Broad Medical Uncertainty and the ethical obligation for openness

Abstract

This paper argues that there exists a collective epistemic state of ‘Broad Medical Uncertainty’ (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a ‘Corrective Response’. We then consider some objections to this position (the ‘Anti-Corrective Response’), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

Deferring to Expertise whilst Maintaining Autonomy

“…Pressure to find 'positive' and impressive results can also lead scientists to exaggerate the significance of their data and engage in bad practice, up to and including creating fraudulent data (Ritchie 2020). The result is an evidence base that systematically overestimates the benefits (and underestimates the harms) of medical interventions (Brown et al 2022;Stegenga 2018).…”

“…provocative language, reservations about the continued flaws in evidence-based medicine (Howick 2019;Mandrola et al 2019;McCartney 2012). Some of the concerns relate to statistically significant but clinically meaningless benefits being identified; a vast volume of evidence being produced; poor methodologies (such as biased trial designs and the adoption of inappropriate measures); the unknown extent of fraudulent research findings; poor adherence to pre-registration requirements/non-publication of 'negative' results, and so on (see also (Brown et al 2022)). The problems with the quality, applicability, and usability of the clinical evidence based cannot always be simply resolved by recourse to selective aggregative methods such as systematic reviews and meta-analyses.…”

Medical necessity under weak evidence and little or perverse regulatory gatekeeping

“…In the meanwhile, one has to live with a mass of largely uncertain and weak evidence. 8 The weakness of the evidence itself has been coupled with raising its interpretation to a level of sacrosanctity. Authority in interpretation tries to remedy (or even cover up) that wide uncertainty.…”