Equality, efficiency and effectiveness: going beyond RCTs in A. L. Cochrane's vision of health care

Abstract

A. L. Cochrane's Effectiveness and Efficiency frequently appears as a key reference in debates over, and a justification for, contemporary evidence-based medicine. Cochrane's concern in this text with the equality of care as the ultimate rationale for why effectiveness and efficiency of cure are needed has, however, largely disappeared from debate. In this article, we reconsider Cochrane's approach through the use of case studies of plural forms of medicine in the Czech Republic, namely traditional Chinese medicine, homeopathy and spa care. In addition to bringing equality back into the picture, we also identify four expansions to Cochrane's original vision arising from the difficulties of separating cure from care; the overlap between prevention and cure; the complex actions of some multifaceted therapies; and recent reconceptualisations of the placebo effect. In conclusion, we suggest that instead of the widely used strictly vertical "evidence pyramid", a descriptor of the horizontal and additive ordering of evidence might be more appropriate. We also argue that in healthcare systems characterised by a multiplicity of approaches, if we want to truly benefit from this heterogeneity, we must take seriously each medical tradition's approaches to prevention, cure, care, as well as efficiency, efficacy and equality.Keywords: complementary and alternative medicine, Central and Eastern Europe, evidencebased medicine, equity, fairness, health policy, ethnography It is difficult to overestimate the wide-scale impact of A. L. Cochrane's 1971 assessment of the British National Health Service, Effectiveness and efficiency: random reflections on health services. Indeed, Cochrane's strong support of Random Clinical Trials (RCTs) as the most reliable method of data generation in assessing the effectiveness of treatment has become part of a revolution in international healthcare standards. Cochrane's legacy is exemplified by the Cochrane Collaboration, an international forum for medical advice, which focuses on "transform[ing] the way health decisions are made" (Cochrane, n.d.). However, as Askheim et al.(2017) note, contemporary advocates of improving healthcare efficiency tend to pick and choose aspects of Cochrane's position that suit the agendas of RCT-driven treatments. In this article, we take up Askheim and co-authors' call for considering more broadly Cochrane's approach to medical care as a tripartite structure, involving not only effectiveness and efficiency but also equality. We revisit these issues, however, by means of not only conceptual analysis, akin to Askheim et al. (2017), but through the use of empirical case studies of plural forms of medical care in the Czech Republic. Our intention is not only to recover Cochrane's

The trouble with IVF and randomised control trials: Professional legitimation narratives on time-lapse imaging and evidence-informed care

“…At the same time, they critically engage with EBM, downplaying the role of evidence in the process of evaluating the worth of the tool. Although there are some calls for a more inclusive approach to evidence (such as in the case of CAM, see Trnka and Stöckelová, 2019 ), fertility professionals do not ultimately challenge the pyramid of evidence or the gold standard of RCTs. Instead, they articulate their critiques of evidence production in a more subtle way, using their professional expertise to challenge the application of a pure EBM discourse to fertility treatments.…”

“…Although CAM treatments are found worldwide and are offered by many state care regimes, they have been ostracised by EBM supporters as ‘unproven medicine’ ( Fontanarosa and Lundberg, 1998 ). Social studies of CAM have underlined the epistemological incompatibility between the orthodox EBM approach and holistic methods focusing on individualised care ( Degele, 2005 ; Trnka and Stöckelová, 2019 ). Borgerson (2005) summarises three possible alternative options for professionals working towards legitimacy of CAM in the medical community: accept EBM standards and produce evidence accordingly; rely on lower evidence to support their decision; critically engage with EBM and propose alternative standards.…”

The Intersection Between Models of Health and How Healing Transpires: A Metaethnographic Synthesis of Complementary Medicine Practitioners' Perceptions

“…Due to the value placed on specific effects in biomedicine, 72 nonspecific factors receive limited attention, 62,72,73 and may be dismissed as inconsequential or confounding. While RCT designs are ''gold standard'' in biomedicine and designed for the purpose of identifying isolated and specific therapeutic interventions, 74,75 the evaluation of CM holistic systems of medicine will only truly be served by approaches that reflect the holistic paradigm. [74][75][76] While research is yet to definitively accord proportional value to specific and nonspecific effects in CM (and biomedicine), it seems possible that within a CM consultation a context is deliberately established that enhances the selfhealing abilities of the patient.…”

“…While RCT designs are ''gold standard'' in biomedicine and designed for the purpose of identifying isolated and specific therapeutic interventions, 74,75 the evaluation of CM holistic systems of medicine will only truly be served by approaches that reflect the holistic paradigm. [74][75][76] While research is yet to definitively accord proportional value to specific and nonspecific effects in CM (and biomedicine), it seems possible that within a CM consultation a context is deliberately established that enhances the selfhealing abilities of the patient. 72,77 The philosophical basis of CM engenders the deliberate use of nonspecific factors as a core component of clinical practice in combination with specific factors.…”

Enacting evidence‐based medicine in fertility care: Tensions between commercialisation and knowledge standardisation

“…The rise of evidence-based medicine (EBM) in the last four decades has made it imperative to use 'the best available evidence' in making decisions about the care of individual patients (Sackett et al, 1996). Hence, EBM has become a core subject of sociological analysis (for a review, see Timmermans, 2010a), which has explored its prevalence in a variety of medical fields, from alternative medicine to cancer services (Broom & Tovey, 2007;Trnka & Stöckelová, 2019). In particular, medical sociology has explored professional resistance to EBM (Jackson & Scambler, 2007;Traynor, 2009), the politics of evidence (Green, 2000;May, 2006) and how medical practice is legitimised and justified when, despite the demand for 'good quality' evidence, professionals have to work in conditions of high uncertainty (Ducey & Nikoo, 2018).…”