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Hi Neal, I think it s a bit disingenuous to talk about society accepting this that or the other, maybe the EBM movement has been hijacked by politicians/public health/drug industry to impose a view on an anxious and gullible public; and an ‘only too willing to conform’ medical profession! Bear with me but there are other ways of thinking about this: Zizek (Sublime Object of Ideology) explains how the Master-Slave dialectic/relationship between people (Lordship - Serfdom qv Hegel) has been displaced by a relationship between ‘things’, commodities that have different values. But this is only to ‘disguise’ (after Marx) that the master-slave slave relationship does in fact continue to exist even within our capitalist globe. He goes on to suggest that the fetishistic relationship between things exhibits the fissure, the moment of disguising reality and that this is an example of the symptom. I wonder if there is a symptom that society is ‘enjoying’ in relation to health and healthcare. I think there is. This can be thought of from either a societal or ‘subject’ perspective If the death/ill-heath/health spectrum is regarded as a commodity relationship. I wonder how this was perceived in the equivalent of feudal times. Fatalistically embracing illness, with the practitioner easing suffering but not expected to produce a cure with a flourish. Though of course treatments would be tried q.v. George IIIrd (bleeding/cupping etc etc). Survival against the odds and quality of life being the driving forces. For a subject there would be a relationship between two states : “I feel well” vs “I feel ill”. Is this fetishistic in any sense? I’m not sure….. Or “I feel well today …… I cannot imagine ever being ill. Or “I feel OK today but I know that illness awaits me unpredictably and I’ll embrace that when it comes but I’m not going to worry about it today”. Or “I feel well but I might get ill if I don’t take some action today.” This preventative action is the fetishistic fissure that disguises or separates the ‘real’ relationship between the subject’s current good health and his inevitable ill heath and demise by the ‘symptom’ that requires fetishstic disavowal (both on the part of the subject and the agencies responsible for providing the preventative healthcare) requiring the subject and the agencies to believe (disavowedly) that ill-heath and death can really be prevented by these preventative treatments (even though the research evidence to support this not only doesn’t exist but what evidence there is actually shows that such treatment will be more likely to do harm than good eg breast cancer screening (refs) (without, for now, complicating this argument by considering the relativity of the sizes of the harms and benefits). The relationship between (states of health) ‘health and ill heath and death’ has been replaced by a relationship between states of ill-health, by which I mean that there is now no such thing as good health, people who were once upon a time regarded as well are now regarded as being at risk, a form of pathologising that is equivalent to ill health. No longer carrying on as if all will be well but knowing ill health awaits, we now carry on knowing we are not well but are ‘already-ill’ at risk whilst imagining that ill health can be postponed for ever. I think this EBM list skirts around reality. As a GP (in the UK) shouldn’t we stand up and say no when asked to prescribe Tamiflu willy nilly. Lets not pretend that prescribing Tamiful is as the politicians would have it : “safe practice” - or playing safe – it isn’t, its playing with fire. Owen -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Maskrey Neal Sent: 10 August 2009 19:46 To: [log in to unmask] Subject: Re: Medical humanism and evidence-based practice may collide So if we accept that argument, what’s the problem with mandating an evidence-based guideline that says statins for everyone >20% 10 year risk then? Society will benefit – fewer heart attacks, and associated hospitalizations, a few individuals will certainly benefit but we can’t predict which one’s they’ll be, and more productivity from those individuals who don’t develop CV disease. Sure a few people will get muscle pain and a very few die from rhabdomyolysis, but for the common good its worth it, surely? So let’s link benefits for seniors to their concordance with statins. I know you do irony so I hope its obvious that I’m playing a game here. Perhaps a reasonable hypothesis would be that value judgments in your society have accepted for some time mandatory childhood vaccinations, but the same society currently makes different value judgments when it comes to other aspects of healthcare – for example the wider use of health economics to decide on the availability of new technologies to extend life. So do the values and context matter as much as the evidence? Yes they do! Sorry if that sounds too much like a Sex and the City script. This will keep me nicely occupied for about the next three decades I reckon – into “retirement” and far far beyond. :-) Bw Neal _____ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Djulbegovic, Benjamin Sent: 10 August 2009 19:09 To: [log in to unmask] Subject: Re: Medical humanism and evidence-based practice may collide Neil, I said I am going to be quiet for while but you have opened the Pandora’s box of societal vs. individual interest…when it comes to what is known in legal jargon “State’s compelling interests”, society has indeed mandated the use of many health care interventions [one of the famous example was case in Massachusetts at the end of 19th century when a reverend was ordered to have small pox vaccination against his religious beliefs + his rational argument that the vaccine was too risky (at the time the vaccine was so risky that many people had died due to vaccination but society deemed that benefits were greater even it meant that some people would die due to intervention itself]. But, the case here (at least the way I understood it) relates to decision about mandating treatment based only on perceived benefits (or, lack of it) to individual patients (no risk to others exist, except, of course, if one makes a case that the use of resources that were wasted on unnecessary interventions represent “risk to society”)… ben From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Maskrey Neal Sent: Monday, August 10, 2009 1:50 PM To: [log in to unmask] Subject: Re: Medical humanism and evidence-based practice may collide Hi Ben At the risk of prolonging this longer than the group can stomach……… >> MANDATING the use of “group” evidence to individual cases is simply crazy. I’m not being difficult, but isn’t there a mandated policy in the US for childhood immunizations? As I understand it people can opt out but only with a lot of paper work. So how is that ethically different from other evidence based interventions? Is it because the magnitude of the benefit is so large that its enough to overcome the ethical perspective of patient- or in this case parental-autonomy? And before anyone comes back to me, I know about herd immunity. :-) If we’re making that decision based on population benefits, arguably we have statins recommended for people with a 20% 10 year CV risk not to help the 5 extra INDIVIDUALS in 100 who don’t have their CV event, but because of the population effect of reducing CV risk in large numbers of people. And that’s before we get to the future “polypill” issues, and giving everybody over 50 an antihypertensive whatever their blood pressure. Evidence based practice / guidelines – necessary but not sufficient for optimal decision making? Is that too radical for an EBH mail group? Bw Neal Neal Maskrey Director of Evidence Based Therapeutics National Prescribing Centre Liverpool UK L69 3GF _____ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Djulbegovic, Benjamin Sent: 07 August 2009 23:25 To: [log in to unmask] Subject: Re: Medical humanism and evidence-based practice may collide Right on target: speaks to impossibility of reconciliation of descriptive (how we actually make decisions) with normative (how should we make decisions) aspects of making practice recommendations. MANDATING the use of “group” evidence to individual cases is simply crazy. ben Benjamin Djulbegovic, MD, PhD Professor of Medicine and Oncology University of South Florida & H. Lee Moffitt Cancer Center & Research Institute Co-Director of USF Clinical Translation Science Institute Director of USF Center for Evidence-based Medicine and Health Outcomes Research Mailing Address: USF Health Clinical Research 12901 Bruce B. Downs Boulevard, MDC02 Tampa, FL 33612 Phone # 813-396-9178 Fax # 813-974-5411 e-mail: <mailto:[log in to unmask]> [log in to unmask] ______________________ Campus Address: MDC02 Office Address : 13101 Bruce B. Downs Boulevard, CMS3057 Tampa, FL 33612 From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Dr. Carlos Cuello Sent: Friday, August 07, 2009 11:44 AM To: [log in to unmask] Subject: Medical humanism and evidence-based practice may collide I would like to hear opinions on this NEJM: Groopman, Hartzband: Medical humanism and evidence-based practice may collide. <http://bit.ly/4YWm3> http://bit.ly/4YWm3 -- Carlos A. Cuello-García, MD Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey NL, México. CP64710 Phone. +52(81)88882154 & 2141. 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