The Doctor's (Ethical and Economic) Dilemma

Sackett, D.L.

August 1996

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In this OHE lecture Professor Sackett sets out a compelling case for evidence-based medicine to be at the core of a comprehensive, tax-funded NHS that enjoys the confidence of the whole population. He also sets out his personal view as to how the conflict between a doctor's responsibilities to each individual patient and to society can be minimised and managed, but not eliminated.

Myths abound as to what evidence-based medicine is, and as to who will win and lose from its acceptance. Some myths take as a starting point the view that evidence-based medicine is an attack on the medical profession. Professor Sackett explains why this is not the case. He sets out very clearly that the practice of evidence-based medicine involves 'integrating individual clinical expertise with the best available external clinical evidence from systematic research'. He cites audits that show that good clinical teams are already providing evidence based care to the majority of their patients, it is not 'cook-book' medicine that threatens professional judgement. This is because individual clinical expertise 'decides whether the external evidence applies to the individual patient at all, and if so, how it should be integrated into a clinical decision'. It is not cost cutting — applying 'the most efficacious interventions to maximise the quality and quantity of life for individual patients' may 'raise rather than lower' the cost of their care.

We can therefore move on to confront another set of concerns that assume evidence-based medicine is part of a fight back by the medical profession against politicians, managers, economists and others who are seen as wanting to erode the power of the medical profession. Professor Sackett is clear that it is not a cover for complacency on the part of doctors. 'Without current best external evidence, practice risks becoming rapidly out of date'. Any thought that most doctors already practice evidence-based medicine 'falls before evidence of striking variations... in the rates with which we provide interventions' which cannot be justified by differences in patient characteristics.

He acknowledges that there will be conflicts between evidence-based medicine (which is about the 'conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients') and group objectives of making the best use of limited health care resources ('optimising the total cost-utility in that group'), noting that his offering 'of specific health care manoevres to my patient may contradict distributive justice (the fair, equitable, and appropriate distribution of benefits and burdens to everyone)'.

On this relationship between evidence-based medicine and issues of cost effectiveness and rationing, Sackett is both thoughtful and thought provoking. He argues that he, as a doctor, recognises the need to ration care and society's right to do this. Indeed lie has willingly participated in committees tasked to draw up restrictions, and argues for more information on the cost-utility of manoeuvres to inform these processes. He as a doctor will accept the resultant 'restrictions on access rules' it they are relevant to his patient and if they are ethical. However, as a doctor he must reserve the right to decide whether the rationing rules are ethical. In effect he is saying that the doctor cannot become merely a tool of society. Whilst we hope rationing in the NHS will be ethical, in other health care systems it may not be — the human rights of some groups may be denied. Society does not want its doctors to always do what they are told by the government, their professional ethics are part of our freedoms. Moreover, even if the 'rules' have been drawn up ethically, there will still be dilemmas that the doctor must have the right to resolve in favour of the patient.

This is an uncomfortable message for many health economists and managers who may fear that this approach can be hijacked by physicians who do not want their autonomy eroded by rationing decisions. However, it may well be that only by recognising and respecting the conflicts caused by the responsibility of the doctor to his or her patient, that consensus on approaches to rationing can be achieved. Indeed Professor Sackett sets out how these dilemmas can be minimised, notably by the generation and use of more information on effectiveness and cost-utility, to expand and restrict care, depending on evidence.

I believe that he is right. No sensible debate about the resourcing of the NHS, rationing (priority setting), or the cost-effectiveness of treatment can be conducted in the absence of a medical profession committed to the provision of evidence-based care. No discussion about restricting the availability of treatment can ignore the need to devise rules and processes that reconcile rationing with the commitment we expect of doctors to individual patients. As Professor Sackett concludes, an evidence based NHS that has rooted out ineffective treatments, and that is transparent about how conflicts between giving every patient the best treatment, and meeting society's overall health care needs are handled, is more likely to have both public confidence and public willingness to pay the taxes needed to fund it.