Evidence-based medicine

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Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients. Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to groups of patients and populations ("evidence-based practice policies"). It has subsequently spread to describe an approach to decision-making that is used at virtually every level of health care as well as other fields (evidence-based practice).

Whether applied to medical education, decisions about individuals, guidelines and policies applied to populations, or administration of health services in general, evidence-based medicine advocates that to the greatest extent possible, decisions and policies should be based on evidence, not just the beliefs of practitioners, experts, or administrators. It thus tries to assure that a clinician's opinion, which may be limited by knowledge gaps or biases, is supplemented with all available knowledge from the scientific literature so that best practice can be determined and applied. It promotes the use of formal, explicit methods to analyze evidence and makes it available to decision makers. It promotes programs to teach the methods to medical students, practitioners, and policy makers.

Criticism

One of the most important reference institutions for "evidence" in conventional medicine is the Cochrane-Collaboration. A study is considered credible if it has received a positive Cochrane review. Recently, the objectivity and trustworthiness of this authority has been questioned by a competent authority: Peter C Gøtzsche; Professor, Director of the Nordic Cochrane Centre, MD, DrMedSci, MSc, in a letter dated 14.9.2018, informs that he had been dismissed from the Governing Board of the Cochrane Collaboration on the basis of a minority vote because he had allegedly damaged the organisation's reputation. As a result, 4 other leading Cochrane leadership members resigned immediately, reducing the Governing Board from 13 to 8 members within one day.

In his letter, Gøtzsche states, inter alia: "This growing top-down authoritarian culture and an increasingly commercial business model that have been manifested within the Cochrane leadership over the past few years threaten the scientific, moral and social objectives of the organization. ... There is stronger and stronger resistance to say anything that could bother pharmaceutical industry interests. ... There has also been great resistance and stalling on the part of the central executive team to improving Cochrane´s conflict of interest policy. A year ago, I proposed that there should be no authors of Cochrane reviews to have financial conflicts of interests with companies related to the products considered in the reviews. This proposal was supported by other members of the Board, but the proposal has not progressed at all. .... Our work informs government legislation globally, it influences medical guidelines and drug approval agencies. Therefore, the integrity of the Cochrane Collaboration is paramount. We pride ourselves on being global providers of “trusted evidence” on a foundation of values such as openness, transparency and collaboration. However, in recent years Cochrane has significantly shifted more to a business - a profit-driven approach. Even though it is a not-for-profit charity, our “brand” and “product” strategies are taking priority over getting out independent, ethical and socially responsible scientific results. Despite our clear policies to the contrary, my centre, and others, have been confronted with attempts at scientific censorship, rather than the promotion of pluralistic, open scientific debate about the merits of concrete Cochrane reviews of the benefits and harms of health care interventions. ... As most people know, much of my work is not very favourable to the financial interests of the pharmaceutical industry. Because of this Cochrane has faced pressure, criticism and complaints. My expulsion is one of the results of these campaigns. What is at stake is the ability of producing credible and trustworthy medical evidence that our society values and needs."

In simple terms, Peter C Gøtzsche, one of the co-founders and most renowned members of the Cochrane Collaboration, notes that the current leadership of this globally active institution has lost its independence from industrial interests and that members who indicate this problem or write reviews and reports containing unwanted criticism are bullied. Since this process described here is just the tip of the iceberg and an incalculable number of expert opinions already issued will be affected, the reliability of these must generally be questioned. The so-called evidence-based medicine thus lacks a central argumentative pillar.

 

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