Evidence-Based Medicine – Necessary but not Sufficient

The passionate proponents of the idea that the public should be “protected” from any kind of healthcare approach that has not been, or cannot practically be, evidenced by RCTs or similar statistical methods, i.e. does not fall into within the usual understanding of the term “evidence-based medicine”, seem to be rather short-sighted.

It can be convincingly argued that in public policy, robust evidence of effectiveness for large groups needs to be at the heart of prescribing guidelines, especially if treatments are publicly-funded. However, that is a very different thing from justifying eradication or harassment of practices that do not, or cannot, meet the criteria laid down for strong evidence at large scale. It is also likely to be unwise to block public funding in measured quantities for the support and research of success in those fields of unorthodox care by whichever metrics are most helpful in truly gauging their usefulness.

To put this another way, if your job is to deliver acceptably effective treatments for a population of 60 million from a single budget, and that population is largely not committed to maximising preventive and health-enhancing behaviours, then you must largely rely on blunt instruments. The blunt instruments in this case are the kinds of surgical and pharmaceutical interventions that need extensive safety-checking and closely-specified and standardised delivery. Of course 95%+ of the budget will go on these methods and checking which ones are statistically measured as most effective regardless of the practitioner or the patient behaviour. But while doing so, it is necessary to keep in awareness that this is, by definition, not a gold standard of healthcare. The gold standard involves the active collaboration of patients (or ideally potential patients in a preventive context) and a provider-base that is more educator than technician, to minimise interventions in the first place, keeping them as early and gentle as possible where needed.

There are a number of points to the argument that the EBM-only approach can never fully provide what we want from a healthcare system, and here are some of them:

  1. Most fundamentally, as Karl Popper pointed out philosophically, and as we observe casually every day, life processes are emergent, generating new permutations of conditions all the time. At a large scale this means, even with a challenge like Covid, plenty of experimenting and trying out intuitions at the early stages, before any large-scale evidence is gathered. At the individual scale, for a large percentage of doctor-interactions where there is no obvious diagnosis, the person may not experience that as a satisfactory ending. In many such cases, the support of healthcare providers operating outside the mainstream is sought out. Sometime later, if the person feels their problem has been solved, we cannot infer reliably if that support did or did not play a role in the resolution of the problem. It is not enough to talk about all such results being explained by ‘reversion to the mean’ (“statistics say you’d have got better anyway”) as those statistics are after the fact. The stats are entirely ignorant around the amount of change that occurs due to personal reflection, lifestyle adjustment, informal consultations and evidence-free interventions.
  2. Treatments that have effects regardless of the context they are offered in, and with or without patient engagement, are usually things we would prefer to be able to do without. This can be acute, such as surgical interventions, or less so, as with long-term pharamaceutical maintenance and their inevitable side-effects on our biochemical homeostatic processes. The undesirability of medical interventions of this type stacks up for anyone who has reached a chronic stage where multiple treatments and their interactions promote a decline in health. Economically too, the consequences are devastating. In the US, the cost of maintaining a comparatively low level of wellness by allowing healthcare to be like a product market (i.e. selling more treatments must be better) is plain to see, and now eats up nearly 20% of GDP. Personal self-care stands obviously outside of this category, and is the ultimate early-stage medical intervention that is constantly keeping us out of doctors office and hospitals. But there is the necessity for another ‘layer’ here, and that is where the informal sector of practitioners, whose methods indeed seem to range from the sublime to the ridiculous, come in and provide support that is benign enough to be unregulated. These methods usually build greater mind and body awareness for the patient, and in many cases will employ devices and substances in these endeavours, that are equally non-injurious, notwithstanding the occasional and often over-hyped exception.
  3. Health intervention has no objectively agreeable final metrics. There are certain assumptions normally made about extending physical life unless there is radical suffering, and up until a certain age, and even some sophisticated measures like ‘quality-adjusted life-years’ for doing cost-benefit analysis on treatments. But at the non-critical level, there is very little possibility of measuring the trade-offs between suppressing symptoms and allowing them to serve as a message for life changes. It should be obvious that such trade-offs exist and are almost universal. At a large scale, Covid again gives us an example. UK government had little interest in promoting good diet and lifestyle while the lifestyle-related diseases were mainly slow-burn ones such as type 2 diabetes (despite the massive economic cost and quality of life reduction). When it became clear that good lifestyle might be protective against death from a rapid-action infectious disease, this changed quite fast. At the individual level, in a free society, where the public healthcare system has defined a given recommended treatment for a given symptom, the public need access to practitioners who are willing to instead help them explore the root cause, the psychosomatic aspects and the lifestyle and mental adjustments that would allow them to be free of the problem at deeper level.
  4. There is huge evidence that the physical reality we project onto living beings is not as solid as it is comfortable to believe. Placebo effect is a term normally delivered in a derogatory manner when something responds to a treatment that has no clear physical causative mechanism. In reality though, perfect placebo response should be the idealistic goal of every healthcare system. Investigating and creating the conditions under which ‘spontaneous healing’ occurs is the rational ultimate goal of medicine – everthing else is messy. So whether it is the ‘real’ effects of sham surgery, or finding that a consultation with someone whose methods seem crazy makes the necessary change for you, this is sustainable healthcare at its best and it needs our investment, rather than being shunned.

Having recognised that EBM cannot ever deliver the healthcare system we would truly want, even while it is good at addressing acute problems and rolling out solutions at scale, we can allow ourselves the intellectual freedom, without fear of being branded as anti-science or otherwise deluded, to work out how to fill the gaps.

Those gaps can be filled by looking deeply at the relationship-centred care provided by the alternative health sector, and considering what the role of the various methods practised there really is. Often they are not what they seem, particularly if your primary view of a human being is as a biomechanical system that will respond like a machine. Practitioners in these fields often demomstrate a level of intuition that would be well beyond writing into a diagnostic manual, and this is partly what orthodox medicine has been losing due to excessive standardisation and technician-mentality.

It is to be hoped that those parts of the medical profession, associated academia and pressure groups that have made it their goal to eliminate a diverse range of practices might soon get wise and instead choose engagement on terms that don’t leave out the question of what healthcare is really for. In many cases they will meet practitioners who are among the most subtle observers of the human condition, and observe the possibility of resolving health issues with far less dollars and drama.