Introduction

Integrative veterinary medicine (IVM), a field also known as “complementary and alternative veterinary medicine,” “holistic medicine,” “unconventional,” and “natural medicine,” first began in the 1970s in North America and has expanded ever since. IVM “describes the combination of complementary and alternative therapies with conventional care and is guided by the best available evidence. Veterinarians frequently encounter questions about complementary and alternative veterinary medicine (CAVM) in practice, and the public has demonstrated increased interest in these areas for both human and animal health” (Memon et al. 2016).

IVM presents a gamut of opportunities and difficulties when it comes to ethical practice. Even the title that one employs to describe it carries a considerable amount of nuance and implications as to its relationship with the “other,” “conventional,” “allopathic,” or “mainstream” methodologies. The cumbersome nomenclature reflects the difficulty in separating diverse types of practices, each with their own origins from human medicine, scientific and unscientific foundations, proponents, and critics. Both “sides” should eschew the term “traditional” medicine as it introduces confusion. That is, is the speaker referring to “traditional” in the modern sense, talking about contemporary treatment with pharmaceuticals and surgery, or are they commenting on indigenous folk-medicine approaches that predate the scientific era?

Most veterinarians who incorporate techniques outside of those typically taught in veterinary curricula prefer the term “integrative.” This sidesteps the awkwardness of “CAVM” as well as excludes the name “alternative,” which implies treatments other than mainstream methodologies. “Holistic,” which is missing its “w” (“wholistic”), suggests that its practitioners consider the entire patient. However, this invites a backlash from “conventional” veterinarians, who also insist that they view patients in their entirety. “Natural” medicine may have sufficed decades ago, but highly technical approaches such as photomedicine, pulsed electromagnetic field therapy, and electroacupuncture are not found in nature. So, in keeping with the prevailing opinions as to the ideal terminology, this chapter will use the term IVM when provided by veterinarians, and IM (minus the “V”) for those situations in which a nonveterinarian or individuals with unknown credentials deliver this type of care. It contains an overview of the field, the pros and cons of each modality, and a case study that illustrates the ethical opportunities and pitfalls that IVM treatments present. The ethics of IVM impact the patient, the client, the profession, veterinary education, and scope of practice.

Expanding Acceptance of IVM

As scientific support for IVM grows, its legitimacy and acceptance are similarly expanding. In fact, the convergence of science-based integrative medicine, fear-free veterinary care, integrative rehabilitation, and bond-centered practice is producing a new vision of what constitutes “typical” veterinary practice. Furthermore, veterinarians are encountering a burgeoning level of enthusiasm among clients for IVM for a wide range of problems in their animals. A survey of 423 horse owners found that 96% had used integrative medicine approaches (whether provided by a veterinarian or not) on their horse (Thirkell and Hyland 2017). The most popular therapies included massage (71%), chiropractic manipulation (59%), and magnet therapy (54%). Most (81%) expressed openness to instituting new treatments without consulting their veterinarian. This is concerning as it can result in potential harm to the treated horse and/or riders. Notably, only half of those surveyed stated that they were “very satisfied” with their “regular” veterinarian. A recent study of 204 horse owners found that 52% contacted an IM therapist before a veterinarian for back pain (Gilberg et al. 2021). Only 10–15% did not use any IM method for prevention or after injury.

Most veterinary teaching hospitals provide IVM services (Memon et al. 2021). Shmalberg et al. (2019a) analyzed the nature of canine and feline patients referred for acupuncture and herbal therapy to an academic veterinary teaching hospital. This two-year retrospective study found dogs (92%) far more frequently referred for treatment than cats (8%) and the most common problems noted were musculoskeletal (27%), neurologic (17%), oncologic (15%), and dermatologic (11%) in nature. Acupuncture in its various forms (dry needling (95%), electroacupuncture (26%), and pharmacopuncture (the injection of vitamins into points) (24%) was the most common therapy provided, followed by herbal supplements (76%). It should be noted, however, that one of the authors is also a manufacturer of Chinese herbal mixtures in addition to working as a professor at the same institution. The same authors published a three-year retrospective analysis of equine patients referred for acupuncture and herbal medicine (Shmalberg et al. 2019b). The three most common problems for which horses presented included musculoskeletal issues (62%), gastrointestinal dysfunction (9.5%), and anhidrosis (6%). Once again, acupuncture constituted the most common treatment (90%). A report of IM therapists treating dogs in Sweden found that the most frequently used methods were massage, stretching, and acupressure (Sohlberg et al. 2021).

Veterinary students who receive exposure to IVM during school or earlier may decide to pursue this type of work upon graduation. Some even report that this was the driving force for their pursuing a career in veterinary medicine (personal communication). More seasoned veterinarians may transition to IVM after they have grown weary with corporate pressures (see Chapter 17) and the limited and sometimes stressful treatment options that may cause the patient to fear the practitioner. Many welcome the opportunity to learn new ways to help their patients heal that provide comfort, restore functional homeostasis, and have a rational basis with evidence of effectiveness. On the other hand, some veterinarians pursue treatment methods that fail to meet requirements for a scientific basis and supportive evidence, whether IVM or “conventional.”

Choosing “Conventional” vs. IVM Approaches

Scientific evidence of effectiveness cannot be the only criterion of what constitutes “good care.” Other relevant factors include risks of treatment, potential complications, pain, and debility that may arise, costs, recovery time, and client’s informed consent. Ethically, clients should receive a complete picture based on evidence of the range of options available. However, surgeons, for example, may not have studied the effectiveness of nonsurgical options, including IVM techniques such as medical acupuncture, massage, movement therapy, and photomedicine. Moreover, veterinary orthopedic surgeries can earn practitioners thousands of dollars for each procedure, with the tibial plateau-leveling osteotomy (TPLO) costing $5000 or more. Could this also constitute a conflict of interest between what is best for the patient and best for the practice’s “bottom line”?

How do results compare between the TPLO and a nonsurgical approach with IVM and rehabilitation for patients with injured cranial cruciate ligaments? To date, no research exists that directly compares a multimodal IVM protocol with the TPLO. Furthermore, IVM methodologies offered by one practitioner may vary in number and type from those of another, in addition to tailoring treatment selections for each patient’s individual needs. A study comparing the TPLO with something as simple as a custom-made stifle joint orthotic indicated “high owner satisfaction rates for both interventions” (Hart et al. 2016). In this case, if a brace that costs under $1000 could allow patients to avoid the risk of severe and costly complications, even without the addition of IVM, why are veterinarians not learning more about nonsurgical options? Could this stem, at least in part, from the limited to nil exposure to IVM that most veterinary schools offer students? Only 30% of veterinary colleges reported offering a formal course in IVM and only 77% offered “some level” of instruction in IVM, with acupuncture and rehabilitation as the most popular modalities covered in the curriculum (Memon et al. 2021). Could a conflict of interest on the part of a teaching institution that nets high profits from TPLOs dissuade faculty from promoting nonsurgical options, especially given the heavy reliance that academia has developed on corporate funding? Where are the ethical discussions on this?

In addition to the pain and invasiveness of the TPLO, the procedure may lead to numerous complications, some severe, painful, and debilitating in an unacceptably (to this author) high percentage of patients. As stated by Bergh and Peirone, “Ten to 34% of TPLO surgical procedures are reported to experience a complication and approximately two to four percent require revision surgery to address a complication” (2012). Soft tissue complications include laceration of regional blood vessels, ligaments, and tendons. Severe blood loss may result from damage to local arteries. Measures instituted to reduce the risk of soft tissue damage, such as the introduction of gauze sponges to decrease iatrogenic tissue trauma, may deposit debris into the wound and lead to tissue reactions, infections, and the formation of a draining tract. Intraoperative complications range from tibial and/or fibular fracture to broken hardware, i.e. bits of screws, pins, drill bits, etc. The authors list over 20 postoperative complications, ranging from meniscal tear to patellar tendonitis, pivot shift, delayed union, internal tibial torsion, implant failure, and more. In contrast, medical acupuncture, photomedicine, massage, and movement therapy all have extremely low rates of injury and complications.

An IVM approach for cranial cruciate ligament injury offers a multimodal, relatively pain-free treatment series that addresses the plural causalities of ligamentous deterioration and its consequences instead of altering the limb’s configuration. As we apply critical scrutiny to all practices, we should also weigh the ethical pros and cons of the physiologic considerations, pain and stress, financial impacts, and long-term risks of each approach. An exhaustive comparison of conventional and IVM procedures for common problems in veterinary practice would be a worthy undertaking but is beyond the scope of this chapter.

Types of IVM Care

For all IVM therapies, the first step in treating animals safely and effectively involves an accurate assessment and delineation of the patient’s problems. Human practitioners who apply their techniques to animals have neither the requisite veterinary education nor the experience in the field that veterinarians do. Clients who take their animal to a human acupuncturist, chiropractor, or massage therapist often fail to recognize the vast differences and the risks involved. These issues reinforce the need for all IM and IVM providers to maintain a science-based, evidence-informed perspective and to eschew archaic methodologies.

Regulatory and Legal Concerns

Each year, states and provinces across the United States and Canada, respectively, face pressure to allow nonveterinarian healthcare providers direct access to animals. These practitioners range from chiropractors and acupuncturists to massage therapists and physical therapists. Too often, laws change to grant these rights before veterinary medical associations can organize an effort to stop the process. In 2019, the AVMA updated an overview of scope of practice laws regarding CAVM and other practice act exemptions (AVMA 2021). Keep in mind that rarely does a practice act become more restrictive. Instead, the ingress of human practitioners into companion animal and equine practice steadily grows.

Sometimes, this arrangement represents a compromise between the human profession (in this case, chiropractic) and the veterinary profession’s representatives in the state in which the change in law is up for debate. Some veterinarians would prefer not to relax laws and allow nonveterinarians to work on animals without direct supervision, citing issues of potential problems such as misdiagnosis and maltreatment. Others welcome more providers to treat animals: they may feel that animals are underserved (a claim that chiropractors have been known to make) and that clients should have the “right” to seek whatever types of treatments and practitioners they want to treat their animals (another contention made by chiropractors to state regulatory authorities).

Chiropractors will also cite “restraint of trade” when pushing to gain entry to animal work – the same argument they lodged successfully against the American Medical Association in the mid-twentieth century. However, several differences exist between treating humans as a human-trained healthcare provider and demanding access to nonhumans. Obviously, the human biped’s form and function differ from the horse, dog, and cat. Moreover, nonhumans experience a wide range of diseases and injuries that veterinarians learn how to diagnose and treat, but chiropractors do not. With practically no studies on the safety and effectiveness of chiropractic manipulation in nonhumans, how can one argue that animals will benefit and not be injured? (And how can veterinary schools allow faculty to practice and promote chiropractic when they are precisely the ones who should be performing research to test these approaches before instituting them in a veterinary teaching hospital?)

In some instances, as with chiropractic, for example, states may require a special “certification” that requires a human chiropractor to have satisfied requirements from a self-proclaimed certifying body. They may have to attend a specific number of hours of coursework, complete testing by an “approved” course, and agree to practice in accordance with the guidelines set forth by the certifying body and the state board of chiropractic. So, what is “certification”? Essentially, anyone can “certify” anyone in anything. On the one hand, dedicating 50–150 hours to learning a rational, evidence-informed technique such as medical acupuncture has a science-based foundation as strong as many other practices taught to veterinarians during their professional school years. On the other hand, one can spend five minutes on the internet and obtain certification as a Reiki (energy healing) master. In their work, they may claim to connect with an animal’s “spirit” guides. This involves “interspecies telepathic communication” as the Reiki master “listens” to what the patient communicates to them. If the animal “dislikes” taking antiepileptic medication every day, for example, the practitioner may relay this to the client, who then has a quandary. Do they listen to what the animal “wants” or rely on their primary care veterinarian’s recommendations?

Thus, while a veterinarian’s license to practice veterinary medicine usually allows them to include IVM, more nonveterinarians are gaining access to treating animals by applying continual pressure to state regulatory authorities. Legislators may possess little background in science and animal healthcare, so arguments made by veterinarians about the need to protect the health and safety of veterinary patients may make little impact. Even state veterinary boards may seem ineffectual to resist the ongoing onslaught of human healthcare providers in this regard. Their “customer” is the consumer, and veterinarians that volunteer their time to serve on the state board have limited capacity to resist organized assaults on the state’s practice act, at least over time. This explains why, in jurisdiction after jurisdiction, more nonveterinarians are advertising their nonhuman work. They may make unjustified claims and try to convince the public that they are the true experts in each modality. Veterinarians who seek training or “certification” from courses taught by these human healthcare providers (such as chiropractors) who are seeking more rights to work with animals lend credence to these practices.

Changing laws to ease access to animals by nonveterinarians may invite a host of unintended consequences. With chiropractic, for example, beyond the wide array of manipulative approaches they may apply to an animal, they may make nutritional recommendations, sell clients supplements for the animal, discourage vaccines, and perform their own kind of “diagnosis,” which they disguise by using a term, “functional neurology.” Functional neurology represents a means by which they employ a surrogate (often the client) to touch the animal. With the client touching the animal, the chiropractor tests the strength of the client’s deltoid muscle of the other outstretched arm. This supposedly indicates the vitality of an “energy circuit” going through the animal to the client. The chiropractor may ask the client to hold a vial that has a supplement (nutraceutical) or vitamin. If the client can resist the chiropractor’s downward pressure on the outstretched arm, that reflects strengthened “energy” and the chiropractor will recommend that the client purchase that supplement. While this scenario sounds outlandish, this method of selling supplements has existed for decades within the chiropractic profession.

So, what if problems arise related to IM, whether one holds a veterinary license or not? What if a client makes a complaint to the state veterinary board or pursues other legal recourse? As stated by Pugliese et al. (2019), “In veterinary malpractice litigation, standards of care expressed in guideline statements could influence the civil and penal courts in the decision-making process.” However, they also indicate, “Despite their popularity, clinical practice guidelines (CPGs) are not used often in clinical practice and their use remains controversial.” Furthermore, “The majority of CPGs are based on trials considering homogenous populations.” In veterinary medicine this is a limiting factor in their application, because in clinical practice, patients are rarely homogenous (i.e. species, breed, body weight, etc.). This author would also add that those who develop CPGs may, like many veterinary healthcare professionals, lack an adequate understanding of what IVM is, the pitfalls of unscientific practices, and how a rational IVM approach to a clinical condition may provide superior results, even if the evidence is only now emerging. As such, an implicit bias against IVM practice may exist based on lack of knowledge about the discipline’s complexity and those modalities that do meet scientific muster.

In a commentary, “A new look at standard of care,” Block (2018) exposes the fluidity and confusion surrounding what standard of care (SOC) constitutes. He cites a definition from 1837, one of the oldest legal references available, as what “an individual under a duty of care must have proceeded with such reasonable caution as a prudent man would have exercised under such circumstances” (Vaughan vs. Menlove, cited in Block 2018). By 1966, in veterinary case law, Block recounts the SOC definition as “the standard of care required of and practiced by the average reasonably prudent, competent veterinarian in the community” (Dyess vs. Caraway, cited in Block 2018). He notes that one court emphasized that SOC fails to outline clear, practical, clinically relevant recommendations and instead alludes to what the average practitioner would do – not the best or the most well-informed. As such, SOC does not constitute “best practices,” the “gold standard,” or “ideal care.” Instead, SOC compares a veterinarian’s action to prevailing community standards. In other words, SOC can vary according to geography, and not on scientific or evidential reasoning. Focusing too much attention on SOC, rather than quality of care, could put animal health and welfare in jeopardy. In this case, “majority rule,” as opposed to factual analysis, may exert a downward pressure on practice standards and keep outdated, unnecessarily invasive procedures in place when equally or more effective IVM approaches warrant broader introduction into first-line care.

Consequently, veterinarians navigating the multimodal field of IVM face a steep challenge when designing documents on informed consent (see Chapter 5). Listing every potential benefit and adverse effect for each modality offered, for the specific condition(s) an animal has, may quickly become insurmountable. That said, it is unlikely that many/any veterinarians also list all the potential complications of the TPLO, or present the comparative, evidence-based outcomes of a surgical vs. nonsurgical approach to presumed cranial cruciate ligament injury.

Ethical Aspects

While veterinarians have responsibilities to meet standards of accountability to their patients, clients, society, public health, and the profession, do human healthcare professionals who push to legally work with animals? And who writes these standards, publishes them, with what biases, industry connections and conflicts of interest, and based on what evidence? In fact, the term “evidence-based medicine” is glaringly absent from the AVMA PVME (AVMA n.d.).

“Allopathic” practitioners often press veterinary IVM providers for more research proof. However, does the veterinary profession expect the same degree of evidence from them, for their “conventional” treatments involving drugs and surgery? A recent commentary notes a lack of such standards for many common invasive procedures (Vigano et al. 2019):

What’s the strongest evidence in surgery? The lack of evidences [sic] to guide practice. Several justifications have been advanced, including difficulty randomizing patients for surgical interventions, large benefits from innovative procedures that do not need confirmation, and peculiarities of surgical patients that preclude applicability of any fixed rule. In this scientific anomaly, surgical education became studded with myths that inappropriately gained the rank of evidences [sic].

The veterinary profession has little evidence to support many of its routine practices. Rarely do surgeons select techniques based on double-blind, controlled studies. Furthermore, how forthcoming are veterinary school faculty members about the funding they receive from pharmaceutical or surgical supply companies, and how do these affiliations impact what they teach?