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

Erich H. Loewy, MD

In This Article

An Educative and Not a Punitive Instrument

EBM, when it is properly followed and when the physician has the right to deviate from it for good reasons, can be used as a tool for education. It rarely is. The question "Why are you giving him 'X,'" when answered with "Because that is what the MCO tells us to do," is a demeaning and anti-intellectual answer. The problem is that the system is blamed, without realizing that a social system is not "an act of God or nature" but something we constructed together and that can, therefore, change. A few sentences from the Holocaust literature are apt:


A "system" -- a political, economic, or cultural system -- insinuates itself between myself and the other. If the other is excluded, it is the system that is doing the excluding, a system in which I participate because I must survive and against which I do not rebel because it cannot be changed...I start to view horror and my implication in it as normalcy.[11]

Today we blame many of our social ills (which, in the United States, include a lack of access for a large part of the population and inadequate insurance for the rest) on the system. That is quite true and may serve as an explanation. However, it does not serve as an excuse. In the Nazi era there was one high official in the railroad who was responsible for the train schedules in the East. All he "did" was make schedules for trains to go to Warsaw, Lodz, and, of course, Treblinka, Sobibor, Auschwitz II, etc. Their destination, he felt, was none of his business. He was part of a system. The comparison is not so far-fetched. At most clinics, MCOs, and HMOs in the United States, the secretary will send the uninsured sick old lady away before any healthcare professional even knows that she is present. Likewise, we physicians living in comfortable middle-class homes do not see the poverty, hunger, and misery virtually next door. It was not the secretary who sent a sick, old lady away; it was not the doctor who ultimately did not see the lady; it is not us who ignore poverty, ignorance, and want; it is the system. As the quotation above shows, atrocities, when performed by "the system," become the norm and the person engaged in them comes to accept them as a norm. In effect, they have surrendered their humanity and given up their moral agency.

Essentially there are two sorts of social systems: One is a "natural system," that is, one imposed on us by nature. Here, by using our biological capacities, we may "push the envelope," wiping out some diseases and curing others but recognizing many others as beyond our capacity today. Modifying that natural envelope allows us to change the shape but still leaves the natural, albeit newer, envelope for us to deal with. The other is a social system that we ourselves have created. It is quite a different system for it has been established by us and can be changed fairly well by us. This sort of social system includes the distribution of wealth, "honors," and emoluments as well as -- and most essentially -- how we as a society deal with the horrendous poverty and lack of healthcare in the United States as well as what we condescendingly call the "developing nations."

It is entirely possible to change a social system -- a sentence that should be even truer in a democracy. EBM is heedless to personal or social circumstances, uninterested in psychological factors, but spawned by the belief that what physicians deal with is disease and not patients who happened to be afflicted with a particular disease. "A herniorrhaphy patient can go home in 1 or 2 days" -- is that really true? It is probably true if the patient lives in a middle-class suburb with a spouse and adequate sanitation. But is it true for a 55-year-old man who lives in a rat-infested "project" building on the fifth floor and without a functioning elevator? EBM tends to take the critical faculty of judgment away from the physician while often still holding him accountable when the herniorrhaphy breaks down.

It is useless to try to punish people for the outcome of such a system. The white, middle-class, male American is not culpable for slavery, for the past treatment of women, or for the deplorable treatment of minorities today. Guilt or culpability is judged on an individual basis, and I have participated in none of these -- perhaps because I lacked the opportunity? But as a member of a society that did these tragic things and profited from such things in the past and in many respects still does today, I must assume the obligation of trying to ameliorate and abolish conditions from which -- wish it or not -- I profit daily. Therefore, we all are responsible for doing our part to see that crass inequities are abolished, for if we fail to do so we, indeed, become guilty. Depending upon our profession, how we do it may be different, but at least we cannot sit quietly by while people in Bosnia, Uganda, Iraq, or the United States are grossly mistreated or while patient care is reduced to a rigid stereotypic formula. Fighting "the system" by your own methods will not work; only getting together and saying a united "NO" can accomplish a change from a system in which 5% of this good earth's inhabitants own 90% of all property. EBM adds a little contribution against social justice by making it difficult to step outside "the system" and see that this poor, sick lady or those hungry, poverty-stricken, and desperate people get care.

All of this basically means that we must craft what Margalit calls, in The Decent Society, a society that aims to minimize the disparagement of its members by poverty, lack of decent housing, and healthcare and the lack of all those things that people need in order to live with self-respect.[12] In many ways, EBM disparages the physician who must follow a protocol that he or she knows may not be in the patient's best interest and consequently decreases the physician's self-respect. We are a strange society: On the one hand we have made autonomy into the supreme virtue; on the other we have created instruments which force others (physicians) to act in ways they find suboptimal. We have created a society that worships autonomy and then turns around and prescribes to their professionals what they can do.


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