Sydney Ross Singer, Medical Anthropologist
7/22/24
Evidence Based Medicine, or EBM, is the new catchphrase suggesting that healthcare goals can be better reached by using the best research available to inform doctors and patients. But consumer beware! EBM is another power grab by the pharmaceutical industry, and is more about censoring alternative treatments than anything else.
The assumption in the term “evidence based medicine” is that current medical care is not based on solid scientific evidence. And this is surprisingly true. Much of the time, things are done because of tradition, or due to effective marketing of a product. Medicine, after all, is an “art”, not a science. Doctors “practice” medicine, learning on each patient. Knowing what to use for a treatment is really guesswork, as the doctor cannot know how a particular patient will react to any particular drug or therapy.
The art of medicine also requires that doctors understand the cultural underpinnings of medical complaints. Humans are complex social organisms with lots of cultural impositions on the human body and mind, with often striking health consequences. Humans also have powerful minds that can create and cure disease through sheer willpower. These are called the placebo and nocebo effects, where people experience health impacts from positive or negative expectations. Doctors must interpret disease through not only a biological lens, but also with an eye on socio-cultural factors and personal expectations and beliefs. And doctors must filter out their own prejudices and biases, and ascertain those of their patients, too, in order to mitigate personal subjectivity and best develop the most effective treatment plan.
The art of medicine also includes knowing the science of medicine and how the body works. And this is where evidence based medicine comes into the picture, trying to turn medicine from an art into a science.
According to proponents of EBM, medical care is too diverse as an art, with different doctors employing different treatments for the same condition. According to EBM, medical care should rely on the best available evidence, which would standardize treatment for people with a similar condition.
Using EBM, a doctor is supposed to ask a specific question about their patient’s condition, and then do a literature search to see what studies have addressed that condition. These studies are then ranked according to reliability, with large reviews and meta-analyses taking priority over single studies, which take priority over a doctor’s opinions or experiences. Statistical conclusions based on large sample sizes are valued over case studies of specific examples. Studies of the effectiveness of different treatments are to be used to determine the best treatment option. Even an artificial intelligence program can treat disease using this algorithm.
This sounds like a good way to fight against pseudoscience and medical charlatans. There is no doubt that scientific information can benefit medical decision-making and weed out useless and harmful treatments. But there is a fly in this EBM ointment.
Here are some of the problems with EBM:
1. All research studies need funding. Funding research is an economic and political issue. It’s the art of business to know what studies to pursue, since research is very expensive. But the results can be extremely profitable, which drives the research agenda forward. This means that studies are done for profit motive, not for scientific plausibility. Lots of plausible theories are ignored, and research into these theories goes unfunded, because of economic realities and pressures, not because of their inherent worth and potential as theories.
2. If there is no research into a particular medical treatment or approach, then EBM would disallow its use. Doctors are supposed to base their judgments on solid research evidence. If there is no evidence, there can be no scientifically-justifiable reason for pursuing that approach. However, this says nothing about the benefit of that unstudied approach. It could be the best approach to treatment, but without data and evidence to support its use, the medical industry will say that there is no support for that approach, and will ignore it. They equate lack of studies to lack of validity or medical worthiness.
This means that new ideas and treatments will be discarded, ignored, or labeled as pseudoscience if there are no studies to back them. Note that this is not the same as having studies showing these alternative approaches are bad. EBM excludes anything that is not studied, and assumes that if it has not been studied, then it is not valid. This allows EBM to refute as pseudoscience anything that has not been scientifically studied.
3. By relying on funded research for all medical advice, EBM censors any alternative theories or treatments that are economically threatening to the scientific status quo and have, therefore, not been studied. By ignoring a subject for research funding and attention, those who control the EBM agenda can monopolize medical care. If doctors cannot use any treatment that has not been studied scientifically, and is backed by lots of statistical analyses, then medical practice can be limited to only those treatments and theories which the EBM proponents find profitable to research. This will limit development of new medical approaches and theories, and stifle medical advancement. Whoever controls the search for evidence controls medicine, and controls all the people who seek medical care.
4. This EBM model tries to strip the art out of medicine in the name of science, but we need to look at the quality of the science used by EBM. Unfortunately for everyone seeking medical care, most of the research used by EBM comes from studies done on rats, mice, dogs, cats, monkeys, and other non-human creatures unfortunate enough to be exploited as research subjects. Animal research is a central component of modern medicine. In the search for scientific data, researchers have discovered that it’s easier to experiment on helpless animals than on litigious humans. This requires that scientists develop “models” of human disease in these poor non-human creatures. Every imaginable harm and disease that humans can experience is studied by simulating those harms and diseases in non-humans. This is shaky science, with false equivalences between species, and results of unknown application or relevance to humans. This is admitted by animal researchers, or vivisectors, who know that human trials are needed to assess human responses. But it’s easier to test treatments for simulated diseases in animals than it is to do so in humans. The results may be scientific and repeatable. But they are of unknown relevance to healthcare. And yet, such inhuman and inhumane evidence is used by EBM to “scientifically” determine the best treatment for a human. Animal studies are lumped in with human studies, and the result is pseudoscience, not human medical science.
Reliance on animal models completely overlooks the cultural factors that make us human. Unlike other animals, human biology is modified by human culture. You cannot understand people and their diseases without addressing cultural factors that influence health. Lifestyle is known to be the cause of most human diseases. You could not understand this from animal studies. Mice in a cage are not the same as humans in a city, even if you genetically engineer the mice to have diseases that look similar to human disease. This is not valid medical science.
Proponents of EBM will respond to this charge by saying that it is up to the doctor to assess the validity of all research. Each doctor is supposed to read every study, including meta-analyses and reviews of large numbers of studies, to assess their validity. Of course, this defeats the purpose of review articles, which EBM places at the top of the information food chain, which pre-digest large amounts of research to save busy people the time of doing it themselves. In reality, then, doctors will accept what these review articles say without much reflective or critical thought, despite the ideal of an independent medical thinker that the EBM envisions.
Of course, EBM proponents will also defend animal research, and say it is central to medical research. Indeed, vivisection, with all its cruelty, psychopathology, and cross-species confusion, is central to medical research, just as an evil mind is central to a lie. But it doesn’t make it good science. Is science ever good when it involves cruelty? And can you trust those doing cruel science?
5. Even without human studies, reliance on large studies and statistical models to determine the best treatment for a given patient is the definition of impersonal medical care. It’s what medical care would look like when dispensed from some AI robot, which may be in the near future. Artificial Intelligence models, like ChatGPT, can access medical research and dispense treatment prescriptions, but is will be based on many animal studies of dubious validity, selected from a pool of studies that have been designed to promote certain healthcare products. This will create the same treatment for the same problem in different people, even if it isn’t the best treatment. The best treatment may have been censored and ignored for research studies due to lack of economic potential.
For example, a 38 year old male with back pain may be prescribed a pain reliever, and perhaps also a muscle relaxant, since there are lots of studies looking into pain relief with drugs. Just rest might help, too, although rest alone as a treatment is rarely studied by drug-focused research. Given little research about the benefits of rest, evidence based medicine has no evidence to support resting as a solution, so it will not be considered. The EBM model would search the medical literature for this problem, looking for the appropriate solution — but will ignore other modalities, too, such as chiropractic adjustments of the spine, which may solve the problem immediately without drugs or rest. Literature on the use of acupuncture or meditation to resolve back pain may exist, too, and may prove effective, but it is not something medical doctors do for patients, so it will not be part of the treatment options considered. Doctors of medicine use medicine. Chiropractors, herbalists, acupuncturists, naturopaths, massage therapists, physical therapists, and other healthcare modalities are competitors with drug-prescribing doctors. If you go to a drug doctor, expect a drug solution, and the research they will rely on will be about drugs, not other non-drug options.
As you can see, EBM is really a marketing tool by drug companies, designed to limit treatment options to focus on drug solutions that make money. It tries to turn medicine from an art into a science, but it’s the science of how to make money on disease.
Realize that science is merely one method for systematically searching for information. If the assumptions are wrong, then the results will be useless, and could be harmful if believed and put into practice. Scientific research must plumb the depths of our ignorance while we are still ignorant. All the data in the world will not yield helpful treatments if the assumptions beneath that data are wrong. And you don’t know if this is the case until you try it on people.
This means that statistics can point in a direction, but you don’t know if it is a false lead until you try it in a case study. EBM values statistical studies with large populations over small case studies of individual people, but in the end, the case studies are the proof. At least, they are the proof for the individuals studied in the case. It may not be the same for others. Not everyone is a data point at the center of the statistical curve. In other words, not everyone is “normal”, in a statistical sense.
In summary, EBM is a marketing ploy used by drug companies to promote their products and exclude any information or treatment that is not profitable, or is a threat to current profits. By demanding that treatment be based on scientific evidence, it excludes any approach that has not been funded for research. Literature searches are limited to drug-oriented modalities, so that alternative approaches, even those with studies to back them, are not included in the search. This is how drug companies maintain their medical monopoly. Make medicine rely on studies that show only one way to do things. Create a monoculture of medical treatment, where only the profitable treatments see the light of day.
As you can see, EBM is managing the opposition to the pharmaceutical model of disease and treatment, and maintaining control over the way doctors practice, and what alternatives patients are offered. It may keep out some quacks who prescribe treatments with no valid scientific or medical support. But it’s a quackery of its own, a faith in “science” that is based on economics and animal torture.
What people need is to develop the art of finding effective healthcare. People need to use their intuition and survival instincts to negotiate this medical quagmire of misleading animal studies and biased research agendas.
Living a healthy life is an art that no corrupted EBM science can replace. We are not machines, like the AI robots that will soon dispense EBM prescriptions. Humans are complex, culture-defined, often irrational, highly emotional, mostly ignorant, and sometimes self-destructive animals. Any science humans will come up with will reflect the subjective and self-serving nature of the human animal. There is no pure science, devoid of human impurities.
We must accept that doctors are guessing the best they can, that the science they use is shaky at best and changes radically over time, and that each person is a unique, culturally-defined being, not a data point. It means that medical care is an art by necessity, despite the attempts by drug companies to turn medical care into a one-size fits all treatment approach that can be dispensed by a robot, and which feeds the corporate bottom line.