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Evidence-based medicine: ethically obligatory or ethically suspect?
  1. Mona Gupta, MD CM
  1. Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada;

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In the pages of Evidence-Based Mental Health and elsewhere, authors have argued that it is ethically obligatory to practice evidence-based medicine (EBM).1–,3 The argument in favour of this position begins with the assumption that EBM is more able than other strategies to provide us with accurate information about the effectiveness of medical interventions. Accurate information is essential to making clinical recommendations that will be effective in optimising our patients’ health. Optimising patients’ health is a basic ethical duty for medical practitioners. Therefore, the most accurate information—delivered by EBM—is required for practitioners to fulfil a primary ethical obligation. Similarly, knowingly using less accurate information is less likely to optimise patients’ health and is therefore inherently unethical.

This ethical argument relies on an epistemological assumption—that EBM provides us with a more reliable way of knowing than pre-EBM medicine. To date, there is no body of evidence, although there are case examples, demonstrating that EBM is more able to generate accurate medical information than pre-EBM medicine. Furthermore, it is also uncertain whether EBM achieves its ultimate goal of improving patient health compared with previous modes of practice. In the absence of such evidence, EBM relies on this ethical argument to support—and indeed demand—its use.

Because EBM’s ethical rationale depends upon the correctness of its epistemological assumption, the assumption must be capable of withstanding scrutiny before one is ethically obliged to practice EBM. In EBM, as the name suggests, it is evidence upon which medical practice is based and it is evidence that will improve the accuracy and reliability of our knowledge. Thus, in order to test EBM’s epistemological assumption, it is essential to understand how EBM defines “evidence”.

In the authoritative accounts of EBM, “evidence” is never formally defined, but is implied to be quantitative data obtained from research studies—preferably …

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