Can Complementary and Alternative Medicine be Evidence-Based Medicine?

What is EBVM?Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. …integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Sackett, DL. et al. Evidence based medicine: what it is and what it isn't BMJ1996;312:71

What is EBVM?The integration of the best research evidence with our clinical expertise and our patient's unique values and circumstances.

Strauss, SE. et al. Evidence-based medicine: how to practice and teach EBM. (2005) 3rd ed. Edinburgh: Churchill Livingstone.

All Evidence is not Created Equal

Critical Appraisal•Level of evidence

•Control for Bias/Confounding

•Plausibility, Consistency, Coherence, Strength

What is EBVM?This succinct, some would say obvious, definition of what we all try to do anyway, belies the more profound philosophy behind EBVM. At its heart is the confidence in the scientific methodology that has developed over the centuries to enable us to distinguish what is likely to be true from what is likely to be false (or unproven).

Cockroft, P. Holmes, M. et al. Evidence-Based Veterinary Medicine (2003) Oxford: Blackwell.

“Democracy is the worst form of government, except for all those other forms that have been tried." (Winston Churchill, from a House of Commons speech on Nov. 11, 1947)

“[Science] is the worst form of [epistemology], except for all those other forms that have been tried." (Winston Churchill, from a House of Commons speech on Nov. 11, 1947)

We Are Easily Fooled

•We tend to see what we look for and expect to see, we remember things which confirm our beliefs and ignore or forget those that show us to be wrong

•Being smart, well-educated, experienced, or well-intentioned doesn't protect us much from common errors in judgment

•The judgment of individuals, however respected or numerous, is less reliable than the assessment of objective scientific research

CONCLUSIONS

Self-Doubt is Healthy

…Often getting the right diagnosis and therapy is less about what you know and more about being rigorous about understanding how you know. Only when you are conscious of your ability to think poorly, can you compensate.

Mark Crislip, MDQuackast, Science-Based Medicine, Pus Whisperer

The real purpose of the scientific method is to make sure Nature hasn't misled you into thinking you know something you actually don't know. Robert Pirsig, Zen and the Art of Motorcycle Maintenance

Self-Doubt is Healthy

Philosophy of EBM• Realism

• The world really exists• Empiricism

• We can learn about the world through experiment

• Methodological Naturalism• The only things we can study empirically

are natural phenomena; the supernatural is out of bounds

• Reductionism• We can understand complex systems by

investigating their components• Scientific Skepticism

• Knowledge claims must be justified by empirical evidence

What is CAM?The identification of standard and broadly accepted definitions applicable to CAVM, including the definition of CAVM itself, is challenging. …a heterogeneous group of preventive, diagnostic, and therapeutic philosophies and practices. The theoretical bases and techniques of CAVM may diverge from veterinary medicine routinely taught in North American veterinary medical schools or may differ from current scientific knowledge, or both.

AVMA Guidelines for Complementary and Alternative Veterinary Medicine

What is CAM?Holistic (or Integrative) Veterinary Medicine is the examination and diagnosis of an animal, considering all aspects of the animal's life…as well as the combination of conventional and alternative (or complementary) modalities of treatment.

Holistic thinking is centred on love, empathy and respect.

American Holistic Veterinary Medical Association

What is CAM?Holistic Medicine-

A healing philosophy which views the patient as a whole body rather than as a disease or a collection of symptoms. A patient's emotional and spiritual state can affect the patient's condition. Holistic practitioners may combine traditional forms of treatment (medication and surgery) with alternative forms of treatment including homeopathy, acupuncture, chiropractic, massage, and herbal medicine.

Veterinary Institute of Integrative Medicine

Philosophy of CAM•Holism• Complete systems in

context

• Vitalism• The spiritual or energetic

essence is essential

•Postmodernism/Constructivism• Reality as social construct

•Cultural Relativism• Equivalence of all cultural

points of view

Philosophy of CAMHolismHolism or holistic treatment involves treating the body as a whole, including the mind and spirit …The whole is not entirely explicable in terms of its parts…This means that we cannot usefully consider one part of the animal in isolation

Animals (and humans) do not function in parts, we function as a whole and mind, body…and spirit are an inseparable entity. This is a fact and to think and work otherwise will inevitably lead to failure.

Day, C.Alternative Veterinary Medical Centre

Philosophy of CAMVitalismAcupuncture reconnects and balances Life energy… Energy medicines such as homeopathy, homotoxicology, Reiki, craniosacral therapy, and others align the physical, mental, and spiritual portions of the organism. Yes, I did say spiritual and that is a big part of holistic medicine – recognizing the spiritual nature of Life.

Richard Palmquist, DVMWhole Dog Journal

Philosophy of CAMVitalism"pharmacological and surgical approaches appear incomplete because they ignore the Vital Force which animates and breathes life into the biomachinery of living systems…" Energetic force is unique, distinguishing living from nonliving systems and people from machines. Medical therapies that promote this energy…should be given primary consideration.

Stefanatos, J.Complementary and Alternative Veterinary Medicine: Principles and Practice

Philosophy of CAMPost-Modernism/RelativismAlthough the basic concepts and conceits of Western and Chinese medicine differ widely, both disciplines address the same physical disorders…TCM considers neither the endocrine nor peripheral nervous systems, and Western medicine has no format for diagnoses of diseases caused by "external pathogenic factors" such as Heat, Cold, Wind, or Damp.

Limehouse, JB. Taylor, PA. Complementary and Alternative Veterinary Medicine: Principles and Practice

Philosophy of CAMPost-Modernism/RelativismIf no paradigm 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.Churchill, W. Journal of Chinese Medicine

Philosophical PrinciplesEvidence-Based Medicine Complementary & Alternative MedicinePrinciple Description Principle Description

Realism The world exists independent of human beliefs

Postmodernism/Constructivism Our models of reality are only social/cultural constructs

Empiricism We can develop true knowledge of the world through perception and experimentation

Cultural Relativism All cultural paradigms are of equal value

Reductionism A powerful way to understand complex entities is to investigate their components

Holism Complex systems can only be truly understood as whole entities in context

Methodological Naturalism

Science can only test and employ claims about the natural, physical world

Vitalism Living systems are defined by the presence of a nonphysical vital essence

Scientific Skepticism

Knowledge claims must be justified by empirical scientific evidence

Panepistemia* Non-empirical forms of evidence, including tradition, intuition, and revelation, are equivalent to scientific evidence

*This is not a standard term in the philosophy of science but a neologism I have coined to describe the view that many forms of evidence are just as cogent and compelling as empiric scientific evidence.

Potential ConflictsHolism…[EBM requires] the idea that there is a legitimate hierarchy of knowledge and method with the RCT as the gold standard and the clinician’s notes, observations and judgments right down there in status with ethnography, sociology and anecdote…

There are practitioners of naturopathic modalities who do not subscribe to this hierarchy at all; they tend to see this as a form of nonholistic reductionism.

It is inappropriate to superimpose reductionistic methodologies that are paradigmatically incongruent with the holistic practice of naturopathy.

Jagtenberg, T. et alJournal of Alternative and Complementary Medicine

Potential ConflictsHolism…Reductionism may be the opposite of holism. It is anyway very foreign to the methodology and reasoning of a holistic vet…Day, C.Alternative Veterinary Medical Centre

Potential ConflictsVitalismHolistic 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.

Doug Knueven, DVM,CVA, CACThe Holistic Health Guide: Natural care for the whole dog

Potential ConflictsVitalismThe belief that spiritual, emotional, psychological, or other non-measurable aspects of the individual patient’s presentation are important for healing does not require one to reject evidence obtained from clinical trials, but it does require the recognition that knowledge gained from such methods will be insufficient to guide optimal clinical practice…The importance of Qi in traditional Chinese medicine means that research that cannot and does not account for the force will never be compelling for a TCM practitioner.

Tonelli, MR. Callahan, TCAcademic Medicine

Potential ConflictsPost-Modernism/RelativismThe 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.

Churchill, A Journal of Chinese Medicine

Potential ConflictsPost-Modernism/RelativismThe methods for obtaining knowledge In a healing art must be coherent with that art’s underlying understanding and theory of illness. Orthodox medicine should consider abandoning demands that CAM become evidence-based, at least as ‘evidence’ is currently narrowly defined…

Tonelli, MR. and Callahan, TC.Academic Medicine[EBM] frameworks presume the “objectivity” of the evidentiary practices of modern Western science and privilege the epistemologies, ontologies, and practices that underlie biomedicine. They hold that notions of evidence underlying EBM standards and RCTs entail a series of assumptions that are incompatible with theories and practices central to Chinese medicine.

Shea, JLJournal of Complementary and Alternative Medicine

Potential ConflictsWho Needs Scientific Evidence?For ancient and traditional healing modalities, one could argue that history provides the evidence…. One cannot conclude that, because a healing system cannot be measured conventionally, it is ineffective or unsafe. Instead one might come to appreciate the limitations as well as the strengths of the conventional research methodology.

Gaylord, S. et al Evidence-based medicine and complementary and alternative therapies

As a veterinarian now practicing homeopathy and chiropractic almost exclusively, I have all the proof I need every day in my practice to justify these modalities.

Jewell, G.Canadian Veterinary Journal

Potential ConflictsWho Needs Scientific Evidence?Users of homeopathy did not see a need for scientific testing and were happy with their own judgment of whether the treatment was working for…RCTs came at the bottom of their hierarchy of evidence. Anecdotal evidence, particularly from friends and family, rated highest.

Barry CASocial Science and Medicine

To prefer indirect evidence, such as that from clinical trials, over primary experience represents an epistemic choice…CAM practitioners…can continue to emphasize individual outcomes without inconsistency even when the therapies they utilize have failed to demonstrate efficacy in controlled clinical trials.

Tonelli, MR. and Callahan, TC.Academic Medicine

Potential ConflictsEBM Might Change CAMThe very publication of trials can act as a reformulation of the very nature of a therapy, generally in the direction of medicalisation. Where homeopathy has been tested on a biomedically diagnosed disorder…it suggests to the readers that homeopathy can be used in a biomedicalised way…ignoring the mental, spiritual, and relational picture in favour of physical symptoms…

Evidence-based epistemology can in itself have transformative effects on alternative therapies…scientifically constructed ‘evidence’ for an alternative therapy only works when the therapy has mutated into a medicalised version and divested itself of its alternative philosophy.

Barry, CA Social Science and Medicine

Can Complementary and Alternative Medicine be Evidence-Based Medicine?

Can Complementary and Alternative Medicine be Evidence-Based Medicine?Yes- If•Individual interventions are tested for specific indications at all levels of evidence

•Levels of evidence are respected and the highest level given precedence

•Interventions are accepted or rejected as indicated by the formal evidence appraisal

•But will these interventions still be CAM? Will CAM disappear as a category? Should it?

Can Complementary and Alternative Medicine be Evidence-Based Medicine?No- If•If EBM methods are incompatible with CAM therapies because of• Holisms vs Reductionism• Vitalism vs Methodological Naturalism• Post-modernism- No such thing as true or false, just

points of view• Cultural Relativism- Inappropriate to judge one

paradigm by another; all sets of metaphors are equally valid

•Medicalizing CAM therapies strips them of their character and value

•The results of EBM evaluation will be ignored

Things to Think About•What philosophical principles underlie our approach?

•How do these complement or antagonize other approaches? Particular therapies?

•How can understanding these issues facilitate productive debate and discussion?

•Should CAM assimilate? Should EBM accommodate? Should they be separate but equal? Separate but unequal?

•What about other values?• What clients want?• Spiritual or religious values?• Practitioner autonomy?• Protection of the public?