No Method, Thus Madness?

By Caplan, Arthur L. | The Hastings Center Report, March-April 2006 | Go to article overview

No Method, Thus Madness?

Caplan, Arthur L., The Hastings Center Report

If you ask most medical school deans if they have a course, program, or center doing bioethics, they will enthusiastically assure you that they do. And their enthusiasm for bioethics grows exponentially in proportion to their interest in showing that they are doing something about managing research ethics issues at their institutions. The same can be said about the entire biomedical research establishment--from private companies to independent research centers to professional organizations--bioethics is on the masthead, the organizational chart, and the agenda of the annual meeting. Not to worry--medicine's got ethics.

It is certainly fine to feature bioethics as a topic area. But there is mounting evidence that perhaps bioethics is not all or even primarily what the doctor should be ordering just now. Some of the problems now ailing medicine require admitting that what has befallen medicine and the health sciences is an epistemological crisis as much as a moral one.

Now this may seem an odd claim since it is hard, or rather, completely impossible, to avoid the phrase "evidence-based medicine" in the august halls of academic medical centers in the United States, Europe, Australia, and New Zealand these days. There are journals, resource centers, toolkits, web sites, and more publications than anyone interested in evidence-based medicine could possibly ever read.

So how could it be that a field that is embracing evidence at every turn, teaching about outcomes, drilling the need for verifiable data into the heads of the next generation, and extolling the virtue of evidence at every conference, meeting, seminar, and water-cooler, possibly be in the midst of an epistemological crisis? Where is the evidence?

Contemporary medicine is sailing on very rocky seas these days. It is being buffeted by ever-rising costs, doubts about its efficacy, and intrusions on its turf from competitors that range from optometrists, psychologists, chiropractors, midwives, and nurse-anesthetists to the friendly folks at the herb and vitamin store. Recently, there seems to be real uncertainty on the part of medicine's leaders about what to say in the face of a continuing stream of fraud and misconduct. The editors of the Lancet, Science, Nature, and the New England Journal of Medicine--the key guardians of the evidence gates--face a stream of questions about how they plan to secure the gates following the shenanigans of the South Korean researcher who lied about producing stem cells from cloned human embryos and a Norwegian cancer researcher who fabricated findings about ways smokers could reduce their risk of acquiring oral cancer, and their tortured agonizing is painful to watch. Far from having an answer to the question of what distinguishes medicine as a mode of healing and a field capable of minimizing fraud, the leaders of the medical professional cling to the phrase "evidence-based medicine" as if intoning the word "evidence" will act as a talisman to keep all the troubles at bay.

But the fervency of the embrace of evidence-based medicine reflects a deeper and much more serious problem among the stewards of medical knowledge--a crisis of faith in the methods, processes, and checks and balances that have, at least since the nineteenth century, been the infrastructure that has permitted medicine to make the transition from an art to a science. Consider the response to the recent battle over what to do about fetal pain.

In the August 24, 2005, Journal of the American Medical Association, an article claimed that a review of all the available published medical evidence showed that fetuses do not feel pain until they are at least seven months old. The JAMA article appeared at a time when efforts are underway in Congress and state legislatures to use the topic of fetal pain as a way to discourage women from seeking elective abortions. The JAMA article contended that there is no medical evidence showing that fetuses can feel pain at twenty weeks. …

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