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• Is evidence-base medicine ethical?
  Richard G Fiddian-Green
  Published on: 10 August 2004

• Published on: 10 August 2004

  Is evidence-base medicine ethical?

  • Richard G Fiddian-Green, FRCS, FACS

  Dear editor

  The case has been made for environmental influences, which might reasonably include medications taken as prescribed or consumed in contaminated water or food, having a profound effect upon future generations by influencing gamete selection [1].

  In the case of obesity, for example, it was proposed that gametes might be evolutionarily selected to thrive on the diet to which they have access...

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  Dear editor

  The case has been made for environmental influences, which might reasonably include medications taken as prescribed or consumed in contaminated water or food, having a profound effect upon future generations by influencing gamete selection [1].

  In the case of obesity, for example, it was proposed that gametes might be evolutionarily selected to thrive on the diet to which they have access. It was further proposed the rise in prevalence of obesity especially in children might be a direct consequences of parental diet and even exposure to exhaust fumes upon gamete selection.

  In the case of carbon monoxide released in exhaust fumes it was proposed that inhibition of electron transport in the respiratory chain might cause the lipid shift in substrate utilisation in oxidative phosphorylation seen in exercising athletes and responsible for the biochemical risk factors and obesity associated with an increased risk of cerebrovascular and coronary artery diseases.

  Evidence-based medical care, as opposed to surgical or other interventional care, is primarily based upon the results of prospective randomised studies. Many of these have violated the uncertainty principle and are meaningless [2]. Those that have not are by definition ineffective and at best have a fine-tuning effect upon short-term outcome in very clearly defined circumstances. The have an unknown effect upon long-term outcome and certainly upon gamete selection and the state of future generations.

  There is clearly a difference between medications administered for short-term gain, medications such as intravenous aminophylline for acute asthma or penicillin for a streptococcal infection, and those administered for longer term gain. The former are essential for patient care. The latter are not. Of particular concern amongst the latter are the tons of NSAIDS, antidepressants, other psychotropics, and even statins prescribed all of which may change the way people live and die without improving outcome from all causes or longevity. All have the potential to impair mitochondrial function, a particular concern in gamete selection. They may even have been an importent cause or amplifyer of most of the chronic diseases we see today in a develpoped opulation [3]. Add to that the host of over-the-counter medications and herbal remedies that exert little more than an placebo effect and might have adverse effects on present and future generations.

  Should any medication be prescribed for anything other than for a very limited duration in a few highly selected acute illnesses, such as puerperal sepsis or meningococcal septicaemia? If we were to abolish pharmaceutical treatments for the majority of chronic diseases tomorrow we would still have many therapeutic options. What is more if reliance for treatment for chronic disases, such as neurodegenerative diseases, chronic heart and even pulmonary failure, were to be shifted to hightech and invasive options there would be an huge incentive for clinicians and blue chip companies, such as Medtronic, to develop even better and safer invasive treatments. Unlike pharmaceutical treatments invasive treatments should not present a risk to future generations if safe industrial and disposal practices are followed.

  So is evidence-base medicine ethical? It is a legitimate and serious question worthy of consideration. With the projected increase and ageing of the population the hypothetical risk of having a adverse effect upon gamete selection could increase greatly. Are we to leave future generations to decide whether our pharmaceutical interventions have had an adverse effect upon gamete selection and compromised the future of humanity?

  What then of the evidence-base for invasive practices? I think we had been doing just fine until over-regulation and seriously misguided if well-intentioned attempts to enforce lower salaries and clinical pathways upon clinicians started to destroy the foundations of the profession. The damage inflicted upon the profession is severe and it may take decades to recover. Many patients have suffered and many have died unnecessarily. There can be few better examples of chucking the baby out with the bathwater.

  References

  (1) Neither ? Richard G Fiddian-Green (1 August 2004) eLetter re: Obesity in Britain: gluttony or sloth? Prentice and Jebb (12 August 1995)

  (2) Proof of the impossible: p<_0.000000001 xmlns:re="urn:x-prefix:re" xmlns:_328="urn:x-prefix:_328" richard="richard" g="g" fiddian-green="fiddian-green" bmj.com="bmj.com" _11="_11" jan="jan" _2004="_2004" eletter="eletter" re:_="re:_" auro="auro" del="del" giglio="giglio" and="and" luciano="luciano" jose="jose" costa="costa" the="the" quality="quality" of="of" randomised="randomised" controlled="controlled" trials="trials" may="may" be="be" better="better" than="than" assumed="assumed" bmj="bmj" _328:_="_328:_" _24-25="_24-25" p="p"/> (3) Iatrogenic diseases with a common cause? Richard G Fiddian-Green (25 October 2002) eLetter re: Edward H Wagner and Trish Groves Care for chronic diseases BMJ 2002; 325: 913-914

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  Conflict of Interest:
  None declared.

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