Ambiguity-based evidence

I still ask myself whether medicine has anything to do with ethics or whether it does not. Ethical considerations, after all, are derived from philosophy, usually reflecting the values held by a community, often dictated by community leaders or religious authorities, economic considerations, and majority opinion. This implies that ethical values differ from culture to culture and evolve over time. Medicine, on the other hand, applies natural sciences, which do not respect the worth or the meaning of an event, but deal with normal distribution and the standard deviations therefrom. Thus, a patient is seen as an organism rather than as a person. And when statistical analysis is applied as part of stochastics, the patient is reduced even further to a member of a sample.

Whenever exact knowledge is missing there is plenty of room for myths and fairy tales. Although these are mainly for children, we all know, and may still believe in, fairy tales for adults, such as honesty is the best policy, you can get rich by working hard, the boss is the most competent person, and so on.

We find everywhere a type of organization (administrative, commercial or academic) in which the higher officials are plodding and dull, those less senior are active only in intrigue against each other, and the junior men are frustrated or frivolous (Parkinson CN).

Evaluating data scientifically has brought more accuracy to evidence-based medicine. But even the best external evidence available does not make up for personal clinical expertise.

Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients (Sackett DL).

To determine how binding scientific evidence is, the Cochrane Society has devised a ranking system.  Meta-analyses and prospective studies involving thousands of patients are regarded as being close to the truth, whereas case reports and small case series are deemed to be of less significance.

We know that emotions are ambivalent. But is rational thinking, too? Does not every yes, even when it comes from the bottom of the heart, still include a little no? While fact finding may be objective, the interpretation of facts is not.

A conflict of interest may exist when an author (or the author’s institution or employer) has financial or personal relationships or affiliations that could influence (or bias) the author’s decisions, work, or manuscript (Flanagin A).

Does this suggest there are no conflicts of interest when no financial or personal relationships or affiliations influence (or bias) the author’s decisions, work, or manuscript? Regardless of whether market forces favor the superior marketing strategy or subsidize an inferior strategy, there are always conflicts of interest, preference at the least. I can understand that companies and businesses that finance scientific research are not happy when study results question the quality and efficacy of their products. I can understand that researchers who earn a living in the conduct of scientific work do so as a courtesy on the part of their employers. And I can understand that freedom of opinion can test the limits of social acceptance. That something is true does not make it welcome or socially acceptable. In particular, criticism that may soil one’s own nest is generally not tolerated. Furthermore, hypocrisy and euphemism constitute integral parts of a state’s self-image. Praise, regardless how exaggerated, is welcome, if not expected. High-ranking personages of church and state institutions, particularly those of a military or judicial nature, are often resistant to impartial reflection. The bestiality of militarism is perceived mostly in the conduct of our enemies, as long as we assume we are the good guys. We all tend to recognize backwardness and narrow-mindedness in countries we think less of than in our own country. Chauvinism limits objectivity. Freedom of opinion can exist only in the absence of censorship, but what about freedom of scientific research?

Freedom of scientific research and publication might need a national board of scientists or an ethics committee with executive power to intervene in cases of wanton discrimination (Lederer W).

Criticism, even when constructive, hurts. Scaremongers are not appreciated; and public rage may quickly turn against those who first point their finger at the grievance. Isolating boat-rockers is a merciful form of punishment practiced by those who know that is is difficult to hold one’s own on the edge of a society. And when the angry crowd demands more than humiliation, the victim must not bleed.

It is a cardinal principle that if you are injured, either by accident or by intent, you must not bleed. Experience shows that bleeding prompts an even more aggressive attack and will often provoke the participation of sharks that are uninvolved or, as noted above, are usually docile (Cousteau V).

Growing up implies learning how to lie. Lying is creative and requires more complex brain functions than telling the truth. As a general rule, people prefer well-dressed lies to the naked truth. But with reduced alertness, lying becomes more difficult, as shown by the Latin proverb “in vino veritas”, implying that alcohol may diminish the ability to lie. By contrast, substance abuse may increase an audience’s gullibility.

We lie in the lap of immense intelligence, which makes us receivers of its truth and organs of its activity. When we discern justice, when we discern truth, we do nothing of ourselves, but allow a passage to its beams. If we ask whence this comes, if we seek to pry into the soul that causes, all philosophy is at fault. Its presence or its absence is all we can affirm (Emerson RW).

An institution’s reputation may seduce readers to be less cautious about trusting scientific paradigms. But does being more famous also mean being closer to the truth? To win a war is to be stronger, not necessarily to be morally or culturally superior. Preoccupied interpretations by those who write or read about historical events increase the ambiguous and biased nature of historical truth. The history of scientific research is also the history of scientific misapprehension. Evidence is influenced in its scope by our momentary viewpoint.

While the philosophical-normative orientation allows important questions to be raised regarding the quality and appropriateness of evidentiary sources, evidence-based health policy also restricts thinking on evidence-based decision-making to narrowly defined scientific evidence, neglecting the role context plays in impacting on what constitutes evidence (Dobrow MJ).

This has the potential to be a solution. On the other hand, it might just be the beginning of another fairy tale. Who can know for sure?

 

References

  1. Ralph W. Emerson, “Self-reliance”, http://www.emersoncentral.com/selfreliance.htm
  2. Voltaire Cousteau, “How to swim with sharks: a primer”, http://www.apor.org/html/how_to_swim_with_sharks.htm
  3. David L. Sackett, “Evidence-based medicine”. Seminars in Perinatology. 21( 1) (1997): 3–5.
  4. Wolfgang Lederer, “The freedom of scientific research and publication: what price do we pay?,” Acta Anaesthesiologica Scandinavica 50(3) (2006): 394.
  5. Annette Flanagin, Phil B. Fontanarosa, Catherine D. DeAngelis, “Update on JAMA’s Conflict of Interest Policy,” JAMA. 2006;296(2):220-221.
  6. Cyril N. Parkinson, “Injelititis, or palsied paralysis,” in Parkinson’s law, and other studies in administration, ed. Houghton Mifflin (The Riverside Press. Cambridge-Massachusetts, USA, 1957) 77.
  7. Mark J. Dobrowa, Vivek Goelb, R.E.G. Upshurc, “Evidence-based health policy: context and utilization,” Social Science & Medicine 58 (2004) 207–217.

 


 

WOLFGANG LEDERER, MD, DTM&H, CTCM&H, completed medical school at the University of Innsbruck, DTM&H and MSc(CTM) Mahidol University; Physician at Ampil Nong Chan Hospital/ Site II, Thai/Cambodian Border, from 1987-89; CTCM&H University of Liverpool; Med. Superintendent Rushere Community Hopital, Uganda, from 1992-95; since 1996: Specialist in Tropical Medicine and Hygiene; since 2002: Specialist in Anaesthesiology and Critical Care Medicine, Module coordinator medical training in Emergency Medicine; since 2008: Associate Professor in Anaesthesiology and Critical Care, Innsbruck Medical University. He is married with 5 children.

Highlighted in Frontispiece Winter 2014 – Volume 6, Issue 1