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VETERINARY
JOURNAL
CLINICAL SECTION EDITOR MAUREEN REVINGTON
ADVISORY COMMITTEE ANAESTHESIA LEN CULLEN AVIAN MEDICINE AND SURGERY GARRY CROSS EQUINE MEDICINE AND SURGERY JOHN BOLTON LABORATORY ANIMAL MEDICINE MALCOLM FRANCE OPHTHALMOLOGY JEFF SMITH PATHOLOGY CLIVE HUXTABLE PHARMACOLOGY / THERAPEUTICS STEPHEN PAGE PRODUCTION ANIMAL MEDICINE JAKOB MALMO RADIOLOGY ROBERT NICOLL REPRODUCTION PHILIP THOMAS SMALL ANIMAL MEDICINE BRIAN FARROW DAVID WATSON SMALL ANIMAL SURGERY GEOFF ROBINS GERALDINE HUNT WILDLIFE / EXOTIC ANIMALS LARRY VOGELNEST
JOURNAL ABSTRACTS MAUREEN REVINGTON EDITORIAL ASSISTANT AND DESKTOP PUBLISHING ANNA GALLO
CONTRIBUTIONS INVITED Practising veterinarians and others are invited to contribute clinical articles to the Australian Veterinary Journal. We will consider material in a variety of formats, including clinically orientated reviews, reports of case series, individual case studies, diagnostic exercises, and letters containing comments or queries. Contributors should consult instructions for authors on http://www.ava.com.au/avjintro and recent issues of the journal for guidelines as to formatting. Over referencing should be avoided: authors should preferably quote only those articles they feel are most likely to be of interest and benefit to readers. Send all contributions to: Editor, AVJ Clinical Section AVA House, 272 Brunswick Road, Brunswick, Vic 3056 Phone: (03) 9387 2982 Fax: (03) 9388 0112 Email:
[email protected]
Authors, please note that from July 1st, 2005 the manuscript handling fee will be $55, including GST.
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BOOK REVIEW Ethics and evidence-based medicine Complementary and Alternative Veterinary Medicine Considered. Ramey DW, Rollin BE. Iowa State Press, Ames, 2003, 252 pages. Price US$49.99. ISBN 0813826160.
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any therapeutic approaches are frequently grouped together as complementary and alternative veterinary medicine (CAVM). They include such practices as homeopathy, acupuncture, herbalism, naturopathy and chiropractic. Apart from the claim to be complementary or alternative to scientific veterinary medicine, they share little by way of unifying concepts or proposed modes of action. In spite of having been practised in various forms for many years there remains a dearth of evidence for either efficacy or safety although proponents of their use claim that their remedies are effective, natural and harmless. In the absence of objective evidence it is surprising that CAVM, and even more so its human equivalent, is so popular or that veterinary practitioners are so frequently asked to provide such treatments for clients’ animals. In 2000 it was estimated that Australians spent $2.3 billion on ‘alternative’ treatments for themselves.1 Even if it is not clear why CAVM has become so popular there still remains the need for veterinarians to be well informed about its scope and practice, its possible interactions with scientific veterinary medicine, and its safety. What are the ethical and factual considerations that a veterinarian needs to consider when faced with a client’s request for treatment of their animal with a particular CAVM modality? What is homeopathy? Does acupuncture really work? Does it work equally for everything? Are herbal preparations harmless? This book by Ramey and Rollin is an excellent resource for individual veterinarians who wish to become well informed and who wish to consider the ethical arguments raised when contemplating use of CAVM. The book is thought provoking, easy to read and well referenced. It raises important issues about how ethical veterinary medicine should be practised. The authors bring their considerable experience in veterinary practice and veterinary medical ethics to bear in writing this text and their commitment to the responsible and ethical treatment of animals is obvious throughout. David Ramey is an equine veterinarian with 20 years clinical experience and a co-author of the current AVMA guidelines regarding the use of CAVM. Bernard Rollin is a University Distinguished Professor, Professor of Philosophy, Professor of Animal Sciences, Professor of Biomedical Sciences and University Bioethicist at Colorado State University. The book is an excellent summary of the issues surrounding the increasing popularity of CAVM amongst veterinarians and their clients. The discussions on the clinician’s desire to heal, to provide hope and to use unproven modalities because they “can’t hurt and might help” are challenging, and go right to the heart of why many of us became veterinarians. The authors do not claim that this is an unbiased book that promotes evidence-based medicine and CAVM equally. In fact they claim that the book is strongly biased; biased for effective therapies, for science as the best way to test empirical claims, and for truth. Chapter 1 introduces the reader to the topic area and discusses possible social, cultural and philosophical reasons for why CAVM is becoming increasingly popular. The historical longevity of certain CAVM modalities is often cited as evidence for their efficacy and Chapter 2 provides an excellent historical overview of some CAVM practices against which to test this assertion. Of particular interest was the debunking of the oft-quoted claim that veterinary acupuncture has been practised for thousands of years. The authors discuss the history of acupuncture in people and then continue this investigation into the history of veterinary acupuncture. According to the authors, “the first recorded veterinary therapeutic tradition involving needling of any sort appears to begin ….. around 1000 A.D. ….. in contradistinction to what has …. become common knowledge”. The scientific basis of medicine, the ethics of veterinary medicine and the role of placebos and hope in the perception of therapeutic efficacy are covered in Chapters 3 to 6. When considering the reliance that many clients place on anecdote and experience of friends and acquaintances when choosing a medical treatment, it is wise to remember that scientific medicine has a relatively short history and few of life’s other decisions are made according to evidence provided by testing hypotheses and claims with the sort of rigour that is
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ClinicalClinicalClinicalClinical required of properly conducted clinical trials. Add to that a general mistrust of science by much of modern society and a desire for the ‘old days’ when food was healthy, water was pure and everything was ‘natural’, and it becomes less surprising that many turn to CAVM for their animals. In Chapter 7, the authors provide a brief summary of the scientific aspects of numerous CAVM modalities and their efficacy - or lack thereof. This chapter discusses the relative merits of acupuncture, chiropractic, homeopathy, herbals and botanicals, electricity and magnetism. A more detailed account of each of the modalities could have been provided, although this is by far the largest chapter in the book and is provided with extensive referencing (343 references). The final two chapters discuss the implications of using untested therapies and the high regulatory ‘burden of proof ’ required for conventional medicines compared with the absence of such a requirement for proof of efficacy of CAVM modalities. In the preface to this book there is a quote from the New England Journal of Medicine which states “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”.2 This statement underlies the responsibility of veterinarians to clients and their animals to provide accurate advice and proven therapies, or to enroll them in an appropriately designed trial of a new therapy. Veterinarians do not have the luxury of basing their treatments on anecdotal reports. It is questionable ethically for veterinarians to provide unproven treatments as though they were of the same status as properly evaluated and regulated treatments. All treatments should be evaluated critically and the available evidence weighed before they are used on clients’ animals. This should apply equally to various CAVM modalities as it does to registered products from major pharmaceutical companies. This is an important book that addresses issues confronting the profession in these days of increasing de-regulation. It contains a wealth of information and a lead into the wider literature that should enable any interested veterinarian to make an informed decision on the approaches they take in providing veterinary services to their clients. It provides also a number of valuable discourses in ethics, which deal with specific issues of considerable importance. What is it that separates veterinarians from lay-practitioners if it is not their scientific training? Why should veterinarians be allowed to retain special privileges, such as prescribing, if they abandon their scientific training and supply clients with unproven, unregulated remedies because this “is what the clients want”? We can’t even hide behind the claim that such treatments are harmless. There is little published data on untoward side effects of use of CAVM because of a lack of appropriate reporting mechanisms, but a scan of the pages of the Medical Journal of Australia provides sufficient evidence of various poisonings of people with herbal preparations to lay the ‘harmless’ claim to rest.3,4 This book should be made compulsory reading for all veterinary students. It is highly recommended as a valuable and reliable source of information and ethical discourse for all veterinarians interested in practising veterinary science and avoiding the slide into veterinary charlatanism. JR Gilkerson and CR Wilks Dr Gilkerson teaches veterinary microbiology and virology and Professor Wilks teaches veterinary virology and public health at the School of Veterinary Science, The University of Melbourne. 1.MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Prev Med 2002;35:166-173. 2. Angell M, Kassirer JP. Alternative medicine – the risks of untested and unregulated remedies. New Engl J Med 1998;339:839-841. 3. Drew AK, Myers SP. Safety issues in herbal medicine: implications for the health professions. Med J Aust 1997;166:538-541. 4. Tait PA, Vora A, James S, Fitzgerald DJ, Pester BA. Severe lead poisoning in a preterm infant due to a herbal remedy. Med J Aust 2002;177:193-195.
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