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 Continue reading →
The conclusions of a ‘citizens’ jury’, reported recently in the British Medical Journal  shed light on some important weaknesses in the doctrine of ‘informed consent’. The doctrine is commonly thought of as canonical. Be careful about questioning its exalted status: you’ll be branded paternalistic at best, and the indictment may well involve unflattering comparisons with Dr. Mengele.
The ‘jury’, composed of 25 women, commented on how a leaflet on breast cancer screening should be re-drafted. The jury preferred:
- the term ‘overtreatment’ to ‘over-diagnosis’
-to express benefits in the language of lives saved rather than deaths avoided
- to talk about ‘benefits’ and ‘risks’ rather than ‘pros’ and ‘cons’
- to begin the leaflet by an up-beat reference to the numbers of lives saved by screening, followed by the caveat that a small number of women would be over-treated.
What was the priority: reassurance or accuracy? The majority (15), wanted both; 3 thought that reassurance was most important; 7 thought that accuracy was the priority.
How should one list the benefits and harms? Four thought they should be listed together in the same sentence, 8 that they should be listed separately, and 12 for mentioning them first separately and then together.
The point of all this is that there are innumerable different ways, all of which would be smiled on by Bolam , in which entirely accurate information can be conveyed. And yet tiny nuances are seen by the receivers of the information as significant. Continue reading →
‘Patient L’ is a man in a vegetative state, under the care of Pennine Acute Hospitals Trust. The Trust has placed a Do Not Rescuscitate order in his notes, yet his family claim that he himself would want to be revived if his condition deteriorated, because of his faith in Islam. The court of protection has now decided in favour of the Trust.
The Trust’s claim is that it is in Patient L’s best interests to be allowed to die, whereas Patient L himself – if we are to believe his family (and there seems little reason not to) – would almost certainly disagree. Continue reading →
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