In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.
Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”
On those counts, I must plead guilty as charged. I have been trying to sink that baby for a number of years now, attacking it from a variety of angles. I have made a special plea in favor of small data and I have even questioned the intellectual sanity of EBM. On the question of the coexistence between EBM and clinical judgment, I have been decidedly intolerant, relegating EBM to second class citizen status. In other words, I’m an unapologetic EBM-denialist which, as I found out yesterday on Twitter, puts me in the same category as climate change skeptics.
My main concern today, however, is to address the relationship between EBM and the free-market, and to reject Andrew’s point that EBM is somehow compatible with it. First, though, let me say that in no way do I deny the notion that American medicine has, for decades, harbored practices of highly doubtful benefit to benefit to patients, and that many such practices may, in fact, have been dangerous or harmful. I am fully on board with any effort to eradicate “eminence-based medicine.”
But before we reach out for an EBM solution to that problem, perhaps we should first wonder about causes. What keeps the errors of eminence-based medicine persisting for so long? Why do patients and doctors remain so wedded to a course of therapy as to blithely engage in unbeneficial or even harmful care?
If I read Andrew correctly, he seems to believe that these errors persist because outcome uncertainties are inherent to clinical care, hence the need for EBM. But that cannot be the fundamental reason. Why would patients continue to pursue a treatment for which they have neither objective nor subjective tangible benefit? Why wouldn’t they refuse to go along? After all, many of them do exercise their ability to be non-compliant in the case of treatments deemed beneficial to them according to the truths of EBM!
Outcome uncertainty, then cannot be the reason why futile or harmful treatments persist, and if outcome uncertainty is not the reason, reducing it by way of EBM may not be the answer either.
What eludes Andrews is that eminence-based medicine is not simply the result of individual doctors exercising judgment with limited knowledge. Rather, eminence-based medicine happens when doctors apply their own pet theories and disregard the needs and wants of the patient at hand.
By missing that point, Andrew misses that eminence-based medicine is precisely minimized by the free-market and, on the contrary, encouraged by government intervention. The history of American medicine provides ample examples to make that point.
In the late nineteenth century, healthcare in the United States was uniquely unregulated. Yet, contrary to common belief or fabricated myths, care was improving by leaps and bounds, getting at once better, cheaper—and more scientific. It is during that time that some of the finest medical institutions emerged, including the Mayo Clinic and the Johns Hopkins Hospital. Sure, there were snake oil salesmen, but these were by-and-large being driven out of business by a growing community of serious, well-trained, and effective physicians. And competition among these practitioners kept them humble and at the service of patients.
All of this changed in the 1910’s when, following the Flexner reforms, state licensing laws were enacted. It is in the heels of these laws that medical paternalism emerged.
As an illustration, consider this passage excerpted from an official report published soon after the enactment of licensing laws:
The physician is the outstanding practitioner of medicine. The need and the value of his service sets him above all others. He alone, of all types of medical practitioners in the United States, is permitted by law to diagnose and treat all diseases and conditions and to use (with certain minor exceptions) any form of diagnostic or therapeutic technique which he considers necessary, desirable, and within his professional skill. (Report of the Committee on the Cost of Medical Care, 1928, p. 195)
From that point onward, medical abuses of privilege became much more widespread than they had been.
Furthermore, as Kenneth Ludmerer has pointed out, this elevation of the physician to the status of demi-God by government fiat went hand-in-hand with the rise of the academic ivory tower, since academic medical schools were producing the “cream of the crop” among doctors. Academic ivory towers, naturally, become common sources of practices founded on eminence.
Of course, licensing laws and the emergence of the ivory towers are not the only factors to consider. Other government interventions soon followed to bring about systems of third-party payment for medical care—health insurance. Without these government interventions, and without the existence of licensing laws, it is unlikely that health insurance would have emerged from the free market. By unmooring medical decisions from any financial constraints, health insurance contributes immensely to the perpetuation of eminence-based practice.
It is this regulatory context, then, that is at the root of eminence-based medicine, and not the uncertainties of clinical care which, in a profound way, are inherent to the medical encounter.
Andrew believes that EBM discovery is akin to price setting on the free market. I strongly disagree with that analogy. As Andrew himself has noted, prices set in the free market convey consumer values and are the end results of myriad decisions made on the basis of dispersed knowledge.
EBM results, on the other hand, are statistical relationships between interventions and outcomes which are carefully selected by investigators in highly contrived experimental settings. In these settings, the choices and preferences of doctors and patients are ignored or neutered by design in order to isolate the relationship of interest. Any value obtained as a result of an EBM experiment is primarily imputable to the investigators or sponsors, and only secondarily (and statistically) of benefit to patients.
EBM is no free market phenomenon. EBM is an academic invention incubated in Canada, a country with a single-payer healthcare system! As I described in my article, this invention has spun out of control and has turned EBM into a weapon wielded with equal vigor by the pharmaceutical industry, by regulators, and by those who aim to equalize the historical excesses of eminence-based medicine through the dubious doctrine of “Less-Is-More.” None of these movements, it seems, are motivated by a desire to advance a genuine human science that is meaningful to individual patients. In fact, to the extent that is a pet theory which standardizes care for entire populations, EBM is eminence-based medicine on steroids.
But if EBM is by no means a product of the free market, can the free market address our need to improve therapeutic predictions or will it set us back to a clinical stone age?
So long as narrowing clinical outcome expectations is truly desired by doctors and patients—and there is no reason to doubt that it is—then the free market is demonstrably the optimal environment that can allow human ingenuity to devise clever ways and methods to achieve that goal. But what shape or form would those methods take and how closely would they resemble what we now take to be evidence-based science, I have no idea. If I believed I held that knowledge, I would be repudiating Hayek.