Transcript Document

The Ethics of
Evidence-Based Psychiatry
Mona Gupta MD CM, MA, FRCPC
Departments of Psychiatry,
University of Toronto &
Women’s College Hospital
Lakefield Conference on
Ethics & Mental Health
July 6, 2007
Acknowledgements
I would like to acknowledge, with gratitude,
1) the generous support of the people of Canada,
through the Canadian Institutes of Health
Research which funded this research
2) my doctoral thesis committee: Ross Upshur
(supervisor), Bill Harvey, Lynne Lohfeld, and
Lawrie Reznek
3) Dr J Maher
Context
‘Today, no therapeutic method will be fully
accepted unless supported by randomized
controlled trials. In other words, understanding
disease and treating patients increasingly are
dominated by an evidence-based approach.’
Paris (2000) CJP, Vol 45, p.34
‘…the only ethical practice in [child] psychiatry is
one that uses the principles of evidence-based
medicine.’
Szatmari (2003) EBMH, Vol 6, p.1
Key Question
Does evidence-based medicine
(EBM) provide psychiatry with
the ethical support it seeks?
Contents
I. What is evidence-based medicine (EBM)?
II. The ethics of EBM/EBP
III. The ethical debate about psychiatry
IV. What ethical issues are unresolved, or
created, by EBM/EBP?
V. EBP & Spirituality
VI. Conclusions
I. What is EBM?
Definition
Evidence-based medicine
requires the integration of
best research evidence with
our clinical expertise and
our patient’s unique values
and circumstances.
Straus et al, 2005, 1
EBM describes itself in various
ways:
• EBM is...a ‘philosophy of medical practice based
on knowledge and understanding of the medical
literature supporting each clinical decision.’
• ‘...a practice whose goal is forming a diagnostic
and therapeutic alliance between doctor and
patient as a means of optimizing clinical
outcomes and quality of life.’
(Straus et al, 2005)
EBM describes itself in
various ways
• EBM is about ‘clinical decision-making,’
• EBM is about ‘solving clinical problems.’
• ‘…the goal is to be aware of the evidence
on which one’s practice is based, the
soundness of the evidence, and the
strength of inference that evidence
permits.’
Guyatt et al 2002
What is evidence?
‘best research evidence’:
‘… we mean valid and clinically
relevant research, often from the
basic sciences of medicine, but
especially from patient-centered
clinical research…’
Strauss et al 2005, p. 1
What is evidence?
‘…any empirical observation
about the apparent relation
between events.’
Guyatt and Rennie, 2002, p.6
Evidence Hierarchy
(for studies of therapeutics)
• N of 1 randomized controlled trial
• Systematic review of randomized trials
• Single randomized trial
• Systematic review of observational studies
addressing patient-important outcomes
• Single observational study addressing patient
important outcomes
• Physiologic studies
• Unsystematic clinical observations
Guyatt and Rennie, 2002, p.7
II. The Ethics of EBM/EBP
Why should we practice EBM?
There is no scientific answer to this question.
EBM’s/EBP’s scientific superiority and therefore,
greater effectiveness in improving patients’
health are assumed to be true.
Valid, quantitative data = evidence

Increased certainty about healthcare interventions

Improved health outcomes
The “Bottom Line” of EBM
Assumption of EBM
If we pursue EBM we arrive at the most effective
means of achieving the best health outcomes
+ Values of EBM
We ought to pursue the most effective means of
achieving the best health outcomes.
---------------------------
= Ethical conclusion
We SHOULD adopt EBM because it is the most
effective means of achieving the best health
outcomes.
What is morally relevant to
EBM?
Three specific consequences:
• improved health
• decreased harm
• improved cost-effectiveness
• (‘convenience’ is also mentioned but I don’t
consider this to be a moral consequence)
Ethical Critiques of EBM
EITHER
accept the
goals, but
challenge
EBM’s ability
to achieve them
OR
question the
exclusivity of
EBM’s ethical
goals
Critiques challenging EBM’s
ability to meet its ethical goals:
• Scientific (methodological)
• Philosophical (related to the logic of RCTs,
or concept of evidence)
• Sociological (e.g. source-of-funding bias)
Are there critiques specific to
psychiatry?
Mildest argument
“Many studies are inapplicable to real clinical
(psychiatric) practice.”
Moderate argument
“EBP is useful for some psychiatric interventions
(medications) but not for others (social or
psychotherapeutic interventions).”
Strongest argument
EBP is not applicable to psychiatry because of the
unique features of psychiatric disorders
Does EBM apply to psychiatry?
Prognostic Homogeneity
• Not possible in psychiatry because of the
criteria-based method of diagnosing psychiatric
disorders
• Randomization cannot solve this problem since
the group is not uniform
Quantification of Outcomes
• Can numerical ratings capture/convey meaning?
Critiques of EBM/EBP:
questioning the ethical goals
• EBM/EBP could lead to inappropriate
reduction of patient/practitioner choice
• EBM/EBP has the potential to lead to
unjust cost-cutting
• EBM/EBP favours the authority of the
research community over other
communities
III. The ethical debate
about psychiatry
Psychiatric classification
(or diagnosis)
a) inappropriately pathologizes
human differences
b) facilitates the social control of
deviance
Psychiatric treatments
a) even if well-intentioned and/or
scientifically-based, do not help,
or even do more harm than good
b) are inappropriately imposed
involuntarily
c) are malevolently imposed
involuntarily
How does EBP enter the ethical
debate about psychiatry?
1. Improve health: EBP tries to improve
mental health by determining what
treatments work better.
2. Decrease harm: EBP tries to decrease
harm by identifying which treatments
don’t work as well.
IV. What ethical issues are
unresolved or created by
EBP?
Ethical Problems Unresolved
• EBM obscures the normative aspects of
psychiatric diagnosis. e.g. it attempts to
objectify both the description and
measurement of psychiatric symptoms
• EBM obscures the normative aspects of
treatment. e.g. it presumes agreement on basic
values, like what constitutes ‘good mental
health’ and how to achieve it
• EBM’s implicit moral mandate sidesteps the
issue of the legitimacy of involuntary
intervention
Ethical Problems Created
1. EBP is vulnerable to the same ethical
critiques as EBM
2. More particularly for psychiatry, EBM is reshaping which voices and problems our
discipline privileges.
(e.g.behaviours vs experiences
meds vs non-pharmacological therapies)
V. EBP & Spirituality
Is there a moral obligation to address spiritual
needs of patients and their caregivers?
Dr D Sulmasy, CBS, June 1 2007
“…Patients are not just bodies…Patients are first and
foremost persons. Persons are oriented to ask
transcendent questions. When ill or dying, persons ask,
“What does this mean? What do I mean? Is there any
meaning in my suffering?” When ill or dying, persons
ask, “What is my value? Do I have any dignity or worth?
Is my value to be found only in my social contribution,
now limited by my bodily condition? Will I have value
that perdures beyond the grave?” When ill or dying,
persons ask, “How does this affect my relationships with
others?… Will my relationships somehow continue when I
am no longer living?”
Dr D Sulmasy, CBS, June 1 2007 cont’d
“These are spiritual questions. They arise
for people of all faiths and for people of no
faith. Illness occasions such questions.
And science cannot answer them. The
better medical technology has become,
the more alienated and frightened patients
have become…. A medicine that fixes
bodies like machines but ignores the
transcendent questions that are integral to
the personal experience of sickness and
death is no longer a healing art.”
Can EBP address questions
of spirituality?
Not in a meaningful way. Why not?
1) spiritual questions cannot really be addressed
through EBM-preferred research
2) even if you could do EBM-preferred research on
interventions related to spirituality, what is the
meaning of the data?
e.g. imagine that an RCT demonstrates that
attendance at weekly formal religious observance
improves scores on a symptom rating scale in
women with major depression.
VI. Conclusions
1. EBM/EBP is fundamentally and ultimately a valueladen enterprise, however much it sidelines this
aspect of its practice. It justifies itself using an
ethical argument.
2. Although some psychiatrists hope that EBM will lend
scientific/ethical credibility to psychiatry, this is
unlikely to happen because EBM’s foci are too
narrow to provide either a sufficient scientific or
ethical basis for psychiatry.
V. Conclusions cont’d
3. Psychiatry could address its ethical challenges
using ethical arguments, rather than by
substituting science or evidence for moral
justification.
4. The same could be said for including a spiritual
dimension to clinical care. It must be defended as
a good in and of itself, regardless of its impact on
health outcomes. Be wary of an ‘evidence-based
spirituality.’