Mona Gupta has launched a full frontal assault on evidence based-medicine in her provocatively titled book "is evidence-based psychiatry ethical?"
Gupta, a psychiatrist at the University of Montréal and a former faculty member at McMaster's Department of Psychiatry, has a particular interest in bioethics and epistemology.
She combines her interests in psychiatry and philosophy to compose a razor-sharp and penetrating critique of evidence-based medicine (EBM), particularly as it applies to the practice of psychiatry.
Gupta undertook a qualitative study involving analysis of the primary texts of evidence-based medicine and interviews with many of the developers of EBM , mental health practitioners, and scholars who have studied philosophical and ethical aspects of EBM.
She pointedly asserts that there is no "evidence" that evidence-based medicine does what it claims to do i.e. lead to improvements in health outcomes.
Gupta dissects some of the implicit assumptions and values of EBM. She draws attention to some of the problems related to medical research: biases that derive from the social context and research culture; assumptions about what constitutes evidence; the impact of the sources of funding on research outcome; and publication bias.
She goes on to question the accepted wisdom regarding the hierarchy of evidence. She notes that "we're only able to measure what we are able to measure." Much evidence is automatically excluded if it does not fit a paradigm that is essentially derived from internal medicine.
With regard to psychiatry she argues that randomized controlled trials may be applicable to medication studies, but are too narrow a methodology to embrace the complexity of psychiatric practice.
"… The narrative structure and meaningfulness of personal experience are essential components of living with a mental disorder and, in particular, psychotherapeutic treatment of mental disorders. Mental states are complex, subjective experiences and these may be resistant to measurement, at least in the manner envisioned by EBM." (p.94).
Psychiatric research may have to be broader in scope and include subjective and intersubjective experiences that are not captured in the EBM paradigm. Even the definition of treatment outcomes is arbitrary and infused with implicit values as to what is most important both for individuals and groups.
The patient's perspective is not taken into account i.e. which types of outcomes are most important for a particular patient. Is it changes in subjective feelings, meaning, and relationships or is it symptom change?
The author considers a number of other factors that may make EBM less suitable as a framework for psychiatric epistemology. The types of evidence accepted by evidence-based medicine do not take into account the range and depth of the experiences of mental disorders and more alarmingly may in fact lead psychiatrists to false beliefs about the effectiveness of clinical interventions:
"EBM's evidence is shaping our understanding of the nature of mental disorders and how we should intervene. This revision of psychiatry's subject matter has arrived on the coattails of EBM, and points to EBM's enormous influence: from shaping the conduct of research, to determining which interventions are deemed acceptable for consideration in clinical decision-making and even to redefining the object of inquiry. EBM is not only changing our approach to researching mental disorders, it is changing psychiatry itself by influencing how we understand mental disorders, and thus the tasks of psychiatrists." (p.113).
Mona Gupta. Is evidence-based psychiatry ethical? Oxford University Press 2014.