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A critical appraisal of evidence-based medicine: some ethical considerations

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  • This paper has relied on the two in-depth English language accounts of EBM that are published in book form (Evidence-Based Medicine: How to Practice and Teach EBM, and The Users’ Guide to the Medical Literature). However, EBM is undergoing ongoing revision through debates in the medical literature. Due to space constraints, this paper has not included proposed modifications of EBM in the analysis unless they contradict what is contained in the two main sources.

  • The Users’ Guide to the Medical Literature, written by the Evidence-Based Medicine Working Group and edited by Guyatt and Rennie, is also considered to be an authoritative account of EBM. There is some authorial overlap between the books and there is consistency in content. Sackett et al.'s basic definition of EBM was chosen as he is considered by many to have been the original and leading proponent of EBM in its current form.

  • The primacy of N-of-1 clinical trials assumes that there are pre-existing valid research studies that permit an intervention's use in practice.

  • There are new versions of the hierarchy being developed. See for example: http://cebm.jr2.ox.ac.uk/docs/levels.html.

  • If EBM cannot demonstrate its superiority empirically, then it should argue in favour of its use using philosophical arguments. That is, EBM should demonstrate why the particular empirical methods it espouses are the most likely basis for drawing truthful conclusions.

  • Numerous scholars have suggested the inclusion of other research methods into the evidence hierarchy, whether they are qualitative (Green & Britten 1998; Barbour 2000; Dixon-Woods et al. 2001; Upshur 2001) or conceptual (Berkwits 1998). The JAMA Users’ Guide does contain a chapter on critically appraising qualitative research, which suggests EBM's nascent openness to these concerns.

  • Positive results are results that show that there is a statistically significant difference in the effect of the study intervention as compared with the control intervention. Negative results are results that show that there is no such difference.

Dr M. Gupta Department of Psychiatry 3G Clinic Hamilton Health Sciences McMaster University Medical Centre Hamilton, Ontario L8N 3Z5 Canada

Abstract

Evidence-based medicine (EBM) is a concept that has grown to dominate the medical literature over the last decade. EBM has provoked a variety of criticisms, scientific, philosophical and sociological. However, while its basic conclusion – that we should practise EBM – is ethical, there has been limited ethical analysis of EBM. This paper aims to provide an analysis of EBM from an ethical perspective and identify some of EBM's potential ethical implications. Following a description of what constitutes EBM, this paper will identify and assess some of the basic values and epistemological assumptions of EBM that provide support for the moral duty to practise EBM. It will then examine potential ethical implications that could arise from practising EBM, given the challenges that have been made of EBM's assumptions and claims to authority. This paper will conclude by arguing that practitioners could strengthen the ethics of EBM by embracing a broader definition of evidence and including ethical criteria in the critical appraisal of research studies.

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