We supposedly live in an era of “evidence-based medicine,” in which medical decisions are guided by the published data. But that approach is now being criticized because the “best evidence” is often in the eye of the beholder.
A new approach seems to be aborning — so-called science-based medicine. What is the difference? It seems more than a mere shift in terminology, in that science-based medicine would allow fewer heterodox approaches than permitted by the evidence-based model.
A new advocacy article, “Evidence-Based Medicine Is Broken but Science-Based Medicine Can Fix It,” published by the American Council on Science and Health (which claims to debunk “junk” in medicine), explains (emphasis in the original):
The idea of evidence-based medicine has been around since the 1980s, and the term was officially coined in the 1990s. It arose from the realization that medicine was highly dependent upon the individual specific physician and heavily influenced by pharmaceutical companies’ marketing. . . .
While this was a well-intentioned step forward in the philosophy and practice of medicine, as is often the case, naïve researchers, bad actors, and ulterior motives have found a way to corrupt this standard of treatment. Given laws of large numbers and how they act, you can find evidence for just about anything. Since the shorthand and practice of evidence-based medicine is often “Is there any evidence at all,” the answer is often yes, regardless of scientific rigor or plausibility.
This is the large hole in EBM’s paradigm that has been exploited, as exemplified by America’s Frontline Doctors. You can find evidence that ivermectin and hydroxychloroquine are effective treatments and prevention for COVID-19. However, just because evidence exists does not make it good evidence or scientific fact.
The author, Katie Suleta, suggests a more straight-jacketed approach:
The good news is we can tweak evidence-based medicine to plug the hole. SBM takes the best parts of evidence-based medicine and expounds upon them. Science-based medicine is
“the use of the best scientific evidence available, in the light of our cumulative scientific knowledge from all relevant disciplines, in evaluating health claims, practices, and products.” – Science-Based Medicine Blog
SBM considers the scientific plausibility of a claim, practice, or product along with what is already known, blending them to assess the plausibility of claims. SBM considers replication, statistical noise, p-hacking, the use of controls, and methodology. Science-based medicine takes us from cherry-picking studies that constitute “evidence” to discounting poorly designed studies that cannot be replicated and may also be scientifically implausible. Add in the requirement of thoughtful review and consideration of methodologies and statistics, and science-based medicine goes from “there is evidence that hydroxychloroquine is an effective treatment for COVID-19” to “hydroxychloroquine and ivermectin don’t work against COVID-19.” That is the real difference between evidence-based medicine and science-based medicine.
Ethically, science-based medicine honors the patient’s implicit or explicit request for the best care available and helps them to make sense of overwhelming amounts of information. Especially in an era where disinformation circulates freely, science-based medicine is one of the best perspectives allowing us to sift through the myriad of claims and determine if they are even scientifically plausible. Science-based medicine raises the floor on the quality of evidence. It’s time we start using it.
That may sound reasonable, but it strikes me as actually seeking to impose methodologies approved by the medical establishment throughout the health-care system, and perhaps prohibit and/or punish heterodox thinking and interventions that run contrary to what the powers that be want. As in our recent public-health controversies in which we were told that “The science tells us!” or, “It’s settled science!”
Sorry, “the science” is rarely that cut-and-dried, and never “settled” — or it’s not science. Moreover, peer-reviewed studies deemed dispositive are often mistaken or wrong, a fact recognized by the editor of the Lancet back in 2015.
Here’s another problem. “Science” today has become depressingly ideological. Here are a few examples:
“Gender-affirming care” for children: The American medical establishment has gone all-in supporting immediate affirmation of a child’s feelings that he or she was born the wrong sex. We have been hammered repeatedly by argumentation that the off-label use of drugs such as puberty blockers — and even serious transition surgeries like mastectomies — are the “settled scientific approach” to caring for gender-confused children.
But this isn’t true. Indeed, a good argument can be made that the claim is ideologically rather than scientifically based. For example, many of these studies come from members of WPATH (World Professional Association for Transgender Health), which has an ideological (and financial) axe to grind by claiming that gender affirmation is “settled” science. And yet, these claims have been repeated ubiquitously in the world’s most prestigious medical journals, such as the New England Journal of Medicine, often without even mentioning that health authorities in socially liberal European countries have used evidence-based medicine to challenge that conclusion. Indeed, these countries recently backpedaled furiously against gender-affirmation in children, instead urging lengthy mental-health interventions. I suspect a “science-based” approach would preclude such policy shifts by imposing uniformity on a highly controversial and contentious field of medicine.
Covid: The Covid pandemic illustrates how politics can skew public health and, indeed, how the scientific method can be made subservient to ideology and the desire to exercise power. Thus, when three prominent epidemiologists from Harvard, Stanford, and Oxford published the Great Barrington Declaration questioning the societal lockdowns and keeping children out of school, they were subverted by Francis Collins and Anthony Fauci as “fringe,” with many efforts taken to discredit the declaration rather than openly debate it. (And remember how Fauci responded to criticisms of his recommended policies by claiming, “I represent science”?)
Similarly, vaccines were mandated for government workers because they supposedly prevented transmission, as the private sector was conscripted as workplace enforcers. This led to unnecessary job terminations that inflicted unnecessary harm to the military, hospitals, law enforcement, aviation, and other crucial sectors. Then it turned out that the vaccines don’t prevent transmission after all. Again, “evidence-based medicine” permitted the deployment of diverse policies, where “scientific-based medicine” could have imposed mistaken and misguided orthodoxies.
Embryonic-stem-cell research: During the great stem-cell debate of the early 2000s, we were told that it was “settled science” that embryonic stem cells are the “gold standard” for regenerative medicine and would soon allow people to get out of their wheelchairs and liberate diabetics from insulin. Heterodox thinkers who said that adult stem cells actually offered greater hope were castigated as “anti-science” and religious fanatics. And how did it all turn out? Twenty years later, the adult-stem-cell sector is growing, while there are zero FDA-approved embryonic-stem-cell therapies — meaning that invoking science-based medicine could have actually kept useful care from reaching sick patients.
Here’s the bottom line: Trust must be earned, not imposed. Information gatekeepers can be wrong. The danger of censorship in the name of “science” is growing. Claims of “disinformation” are often based on ideology and politics. We should welcome rather than stifle diverse thinking and robust debate in all matters scientific. But I fear that stifling debate would be the primary point of shifting from “evidence-based” to a supposedly “science-based” medical approach.