Ethics, philosophy, and evidence based medicine.

T his symposium is devoted to evidence based medicine (EBM) and the ethical issues it raises. Since Sir Archie Cochrane’s seminal Nuffield Provincial Hospitals Trust lectures in 1972 and their publication as the Rock Carling monograph for that year, Effectiveness and Efficiency: Random Reflections on Health Services, the idea that medical interventions and health services should be evaluated and selected on the basis of the most reliable evidence available for their effectiveness and cost effectiveness has become very widely accepted. 2 This widespread acceptance has not been complete, and it sometimes seems that there are as many critics of EBM as advocates. Whereas the importance of randomised trial evidence, critical appraisal, metaanalysis, and systematic review cannot be overestimated, the extent to which they comprise a panacea is open to question. The questions of how far EBM is able to answer questions of policy and value, and how far EBM is itself a value laden project, remain hotly debated. How can rational and ethical medical care and health policy be made in the absence of ‘‘perfect’’ evidence? How can we incorporate patient or community views into decision making? When does the search for evidence lead to problems of research ethics? How well founded is the claim that ‘‘evidence’’ gives us knowledge in the first place? The papers in this issue were prepared under the auspices of the EVIBASE project. EVIBASE was a three year collaborative project funded by the European Commission to examine the ethical and philosophical issues underlying the theory and practice of EBM. The project involved theoretical research and empirical inquiry, with the latter concentrating on a series of country reports on the status of EBM in different European countries, the United States of America, and Australia, and interviews with key individuals involved in health policy, health services, medical research, and the Cochrane Collaboration. Some earlier results from the project have been published elsewhere. Those earlier papers concentrated on the role of EBM as a tool in health policy and health systems reform. The present papers concentrate on medical practice and research. The papers by Lie, Vineis, and Ashcroft examine the foundations of EBM in clinical research. Ashcroft and Vineis consider the logical, epistemological, and metaphysical foundations of clinical research evidence, wherease Lie considers how far EBM and health policy depend upon the randomised controlled trial, and how far trials are useful in making resource allocation decisions. The issue of the relationship between EBM and health care management is taken up by Biller-Andorno and colleagues, and by Rogers. BillerAndorno discusses the relationship between EBM and decisions to fund treatment, whereas Rogers looks more widely at its implications for justice. Similar issues are taken up by Berghmans and colleagues in their contribution to the final group of papers, on ethics and EBM in the case of cases often thought to present difficulties for evidence based approaches. Berghmans and colleagues discuss the case of psychiatry; Slowther and colleagues look at general practice; Ernst and colleagues discuss complementary and alternative medicine; Stirrat considers surgery; and Vos and colleagues examine the case of ‘‘orphaned fields of medicine’’. The message of many of the papers collected here is of moderated scepticism. There is scepticism because there are serious philosophical and analytical problems yet to be overcome in delivering on the promise of EBM. There is moderated scepticism because EBM offers tools and concepts which do offer practical approaches to the challenge of a rational practice of medicine and health policy which are superior to most of the available alternative approaches. To question the foundations of a discipline or a practice is not necessarily to deny its value, but rather to stimulate a judicious and balanced appraisal of its merits; we offer the present selection of papers in that spirit.