CURRENT ISSUES

Debating evidence-based individual ethic vs population health ethic

Evidence-based medicine combines physicians' expertise and patient values with the best external evidence, and in this way identifies the 'win-win strategies' that fulfil patients goals and free-up health­care resources. 1 Professor David Sackett from John Radcliffe Hospital in Oxford, UK, has made this comment in response to earlier views on evidence­based medicine by Professor Alan Maynard from the University of York, UK. Professor Maynard claimed that allowing evidence-based medicine and the individual patient approach to determine treatment choices will result in the inefficient and unethical use of resources.*

Society has high expectations Professor Sackett believes that contrary to

Professor Maynard's opinion, physicians regularly make cost-utility decisions that consider groups of patients, not just the individual. However, he points out that the conflict between evidence-based medicine from the patient perspective and cost-effective medicine from the population perspective comes when physicians identify so strongly with a patient's goals for treatment that they want to follow these goals, even if it means resources will be used inefficiently.

Jackie Cassell from Mortimer Market Centre in London, UK, adds that society's expectation that general practitioners will provide the best available treatment to the individual patient is 'not an optional extra' .2 To ignore such expectations 'is naively reductionist', says Ms Cassell.

Look to general practice DP Kernick from StThomas' Health Centre, Exeter,

UK, responded strongly to Professor Maynard's and Professor Sackett's comments by claiming that 'icono­clasts in ivory towers' cannot optimise cost, effective­ness and utility. He suggests that being 'obsessed with opportunity cost and allocative efficiency' and 'mesmerised by the fools gold of evidence-based medicine' will not resolve the conflicting demands of individuals and the population.3 DP Kernick believes that UK general practice is one system that can consoli­date evidence, economics, equity a..'1d empowerment

Tension is healthy? D Churchill from Good Hope Hospital, West

Midlands, UK, concurs with Professor Maynard on the need to resolve the conflicts between individual and population health ethics.4 However, D Churchill does not believe that such resolution can be achieved at the expense of the physician-patient relationship, and by making the government responsible for medicine. D Churchill suggests that the tension between the individual and population approaches should be conserved and nurtured as a means of safeguarding the interests of both the individual and society.

1173-5503197/010Hl0051$01.00° Adla International Limited 1997. All rights reserved

Don't ignore purchasers' decisions Professor Maynard suggests that while these corres­

pondents accept the need to consider costs and outcomes in both clinical practice and evidence-based purchasing, they ignore the challenge of equity weighting of efficiency. 5

For example, in order to reduce disparities in health status between blue and white collar workers, healthcare purchasers may decide to buy relatively inefficient treatments for manual workers rather than spending the money on more efficient treatments for nonmanual workers. As it stands, the correspondents will ignore such purchasing demands, comments Professor Maynard. If physicians ignore purchasers' decisions, their clinical freedom will be eroded, he warns.

Professor Maynard believes that evidence-based purchasing is a more valuable approach than evidence­based medicine.* However, drawbacks of the former approach to date include limited availability of effectiveness and cost data. Professor Maynard believes that evidence-based medicine is an inadequate basis for allocating scarce resources; what healthcare providers, purchasers and consumers need is data about cost-effectiveness and equity considerations, he says. *see PharmacoEconomics & Outcomes News 95: 2, 18 Jan 1997; 800494927 1. Sackett DL. Evidence-based medicine and treaunent choices. Lancet 349: 570, 22 Feb 1997 2. Cassell J. Evidence-based medicine and treaunent choices. Lancet 349: 570-571,22 Feb 1997 3. Kemick DP Evidence-based medicine and treaunent choices. Lancet 349: 570, 22 Feb 1997 4. Churchill D. Evidence-based medicine and treaunent choices. Lancet 349: 571-572, 22 Feb 1997 5. Maynard A. Evidence-based medicine and treaunent choices. Reply. Lancet 349: 572-573, 22 Feb 1997 8004511402

PhannacoEconomics & Outcomes News 1 Mar 1997 No. 101

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