Academic journal article The Hastings Center Report

Daddy Will Make It Better, Even If It's Arthritis

Academic journal article The Hastings Center Report

Daddy Will Make It Better, Even If It's Arthritis

Article excerpt

The recent announcement that arthroscopic knee surgery is objectively no better than a placebo control should cause little surprise. Most of our currently accepted surgical techniques have never been validated in prospective, randomized, double-blind, placebo-controlled clinical trials, and therefore many things are done to many patients in the firm belief that they are the best treatment for the patient's condition, without clear and objective evidence that the belief is true.

The finding should raise doubts about the efficacy and scientific status of surgical intervention and particularly of high-tech surgical intervention. Indeed, it identifies an endemic problem in any enterprise that has elements both of science and of craftsmanship, and where the system one is working on is so complex that sometimes one might be guided by higher-order pattern recognition skills, or intuition, just as well as by statistical evidence.

In surgery, what tends to happen is that a new technique or device comes onto the market and is promoted as the best way of doing this or that operation, and the logically prior discussion of whether the operation in question ought to be done at all is finessed away. There is then a domino effect whereby the company conveys to the surgeons that its new technique is the new best practice standard, younger surgeons see mastery of the technique as distinguishing them from older surgeons, and surgeons who use older techniques are swayed into "updating" (or even "upskilling") their practice.

The move toward "evidence-based" medicine is a powerful corrective to these tendencies, but introduces problems of its own. Evidence-based medicine necessarily attends to studies that use valid statistical methods. These studies collect data from multiple patients, who typically meet inclusion criteria-based on fairly simple objective indicators of a disease process. Yet the condition might in fact be quite complex, and manifest itself in many different ways in individual patients. …

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