Ethics and evidence-based medicine

To the Editor: We consider that Leeder and Rychetnik make several mistakes in their exploration of the relationships between ethics and evidence-based medicine (EBM).1 We share some of their ethical concerns about the determinants of the research agenda — lack of consumer input, emphasis on the benefits of interventions rather than harms, and funding structures favouring commercially promising interventions or biased by the status of the methodology to be used. However, these are criticisms that relate to producing new research, not using available research.

The definition of EBM used by Leeder and Rychetnik2 values evidence that is non-quantitative, and explicitly demands the inclusion of patient preferences in clinical decision-making. Evidence about effects comes from research, while evidence about concerns and values comes from individual patients. To incorporate a patient's pre-ferences in the consultation is crucial to ethical practice, but quite independent of any particular hierarchy of evidence.

Similarly, in claiming that treatment may be denied those of low social utility if patient autonomy is not valued, they mistakenly confuse preference or value with the quality of the evidence. The sin of old-fashioned paternalism is falsely attributed to EBM. The suggestion that EBM can exclude the importance of patient narrative is also at odds with the authors' chosen definition, which emphasises the "identification and compassionate use of patients' predicaments, rights, and preferences".

Next, they worry that EBM might be misused in public health policy by neglecting areas where evidence is difficult to obtain, offering mental illness as an example. In fact, mental health attracts considerable attention3 and funding as one of the Commonwealth's current priority health areas.4 It has also been an area of considerable activity in EBM, with the Cochrane Mental Health groups and the BMJ's evidence-based summary journal Evidence-Based Mental Health. It may be that EBM has done the opposite of their prediction by highlighting an area of "evidence need".

We agree that patients require support when they confront ambiguity and uncertainty. Nevertheless, doctors are ethically and legally obliged5 to provide full disclosure. Patients should be given correct information — warts, uncertainty and all — as often as possible. To suggest that the time spent seeking evidence threatens other elements of clinical practice is misleading. Clinical practice requires judgement to balance all its competing demands. We suggest that, by increasing the efficiency of continuing education, EBM should actually release more time for other requirements.

Leeder and Rychetnik also misinterpret the relation between EBM and the law. They suggest that some practitioners who consult evidence, but practise against published guidelines, may be compromised. The point of EBM is to find the best available evidence. If that is clinical experience, consensus or narrative, rather than quantitative data, then so be it. Similarly, it is wrong to imply that those who practise EBM may be sued because they fail "to try everything". EBM, which is simply the getting of the best available information, changes nothing in the formal relationship between clinical evidence and the legal standard of care. Moreover, we believe that, by fostering patient involvement in decision-making, EBM should help protect clinicians from medicolegal dispute.

We are always at risk of using new tools overzealously. But the champions of EBM temper its promotion with words like "judgement", "incorporating patient preference" and "conscientiousness". EBM involves a sensible and systematic search for the best information to include in the decision-making process. Great care should be exercised in issuing warnings about how it might be misused, in case EBM becomes unfairly caricatured, which may reduce the motivation of health professionals to find and apply the best treatment.