition. If some groups of people have practiced acupuncture, used herbal remedies, or relied some other alternative healing method for decades, maybe even centuries, those treatments must do something useful, right?! Unfortunately, once again this seemingly simple and obvious conclusion turns out not to be very reliable.
Bloodletting is a classic example of a medical practice that endured for thousands of years and was widely believed to be effective based on the experience of millions of people. However, it ultimately proved not only useless but actively dangerous. Many cultures around the world, from Ancient Egypt to China to Europe to pre-Colombian North America, practiced some form of bloodletting as a medical therapy. With a limited understanding of anatomy and little idea of the function of blood or internal organs, these cultures had a variety of theoretical ideas about the role of blood and other bodily fluids in health, and these ideas were often connected to the prevailing religious beliefs.[16]
Illustration of nineteenth-century bloodletting. Image from the Burns Archive
The theories underlying the practice of bloodletting were intricate and varied with the specific time and place. In medieval Europe, for example, it was believed that our bodies contained four major fluids or “humors,” and these had to be in balance for good health. These humors were names for fluids observed in the body at a time when people did not understand their real origin or function: yellow bile, black bile, blood, and phlegm. These were thought to be connected to the seasons, to the “elements” thought at the time to make up everything in the universe (earth, air, fire, and water), and to specific patterns of symptoms in people with illness. The four humors formed the core of a complex set of theories and metaphors that dominated Western medical thought from the days of Ancient Greece until the 1800s.[17],[18]
According to this theory bloodletting was useful as a medical therapy because it removed excess blood and kept the humors in balance. The same theory was also used to justify other now-abandoned therapies, such as inducing vomiting (emesis) or diarrhea (purging) in order to balance humors other than blood.
The four humors
In scientific medicine around the world, the humoral theory has been replaced by a more detailed and sophisticated understanding of physiology and disease supported by experimental scientific evidence. However, humorism is still a prominent concept in several modern schools of alternative medicine. There are the Five Elements in so-called Traditional Chinese Medicine, the three Doshas of Ayurvedic practices of India, and the four humors of some folk medicine practices in Tibet and parts of Latin America.[19]–[23]These folk beliefs often have historical connections with those of Ancient Greece and with each other that contribute to the similarities in their theories. The same theories have also been applied to veterinary patients in these traditions, historically and even today.[24],[25],[26]
For thousands of years, millions of people had blood drained from their bodies to cure almost every condition imaginable, and for all this time both ordinary people and the most respected medical authorities believed this was an effective practice. And then, little more than a hundred years ago, bloodletting was abandoned by virtually everyone over the course of a few decades; almost overnight by the standards of history.Why? 8,[27],[28]
In the late eighteenth and early nineteenth centuries, the developing methods of science began to provide evidence which ultimately led to the rejection of bloodletting and other practices based on humorism in most of the world. First, our understanding of how the human body works grew more accurate, and it gradually became clear that the notion of physiology as simply the maintenance of balance between a small number of humors didn’t fit the facts. Origins and functions were found for various bodily fluids that didn’t match the guesses of Ancient Egyptian and Greek healers.
For example, the redness and swelling associated with inflammation in one part of the body was once seen as an excessive accumulation of blood in that body part. The sensible treatment for this, according to humoral theory, was to drain blood from that part of the body, through cutting nearby veins or lacerating the skin. Once it was shown, however, that blood circulates everywhere in the body and does not accumulate or stagnate at sites of inflammation, this practiced couldn’t be justified by humoral theories anymore. And once, much later, the true causes and processes of inflammation were understood, humoral theory turned out to be completely wrong about the nature of this symptom.
However, the practice of bloodletting outlasted the replacement of humoral theory. As elements of the theory were disproven, proponents of bloodletting rearranged their arguments to defend the practice. Personal experience is very persuasive, and these doctors had thousands of years of anecdotes showing miraculous benefits from bloodletting. One late defender of the practice wrote in 1829 “Who is there with ten or twenty years experience in the profession, that has not seen the most marked advantages from bleeding…”[29] Another learned physician wrote even later, in 1875, that “He thought it really saying too much…that we should assume to be so much wiser than our fathers, who had lent their approval to a custom that had been sanctioned by ages of experience.” With so many anecdotes accumulated over so many years, and in light of their own experience practicing bloodletting, it was simply impossible for these advocates of the therapy to accept the growing evidence that the practice made no sense and didn’t work.
Of course, there were always anecdotes which suggested bloodletting wasn’t beneficial, and even that it was harmful. One of the most famous victims of bloodletting was George Washington, first president of the United States.[30] After contracting what is now believed to be a case of the bacterial disease strep throat, Washington was fed various concoctions and drained of a significant quantity of blood. This certainly didn’t help his infection, and it likely caused, or at least hastened, his death. Even at the time, there were doctors who doubted the wisdom of bloodletting based on such experiences.
