Posted on December 4, 2017
In this blog I want to explore the question of what moral values underpin or justify the practice of evidence-based medicine (EBM). For example, we might be interested in patient outcomes, patient choice, economic factors, public health, or a combination of these. It matters because this provides the standard for evaluating the success of EBM, and informs us about how we can make EBM better. In particular, I want to respond to a recent paper by Anjum and Mumford on ‘A philosophical argument against EBM’ , which argues that the values underpinning EBM inevitably collapse.
Utilitarianism is the view that, when faced with a moral dilemma, we ought to act according to which of our options causes the greatest amount of overall wellbeing or happiness, and the least amount of suffering. Rule utilitarianism specifically looks at which rules, heuristics or policies are able to do this, rather than looking at each action individually . In the context of medicine, this means we should aim to create healthcare policies which promote the best standard of health for the greatest number of patients.
An important aspect to this approach is that these policies do not always create the best possible benefit for the patient. In some cases, the guidelines will be ineffective. For example, a given treatment may be recommended in general cases of patients with an illness, but in the case of a particular patient we know it would be harmful. It’s just that having this policy in place for all patients is worthwhile overall. How we respond to such scenarios poses a problem for the rule utilitarian.
Here, we might still say that the treatment recommendation is a good guideline (because it maximises patient health) but in this case, it would seem unethical to prescribe the treatment in the knowledge that it will cause harm. We therefore probably want to say that even good evidence-based guidelines have exceptions. However, this risks compromising the whole point of rule utilitarianism – if we have a set of rules which determine how we should act, but we can contradict or find exception to these rules whenever we need to, what’s the point of having those rules at all? It seems we haven’t said anything that won’t dissolve back down into the more general utilitarian principle of maximising health, regardless of what rules/policies we create .
This way, policies which are based on EBM can offer us guidance for how a practitioner should act, but nonetheless require a practitioner to use their own judgement and common sense in applying them.
I want to respond to this paper by contesting the authors’ initial premise that EBM implies a kind of rule utilitarianism. I would suggest that, if we seriously look at our medical policies, conventions and laws, the picture is in reality far more complicated than this.
To see why this is the case we need to bear in mind that utilitarianism is not the view that ‘consequences matter’. Everyone cares about what the outcomes of their actions are, and pretty much everyone agrees that it’s generally better to cause happiness rather than suffering. What makes utilitarianism unique is the view that only these consequences matter, meaning there are no values that should influence our actions other than the impact that the action will have on other peoples’ lives. For example, this suggests that there is nothing wrong with lying, coercion, torture or manipulation, except for the fact that they can have bad consequences.
Whether these non-utilitarian values should have any significance from a moral perspective is beyond the scope of this article.
An adult patient requires medication for a fatal illness that they are at significant risk of contracting. However, due to their religious beliefs they refuse to take this medication because it contains an ingredient derived from animals. This refusal is clearly bad for them – they have a high chance of dying if they don’t take the medication. A week after the patient saw her doctor and refused to take this medication, she has a small accident and is taken to hospital unconscious.
In a stroke of luck, the same doctor who saw her a week before is passing her ward. The doctor knows the patient’s medical history and knows there is no chance of the patient having an adverse reaction to the medication which she refused. The doctor (a utilitarian) decides to take the opportunity, while the patient is unconscious and while there are no other patients around, to administer the medication to her, without her consent. The doctor has done something good for the patient – she has potentially saved her life, and there is no chance of being found out.
I hope we would agree that in this case the doctor has done something unethical. She has clearly ignored the patient’s own wishes and values, violated her right to consent and openly deceived her. Of course, a rule utilitarian could always avoid stating the uncomfortable conclusion that the doctor was ethical by deferring to policies – it’s better for everyone if we have policies and regulations against doctors deceiving patients, for example. This conclusion seems pretty unsatisfactory however. This suggests that the only reason this doctor’s actions are unethical is because she has violated hospital regulations. There would be nothing wrong, in this view, with creating a law which allowed doctors to deceive patients if only it had desirable consequences for the overall health of patients.
What’s ultimately at issue here is the patient’s right to decide how to live her own life – according to her own values, judgements and preferences, which may not always align with a medical model of what a healthy patient looks like. The role of the doctor is not to decide on a set of desirable outcomes for the patient and enforce them on her; rather, it should be to help the patient to determine her own ends, insofar as her health affects this.
These non-utilitarian values also play a role in the literature on EBM specifically. For example, an article from the Evidence-Based Medicine Working Group in 1992 defends EBM on the grounds that it gives patients a clearer understanding of their prognosis, diagnosis and treatment/s . According to their argument, deferring to clinical intuition or expertise, risks leaving patients “in a state of vague trepidation” about their health prospects and choices. By contrast, the openness about evidence which EBM encourages, offers the patient a more transparent picture of their expected outcomes and options. EBM in this way doesn’t just aim at increasing positive utilitarian outcomes, it can also have benefits from the perspective of the patients’ rights, autonomy, and choice.
 Anjum RL and Mumford SD. A philosophical argument against evidence-based policy: Philosophical argument against EBP. Journal of Evaluation in Clinical Practice. 2017,October;23(5): 1045–1050. doi:10.1111/jep.12578
 For an explanation of the difference between act and rule utilitarianism see: Utilitarianism, Act and Rule | Internet Encyclopedia of Philosophy
 This is a version of an argument by Smart. Smart JCC (1973) An outline of a system of utilitarian ethics. In Utilitarianism: For and Against (eds J. C. C. Smart & B. Williams), pp. 1–74. Cambridge: Cambridge University Press.
 Hooker B. (1995) Rule-consequentialism, incoherence and fairness. Proceedings of the Aristotelian Society;95:19–35.
 Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine A New Approach to Teaching the Practice of Medicine. JAMA. 1992 November;268(17):2420–2425. doi:10.1001/jama.1992.03490170092032