Ethics and evidence-based medicine

To the Editor: Comments made by Parker et al1 in response to Leeder and Rychetnik's article on evidence-based medicine (EBM)2 do not reflect the reality of the dilemmas clinicians face in practice — arguably, because of political misuse of the concept of EBM, which Leeder and Rychetnik warned against.

Parker et al take issue with the "worry that EBM might be misused in public policy . . . where evidence is difficult to obtain", and argue that this is not the case. However, the previous Health Minister, Dr Wooldridge, was a great admirer of the Cochrane Collaboration, and, based on a perceived lack of evidence, he cut Medicare rebates in 1996 (by 50%) for patients needing long-term intensive psychiatric outpatient treatment. Although, after much protest, this decision was amended somewhat, Item 319 of the Medical Benefits Schedule remains today as a stark reminder of how some patients cannot access fully the treatment they desperately need.

There is abundant evidence (international and local) as to the efficacy of this form of intensive treatment.3 There is also abundant and clear evidence that all who seek this treatment are traumatised by previous failed shorter treatments, often have comorbid disorders, and have established DSM-IV diagnoses of long standing.4 All this evidence was made available to the Minister — but Item 319 remains, with its exclusionary and discriminatory criteria to ration access, in my opinion due in large part to political misuse of the concept of EBM. Contrary to the assertion of Parker et al, there is a great deal to worry about.

In addition, Parker and colleagues make the claim that mental health is attracting government attention and funding. Again, in reality, a great deal of money is being spent on promoting education and awareness — and certain kinds of treatment. There is no evidence that short-term treatments (which are heavily promoted) actually help the group excluded by Item 319 regulations. Yet public policy is being pushed along the lines of "one size fits all". It does not.

All this is evidence of misuse of the idea of EBM reflected in public policy, and patients are suffering as a result. To make matters worse, cuts in one area are mindlessly used to push agendas that in clinical reality will be unworkable in other areas — all of which devalues professional expertise and judgement.