Ethics and Evidence-Based Medicine: Is There a Conflict?

Erich H. Loewy, MD

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In This Article

Retarding Progress

Progress, be it in science, art, or philosophy, is made by questioning the status quo, by questioning the way we habitually proceed, and eventually by modifying the old or trying the new. EBM, for all its advantages in caring for the "usual case of "X," tends to suppress our curiosity and imagination[5] or at least tends to channel our curiosity and shape our imagination within narrow limits and, therefore, gets in the way of the sort of speculation necessary for scientific progress.[6]

I would have no problem with EBM -- with, in other words, having drugs and procedures rigidly evaluated before their release (with proper warnings) to the public whether by prescription or over the counter. I do fear that EBM findings soon become protocols which are suggested or are used to jog a physician's memory, and that these in turn become the norm in which the physician admitting a patient with pneumonia only writes "pneumonia protocol" often not even knowing what follows. Soon this is the standard of care, and physicians who do not follow that protocol are called on the carpet. My greatest fear, then, is not EBM but the use to which it is put. What I hear from colleagues around the country is that saving money has a lot to do with how a protocol is written. I fear these protocols mainly because they are an anti-intellectual way of practicing medicine. I shudder when I think that a physician, when asked why he did this or that, will answer, "Because that's what it says in the 'protocol.'" I suggest that that would be too bad in an EMT or NP; but in an MD, for whom the proper priority is thinking and then writing, this is a demeaning and ultimately dangerous habit.

I suspect that the emphasis on EBM, as well as the consequent keeping curiosity and imagination within narrow bounds, is in large measure due to our society's preoccupation with profit. Except for the "not for profit" managed care organizations (MCOs) (of which there are not many), healthcare has primarily been a system in which profit (admittedly or not) is the prime interest. It is not surprising that the main interest of the CEO of any of these associations is to make a profit for the company and, indeed, the primary obligation is to the stockholders in the company. As a result, "efficiency" is of the greatest importance. Politicians, on the other hand, are elected by citizens who they are supposed to represent and whose welfare should be -- but, of course, often is not -- their principle concern.

In my view, "efficiency" is not a legitimate measure of the quality of healthcare or of education (which does not mean that inefficiency should be encouraged!). To have -- as recently happened to me -- one's physician forced to defend to a clerk (who probably at best had a high school diploma) why she considered 40 mg of a medication proper for me and why 20 mg would not do is demeaning to the physician, dangerous for the patient, and by any reasonable definition constitutes the practice of medicine without a license to do so. This struggle took quite a bit of time day after day and certainly is an insult to a splendidly trained, competent physician.

As far as research is concerned, bioethicists, as well as physicians, have rightly been eager to protect the patient, to verify that experimentation takes place only with the full consent of the patient, etc. We have tried to protect patients from overtreatment just as we have tried to protect subjects from unwarranted experiments. Unfortunately, we have done little to protect future (and sometimes current) patients from "undertreatment," -- that is, (1) giving up too soon; (2) "selling patients out" to their supposed autonomy;[7] and (3) refraining from following some highly promising leads (such as stem cell therapy and experimentation). If we are to use EBM and the protocols that invariably follow, we shall have to leave the possibility of experimental therapy open. Further, I suspect that EBM -- while allegedly protecting the patient -- has mainly been used (somewhat like "quality control") as a handy foil for those interested in holding down costs. The fact that, like the Nazi government, we feel the necessity to hide what we are doing under euphemisms speaks volumes.

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