Is Evidence-Based Psychiatry Ethical?

by Mona Gupta. In book series: International Perspectives in Philosophy and Psychiatry. Oxford University Press, New York, NY, 2014, 202 pages, $52.95 (paper).

In the marketplace of medical ideas, some "products" combine face validity, cultural attunement, clear explanation, and perfect naming to dominate discourse for extended periods. "Scientific medicine," "biopsychosocial medicine," and "patient-centered medicine" (PCM) are just a few of these ideas. They share a quality of seeming inherently good—of being hard to argue against because their very names capture something positive and aspirational. For instance, I might profess a devotion to PCM without having to worry about (or be capable of) explaining myself, since it is generally considered a good thing to be patient-centered. Yet, the definition of PCM is contestable and often personal.

Evidence-based medicine (EBM) may be the most impactful idea of this type to come along in the past several decades. Its reach extends beyond practice philosophies and mission statements to influence institutional policies, insurance reimbursements, research enterprises, and training curricula in very specific ways. As such, it warrants scrutiny and has received its share of criticism. In Is Evidence-Based Psychiatry Ethical? Mona Gupta contributes to this critique with a focus on the application of EBM to psychiatry.

Is Evidence-Based Psychiatry Ethical? is framed as a research project with literature review and empirical components. The latter component involved interviews with EBM developers, mental health practitioners "involved in the implementation and debate" of EBM, and scholars of its philosophy and ethics. Gupta’s methodology is covered in the book’s appendix. Sections that focus on these interviews provide occasional narrative momentum that is uncommon in an academic text.

A clear and informative review of the history, content, and impact of EBM opens this text. For those of us prone to invoke EBM in a casual, face-value way, this portion of the book is valuable even independently of the critique and ethical analysis to follow. That said, Gupta openly declares on page 9 that she "came to this project as a critic of EBM," and while this project "challenged" her bias at times, there is little to indicate that it ever really made her waver. Holes are poked in the premises of EBM even as they are introduced.

As Is Evidence-Based Psychiatry Ethical? moves explicitly from EBM as an idea to EBM as a guiding principle for medical activity, 2 different readings of its provocative title emerge. The first, and, in my opinion, more important and more compellingly addressed one, is whether or not EBM is an ethical enterprise. Does EBM stake values-based claims about what is right and wrong medical activity? Gupta methodically deconstructs the assumptions that prop up EBM. The idea of professionally conducting ourselves in an "evidence-based" way seems like a responsible, objectively right way to do things until someone inconveniently asks, "What is ‘ best’ evidence?" "Who decides what the ‘ right’ questions are and how they ought to be answered?" "What do I do when the available evidence is not applicable to my needs?" or "What is the evidence supporting EBM as opposed to pre-EBM?" Gupta establishes the legitimacy and importance of all of these questions and more. Refreshingly for a philosophy-of-psychiatry book, she also does so clearly. This is a very accessible book for clinicians and trainees.

The second reading of the title Is Evidence-Based Psychiatry Ethical? asks whether EBM is itself a morally upright way of doing psychiatric work. This reading intersects with the first, but begs for a more partisan answer. There is no sustained section of this book that represents EBM as a responsible way of answering a given clinical or research question. EBM is portrayed as marginalizing questions that the paragon of its hierarchy of evidence, the randomized controlled trial (RCT), is ill-suited to answer. Further, in Gupta’s view, the RCT sabotages its own strengths by greasing the skids for unseemly industry influence over the evidence base.

Much of Is Evidence-Based Psychiatry Ethical? pits EBM-blessed psychopharmacology against an underdog EBM-shunned psychotherapy. This focus on treatment is indirectly supportive of Gupta’s argument; it demonstrates the marginalization of other concerns by psychiatry’s embracing of EBM. However, in medicine, evidence-based or not, diagnosis and prognosis precede treatment. Gupta touches on the former and ignores the latter, thus contributing to the privileging of interventionism over other psychiatric tasks. The psychopharmacology-psychotherapy focus of this book sometimes seems like another airing of grievances in medicine’s scientism-versus-humanism wars. Gupta’s arguments are diminished when EBM feels more like a stand-in for "biomedicine" than a concept being debated on its own merits.

Just when it seems that Gupta’s verdict on EBM’s ethical legitimacy will be "no," she concludes that EBM’s ethical failure is one of overreach. This conclusion implies a legitimate moral domain for EBM. The boundaries of that territory are left largely, and appropriately, for the reader to discern. In a related vein, Gupta’s conclusion returns to another theme that plays through much of this book: that of patient and physician values. The 2 canonical EBM texts she cites wrap themselves into rhetorical pretzels trying to incorporate values into the EBM method, and make many ethical assumptions in doing so. Gupta convincingly contends that these issues are better left to interactions between physicians, patients, and ethicists and that the evidence-based method offers only illusory settlements of ethical quandaries.

For those who wish not to "get swept along in this latest chapter in the history of medical ideas" (p 186), Is Evidence-Based Psychiatry Ethical? is a 1-stop primer on EBM (albeit a biased one) and a stimulus for thinking critically about its central tenets and implications. If you like to write in the margins of your books, get a fresh pen before starting this one.

Nicholas Kontos, MD

nkontos@partners.org

Author affiliations: Harvard Medical School, Boston, Massachusetts.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(7):e898

dx.doi.org/10.4088/JCP.15bk09890

© Copyright 2015 Physicians Postgraduate Press, Inc.