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"The illusion of evidence based medicine", Jon Jureidini and Leemon B. McHenry, 2022

Some choice excerpts:

The philosophy of critical rationalism, advanced by the philosopher Karl Popper, famously advocated for the integrity of science and its role in an open, democratic society. A science of real integrity would be one in which practitioners are careful not to cling to cherished hypotheses and take seriously the outcome of the most stringent experiments. This ideal is, however, threatened by corporations, in which financial interests trump the common good.

The pharmaceutical industry’s responsibility to its shareholders means that priority must be given to their hierarchical power structures, product loyalty, and public relations propaganda over scientific integrity.

Our proposals for reforms include: liberation of regulators from drug company funding; taxation imposed on pharmaceutical companies to allow public funding of independent trials; and, perhaps most importantly, anonymised individual patient level trial data posted, along with study protocols, on suitably accessible websites so that third parties, self-nominated or commissioned by health technology agencies, could rigorously evaluate the methodology and trial results.

The authors don't discuss any case studies or specific areas of medicine, this is purely in general terms. However, as soon as you look up the authors, Jureidini is a child psychiatrist. Coincidence? McHenry is a philosopher with an interest in medical ethics, so well placed to comment on Big Pharma's hold.

I think this may be a sign the tide is really turning; hopefully for medicine as a whole and trans "medicine" in particular. The BMJ is the place to publish on medicine, so for them to publish this opinion piece suggests the medical academe knows there is a problem. (The responses to it are also interesting.)

["The illusion of evidence based medicine", Jon Jureidini and Leemon B. McHenry, 2022](https://www.bmj.com/content/376/bmj.o702) Some choice excerpts: > The philosophy of critical rationalism, advanced by the philosopher Karl Popper, famously advocated for the integrity of science and its role in an open, democratic society. A science of real integrity would be one in which practitioners are careful not to cling to cherished hypotheses and take seriously the outcome of the most stringent experiments. This ideal is, however, threatened by corporations, in which financial interests trump the common good. > The pharmaceutical industry’s responsibility to its shareholders means that priority must be given to their hierarchical power structures, product loyalty, and public relations propaganda over scientific integrity. > Our proposals for reforms include: liberation of regulators from drug company funding; taxation imposed on pharmaceutical companies to allow public funding of independent trials; and, perhaps most importantly, anonymised individual patient level trial data posted, along with study protocols, on suitably accessible websites so that third parties, self-nominated or commissioned by health technology agencies, could rigorously evaluate the methodology and trial results. The authors don't discuss any case studies or specific areas of medicine, this is purely in general terms. However, as soon as you look up the authors, Jureidini is a child psychiatrist. Coincidence? McHenry is a philosopher with an interest in medical ethics, so well placed to comment on Big Pharma's hold. I think this may be a sign the tide is really turning; hopefully for medicine as a whole and trans "medicine" in particular. The BMJ is *the* place to publish on medicine, so for them to publish this opinion piece suggests the medical academe knows there is a problem. (The responses to it are also interesting.)

20 comments

[–] BlackCirce 19 points Edited

One thing the authors didn’t mention is that the capture of medicine / science by pharmaceutical corporations has eroded public trust in medicine. People don’t trust doctors anymore. The next time a vaccine is needed / developed / suggested for anything it will be 10x more difficult to roll out than the COVID-19 one. People would rather stick a crystal up their ass to cure their ailments than trust pharma, and it’s 100% because of capitalist fantasies about the fundamental virtuousness of market competition.

This LTE says as much

Re: The illusion of evidence based medicine - Losing faith in science itself. Dear Editor

As a concerned citizen, with no formal scientific training or background but a great deal of experience of the reality of the now dominant global corporate culture, I am relieved to see the emerging recognition of the compromised nature of EBM being aired in such straightforward and forthright terms in such a prestigious journal as the BMJ. The scientific/medical community should be very concerned indeed about the implications of, what I believe to be, the revealing insight this opinion piece offers.

I would assert that the general public's faith in the honest nature of scientific and/or medical inquiry and the fundamentally reliable nature of the institutions that embody it, is crumbling. For anyone who has been paying attention over the last twenty years and especially the last two, it has become clear that a highly pathogenic variant of the once mostly honest profit motive has infected and corrupted all aspects of the systems and institutions, commercial, academic, political and scientific that hitherto have appeared at least somewhat reliable. Talk of not 'throwing the baby out with the bath water' is missing the point when It is the entire generation of infants that is actually at risk. If the tipping point of credibility is reached and its is not far off in my estimation, a catastrophic and precipitous collapse of faith will leave us wondering; if not in science, what on earth can we trust in?

This morning, two of my coworkers were saying negative things about the covid vaccine and how they don't want to get boosters because they think the boosters are killing everyone. So much damage has been done.

They're talking about "crumbling" as though it's some kind of natural process, or due to flaws within the research enterprise itself. It's not. For the past fifty-odd years, it has been actively undermined for profit, politics and ideology, by, for example the tobacco industry, the alternative health industry (including the original antivaxxers), climate-change denialists (and their funders in the energy industries), the polluting industries. Both sides of the political spectrum have supported science only as far as the science supported their views.

To be fair, mainstream science has also often shot its own self in the foot, such as when it pushed hard for the diet-heart hypothesis and trying to make everyone eat low-fat or "plant-based." Ancel Keys cherry-picked his data, I'm not sure T. Colin Campbell even understood his own China Study, and WWII-era findings about what actually works in people as pertains to diet have been resoundingly ignored. When you misuse science like that you are going to foster the creation of mavericks and rebels.

If you don't like my examples or think I'm full of it, consider DES and thalidomide. Or frontal lobotomies.

[–] scriptcrone 0 points Edited

DES, thalidomide, and frontal lobotomies are all frequently referenced as research failures and science harms, but they precede Evidence Based Medicine (EBM) as a discipline. They were introduced into practice on the basis of what we would today consider inadequate or seriously flawed evidence. DES was prescribed in the US from the 1940s to 1971 (per Wikipedia), thalidomide was marketed in the late 1950s and early 1960s (but not in the US, thanks to FDA reviewer Frances Kelsey ), and lobotomy was performed from the 1930s to 1950s. Thanks for pointing me to the diet-heart literature. I've found commentaries tracing the evolution and re-analyzing the trials.

EBM started around 1980, in a group of clinical epidemiologists at McMaster University, and with a series of publications on critical appraisal of clinical trials, especially RCTs. (https://journalofethics.ama-assn.org/article/evidence-based-medicine-short-history-modern-medical-movement/2013-01). The Cochrane Collaboration, which specializes in systematic reviews--one of the major tools of EBM--got its start in 1993 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746659/). Those then spawned a movement to improve the transparency of reporting of clinical studies, which produced the CONSORT statement (http://www.consort-statement.org) and variants addressing other study designs (collected at The Equator Network https://www.equator-network.org/reporting-guidelines/), and a movement to abolish selective publication of results, which produced clinical trial registries (https://www.clinicaltrials.gov and others). And then there was the movement towards open access medical publishing, which ran concurrently.

Not perfect, by any means. Notwithstanding efforts to improve transparency, the sheer complexity of the enterprise makes it opaque, even without commercial interests and the legislation supporting their secrecy. The need for expertise and the heavy regulatory apparatus makes it very expensive. RCTs are difficult to do, and every design stage carries compromise. A large number of research questions simply cannot be addressed by a trial--questions of harms, for one, and questions where people already have strong established preferences. Those have to be studied using observational designs, which are more subject to bias. RCTs works best with simple, well-defined interventions. Drugs are ideal. Surgery and behavioral, social, or other complex interventions, not so much. Design is influenced by what can be measured well; important outcomes are frequently measured by approximation or surrogates--Quality of Life is a major one. Standard statistical methods demand sufficient numbers to overcome variability, but there are ~7000 rare diseases, affecting about 1:10 people (and far higher than that in some subgroups, who may also be disadvantaged). Those need special approaches, which have limitations. Standard statistical methods assume all variability is random, but people have sex, age, racial, and other individual differences; these subgroups need to be identified and looked at, which is frequently not done well, and we may be back to small numbers. Most RCTs simply do not involve enough people to detect a side effect that is rare, no matter how severe. Pharma companies don't yet face penalties severe enough for failure to disclose safety signals early enough. There are ethical conundra lodged at the heart of human research, which will not go away. Randomization, one of the most powerful tools we have for dealing with bias, is antithetical to belief. Commercial medical publishing, itself a major industry, is substantially entangled with the pharmaceutical industry, despite its successes in dictating transparency in reporting and clinical trial registration.

Still better than what we used to have, and there are ongoing efforts to improve each of these aspects.

Successes largely independent of the pharmaceutical industry? The example I'm most familiar with is the 50+ year project to develop and refine treatment protocols for childhood acute lymphoblastic leukemia, based on drugs and modalities originally marketed for the treatment of adults. It involves multiple academic clinical research consortia funding and running series of clinical trials to address evolving questions, backed by the basic science effort to identify indicators of prognosis and toxicity. Their work has taken ALL from a terminal diagnosis to a disease with a cure rate in >90% of children diagnosed in the developed world. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771494/

[Edits--some typo-fixes and rewording; added mention of open access medical publishing]

I haven't read this, but John Campbell did a video commentary of it that was interesting.

The profit motive in health care has to go. I'm open to intermediate steps, but when it becomes "misinformation" to talk about any kind of treatment that is out-of-patent so that vaccines can get emergency approval, I'm done.

Right now we have "a pill for every ill" rather than actual health care.

When people would rather catch a dangerous disease and then treat it than prevent it in the first place, I'm done.

A dewormer is not an antiviral.

I would love to see public funding of research where the public is actively deciding what's being studied and discussing the findings. There is a huge issue with corporations only studying what they can turn into profit. I see this being good for women in general because we're so much more aware now of how we've been left behind by the medical industry. I'd love to see it be a requirement to study all different kinds of people so we can actually get a better idea of best practices for various groups and individuals.

I don't want the public deciding what is being studied. I would like to see a system where they can offer suggestions, but we're talking about people who think Elvis is still alive. We need some moderation.

The people who think Elvis is alive are the least ones to be worried about. But the rest of your point stands.

True, but private interests are just as bad. My ideal system would be one where everyone who's interested would vote. Of course I also want to see critical thinking skills taught at a young age. Our educational system (along with the internet making any and all ideas visible) is responsible for our uninformed population.

I don't think this is about trans medicine; it's about COVID medicine.

Oh certainly, the way covid has been treated has opened the doors wide for this sort of criticism of the medical/pharmaceutical industry.

I do think though it's very interesting that Jureidini's specialty is child psychiatry.

I don't think that says much. He may be more interested in the effects of masking children than of transing them.

I do think that's an interesting point. There is no way a child psychiatrist has NOT been exposed to the gender medical scandal by this point.

Why not both and more? Take a look at the long term side effects of the HPV vaccine. Allergies. Psych meds. It's all fucked.

Because this isn't their first editorial about COVID medicine recently. They're pissed in a way they didn't get over issues that go further back.

Fully agree, a lot of modern medicine could be re examined and it would hopefully lead to better care.

This is so great. I can't believe (but am well aware of) that the proposals aren't not current standards.