Medical ethics are ridiculous
In a blistering letter in the current issue of the British Medical Journal, Miran Epstein identifies some of the factors we should consider in assessing the claims of so-called ‘evidence-based medicine’. Nobody rationally disagrees with the suggestion that medicine should have an evidence base, and everybody should agree that in order for medicine to be based on reliable evidence, it should be free of the following ‘polluters’:
- financial conflicts of interest
- inadequately rigorous selection criteria, outcome measures and criteria of statistical significance
- the practice of testing products against placebo or no treatment (rather than current treatment), and then shouting ‘Eureka!’
- recruiting subjects using financial incentives that introduce outcome bias
- marketing campaigns masquerading as research
- research agendas driven by corporate interests rather than patient needs
Yet there’s such pressure on clinicians to be able to assert that their treatment is ‘evidence-based’ that they, in desperation, often give the magic ‘EBM’ endorsement without asking whether the underlying evidence is sound. This has some important ethical corollaries, as Epstein observes. The zeitgeist:
‘…does not regard polluted information as a sufficient condition for rendering disclosure inadequate. Thus it reduces informed consent to a legal fiction and respect for autonomy to a cynical farce.’
I must have written many tens, and very possibly hundreds of thousands of words about informed consent. The journals of medical ethics and medical law are packed full of earnest discussion about informed consent, with long, careful footnotes citing Pico della Mirandola and Hume and Kant and Singer. We’re all so punctilious about our philosophical nuances, and so savage in our peer reviews when we see someone who has overstated the reach of Chester v Afshar or sided too brazenly with Lord Diplock in Sidaway.
Yet isn’t all this care, in the light of the facts, rather ridiculous? Isn’t it classic Titanic deck-chair rearrangement? With (usually) the best of intentions on the part of their clinicians, patients are routinely being fed clinically dangerous misinformation. In the light of a scandal like that, it doesn’t much matter what model of autonomy you’re using, or whether you’re into patient consent or assent or shared decision-making.
It’s unrealistic to expect individual clinicians to conduct an audit of the integrity of the origins of all the information they give to their patients. They have to rely on the summaries they get in the literature.
Journals have a role to play. They need to look beyond the bland and banal declarations of competing interests by authors and peer reviewers, and to look actively for the shady corporate men in suits who stand behind the researchers. But journals can’t do it all. We need a cynical, skeptical, well-funded, well-staffed and ideologically very left-wing regulator. With huge teeth.
M. Epstein ‘Wanted: humanistic medicine’, BMJ 2014; 348:g1133 (1 February 2014, p. 23)