International Journal of Epidemiology 2003;32:672-673
© International Epidemiological Association 2003
Book Review |
Ethics and Evidence-Based Medicine: Fallibility and Responsibility in Clinical Science.
Kenneth W Goodman. Cambridge: Cambridge University Press, 2002, pp. 140, (PB) £19.95 ISBN: 0-521-79653-9, (HB) £55.00 ISBN: 0-521-81933-4.
A glance at the reference list of this book gives a clue of the reading pleasures ahead. In company with Archie Cochrane’s seminal work, Effectiveness and Efficiency, and a host of more recent references to evidence-based medicine and meta-analysis, we find Hume’s Tractatus, Peirce’s Collected Papers, and Wittgenstein’s Philosophical Investigations. Goodman handles this variety of sources with an easy confidence and in a concise and witty style; making this book a joy to read and review. He tackles the fundamental question of epistemology, why do we believe what we do, and not something else? This question is related to the ethical duty of health care practitioners to justify their clinical decisions—hence the imperatives and dilemmas of evidence-based medicine. Goodman pursues the fundamental question in a series of chapters dealing with the origins of evidence-based medicine, the emergence of systematic reviews and meta-analysis, and the revolutionary changes brought by the Internet and electronic data bases. All this is related to epidemiological research ethics, to clinical judgement at the bedside, and to public health policy decisions. A final chapter returns to the fundamental epistemological problem of finding evidential warrants for our beliefs. The author’s conclusion on this is worth quoting in full:
Throughout there has been a delicious tension between uncertainty—or the state of decision making in a probabilistic environment—and the periodic duty to act. It is clear that the decision as to whether, when, and in what way to act must be guided and shaped by the best available evidence. (p. 139)
In other words, we must learn to live with uncertainty, but that is no excuse for failing to use the best available tools for reducing that uncertainty, even while acknowledging that these tools are themselves open to criticism. With this bracing realism Goodman has provided an invaluable introduction to the ethical challenges of evidence-based medicine. If criticism were to be made of his approach, it would be that the ethical criteria on which he relies are largely implied, rather than fully explained and justified. We encounter words like ‘duty’, ‘virtue’, ‘moral imperatives’, but at no point are we offered a sustained ethical analysis, which might link these terms together, The only reference to ethical theory is an appeal to David Hume’s notion of moral convention or agreement, but the limits of such an appeal are not discussed. However, I am not sure whether it matters that in this book the ethics is largely implicit. I regard it as more an essay on the philosophy of science than a systematic treatment of ethics. The author’s own ethical stance is best conveyed by his summary of the final chapter in which he concludes that ‘ethical practice is, in large part scientifically sound practice’ (p. 129). That is certainly the consistent message of the book as a whole.
This work will appeal to a variety of readers—to epidemiologists and clinical scientists concerned about the uncertainties of scientific evidence, to clinicians worried about the information explosion and the conflicting messages coming from the scientists, to philosophers interested in both epistemological and ethical issues in medicine, and even to the ‘ordinary’ reader, who just wants to understand how modern medicine uses science to aid clinical decisions. I commend it, without reservation, to this whole range of potential readers, and can see it as a valuable text in undergraduate medical education, as an antidote to the naïve scientism of much that is taught to future doctors.
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