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

Erich H. Loewy, MD

Disclosures
In This Article

Summary: Advantages and Disadvantages of EBM

There are several advantages and a disadvantage to EBM. The proof of the pudding, so to speak, is in the eating! When properly applied, EBM and its ilk could have the following advantages:

 

  • When reliable and properly applied to an individual who belongs to that particular group (eg, ethnicity, gender, economic standing, etc.) EBM protocols can be helpful, and sometimes necessary, to a particular patient. But EBM is, I suspect, quite unnecessary for a well-trained and thoughtful physician.

  • When used with discretion, EBM is useful as a check-sheet that makes sure that nothing vital has been overlooked.

  • The process of developing EBM, if used correctly and with the patient's good as the most important consideration, may be most useful in the educative process. Suggesting that EBM is a protocol into which a patient with a given disease can simply be plugged destroys any educational value that developing such an instrument ever had.

To me, as a bioethicist and (long ago) a physician who has observed the evolution of EBM, I am impressed with the danger to physicians, patients, the educative process, and, ultimately, to the behavior it encourages. Mindless reliance on EBM does exactly what we do not want our students to do: convert what is a suffering human being, with a unique personal life-history, into a specimen of pathophysiology or a heart murmur. When utilized improperly:

 

  • EBM is basically anti-intellectual and is "doing-" rather than "thinking-" oriented in the sense that it promotes mindless algorithm. I will claim that among a physician's most important tasks is thinking. EBM protocols -- which by their nature are check-sheets -- only rarely teach students or attendings to think; indeed, they discourage it.

  • EBM protocols tend to be looked upon as "the right way to do things" instead of as "the current (minimally effective) way to do things." They violate Hume's and Kant's rule which in essence states that one cannot determine what should be the case by knowing what is the case -- the latter being necessary, but not sufficient.

  • EBM protocols, together with our growing technical ability, increasingly become obstacles to our thinking and ultimately interfere with the patient-physician relationship of trust, a critical component of good care.

  • EBM protocols start out being considered as guideposts and end up being considered as straightjackets -- and straightjackets that are welcomed by many physicians (one actually told me that he was enthusiastic about them because they saved time and did not require him or her to think!).

  • Worse than that -- and even though institutions will deny this -- the institution looks upon these policies not as guidelines but as straightjackets. Physicians who do not follow these "guidelines" can then be called on the carpet -- not because the patient suffered but because the institution lost money.

  • When an official EBM is proclaimed, physicians often are afraid to insist upon elbowroom in their treatment. This is, in my view, a grave mistake and one that is demeaning and disparaging to the profession which is supposed to treat the ill according to their "oaths," all of which state that ethnicity, political, national, or financial circumstances must not enter into the decisions made.[13]

Physicians, just like garbage collectors or police officers, are socialized to believe that they have certain obligations. Society expects it of them, and while an expectation does not create an obligation, a reasonable expectation discharged over the years as though it were indeed an obligation denotes that it has been tacitly accepted as such. Physicians, in fact, have always had the obligation to be the patient's advocate and, in general, they have been. But today we are creating a society in which physicians are torn by what they feel are their obligations (1) to their employer and (2) to their patients. The "for profit" MCO really does not have this quandary. The chief ethical obligation of the CEO is to see that the stockholders are profited. That is hardly the aim of patients or physicians and carries within it at least the seed of conflict.

Physicians could -- if they understood solidarity and did not merely pay lip service to a concept they did not understand -- make certain demands for good patient care (and above all plans that involve enough time to spend with patients) and, if rebuffed, start with incremental strikes. One can begin by refusing to fill out forms and continue by not seeing patients for trivial things -- and I would bet that further escalation would not need to take place. If it did, "treatment of well-defined 'emergencies only'" would, I believe, prove successful in an extremely short time. The physician's demands should mainly be patient-oriented, which would fairly well assure the sympathy of the public. Although most physicians' organizations have rather good plans for universal healthcare, these various plans by internists, family practitioners, etc. will be ignored, whereas a more broadly agreed upon plan well worked out in advance and presented to legislators and other representatives will, especially if the media are involved, be taken seriously. To our everlasting shame, the two largest associations of bioethicists in this country have refused to take a stand. One of these organizations finally voted that it would begin taking stands, but not on things that concerned the population at large -- only on university conflicts, salaries, and other things that profit the organizations' members but fail to help patients or society.

As I watched EBM protocols develop, I was struck by the willingness of intelligent people to be regimented. At the various meetings, the nature of EBM protocols and their potential for abuse were not the topic of discussion. Rather, physicians were narrowly concerned that a particular antibiotic could be used, etc. They failed to see the looming threat that these "helpful guidelines" of today would become the straightjackets of tomorrow that must be obeyed. And, when 2 or 3 years later this is exactly what happened, they grumbled. But because it was "the system" they were not at fault. Soon they even gave up grumbling and, the more thoughtful of them, being thoroughly disenchanted, retired early.

Some years ago, a hospital which was the main teaching hospital at a university where I once taught started to draft protocols for certain diseases. I happened to be present when a pneumonia protocol was agreed to, and I was mystified that sputum cultures were not part of the protocols. Hesitatingly (since I had not done "hands-on" medicine for some time) I asked about this lack and was told that "of course, they should be part of the protocol but they're generally done wrong anyway." Unbelievably bad logic, but there was an algorithm as to what to do and what to order. What I fear is that physicians will give in to this "system error" and, instead of fighting the system, simply comply. Instead of writing a set of orders, physicians may -- after a brief examination, which certainly confirmed pneumonia but missed greatly enlarged axillary nodes -- simply write down "pneumonia protocol" and go home. Patients are individuals, and while statistics are critical to good practice, they cannot be used on an individual patient who not only may fall anywhere on the Gaussian curve but who also happens to have any one of a number of illnesses that should properly modify the protocol.

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