The Perniciousness Of Evidence Based Medicine
Here, from Hugh Hewitt is the outline of Waxman’s health care reform bill. I’d like to specifically comment on the provision for “evidenced based medical practices.” And, to comment on how pernicious a practice that can be. Medicine in not pure science, rather it is more like engineering. It is a reflection that the human body is too complex to accurate model on the lab bench and expect those results from the lab to work in the day to day real world.
The best examples of this concept can be drawn from the world of engineering. One can create a small chemical reaction on the lab bench and prove out that a certain new material can be made, say a plastic. It can then be determined that this new material will have thus and such properties. And, those properties can be deemed desirable enough to make in large quantities for commercial purposes. But, miniscule variables, to small to be detected on the lab bench because of the small quantities involved, now become major problems in creating the same material on an industrial scale as you scale up from making a few ounces of this material to now making hundreds or thousands of pounds per hour of that same material.
One does not create a new aircraft merely by drawing a blueprint and going directly into production. You create models, test the aircraft in wind tunnels. Then you hand craft your first full scale model, the prototype. Then you take that prototype out for a first flight. Which amounts to taking the aircraft off and landing it. Just proving that the basic concept works.
Human bodies, like the examples cited above, involve the concept of the “black box.” Inputs go in and reactions/outputs come out. We, sort of know what happens inside, but not quite. Therefore, we carefully tweek the inputs until we get the desired outputs. Science may give you the ball park figures the basic inputs, but engineering empiricism makes the final adjustments. At every aircraft plant. At every chemical refinery. In every surgical procedure, in every operating room, every day.
The effects of Evidence Based Medicine will be the following. The most important would be to render vast stores of medical knowledge, knowledge that is the reflection of literally thousands of years of empiric experience, “suspect.” In fact, going back and instituting double blinded studies to brings this medical knowledge into the evidence based medicine” clubhouse would be immoral and unethical.
The ancient Egyptians knew that one treated a boil or abscess by incision and drainage. Penicillin was never involved in double blinded trials for bacterial meningitis. What was once a disease that had essentially a one hundred percent mortality was now cured by penicillin. Much of our modern knowledge in handling trauma came from our experiences in handling combat casualties from the Vietnam War. The appendectomy was invented about 120 years ago and has been a well established procedure for the once lethal disease, appendicitis.
And, now we’re going to double blind all of the above? Of course the all-wise solons who will run Obama care will avoid the bad publicity of denying antibiotics for bacterial meningitis sans a double blinded study. But, in the name of cost containment, there are a lot of more obscure treatments and diseases that can be denied for that reason. Because, absent the imprimatur of “evidence based,” these treatments can be denied because they are “experimental.”
The fact is that double blinded studies forever run against the constraint that you are purposely denying a potentially life-saving treatment to one half of the cohort you intend to test for efficacy of some new treatment. And, unless you truly do not know which alternative is indeed better, you are embarking on an unethical and immoral practice of medicine. Further, you must have provisions to break into the blinded study should you discover, mid-study, that one group is indeed benefiting. Yet, with hundreds of billions of dollars at stake, there will be plenty of temptation to start to cut ethical corners.
The second factor will be to freeze new treatments, procedures and drugs from ever making it to the market; to the patient. With the government controlling the purse strings, it will have an enormous financial incentive to not advance medical knowledge. With money controlled and curtained to test new advances, we have no way to meed the “evidence based” standard. And, absent that standard, empiric experience gets buried. Medical advances, for what they will be worth, will be few, highly selective and highly politicized.
Consider the parachute. This was a humorous article published in the British Medical Journal in 2003; but a profound commentary on the serious shortcoming “evidence based medicine.” It pointed out that the efficacy of the parachute had never been tested in a double blinded study. And, why not? People have survived falls from airplanes with out wearing parachutes. People have died despite the proper use of a parachute. Do people who choose to wear (or not wear) parachutes self-select? We have all sorts of variables left unanswered and yet we spend millions of dollars equipping our military pilots and paratroopers with these untested (from an evidence based perspective) devices. Maybe we should take the advice of the authors and put together a “double blind, randomized, placebo controlled, crossover trial of the parachute” for the advocates of evidence based medicine. Maybe Obama, with his cool faith in science, can volunteer his administration.