Evidence-based medicine: why clinical ethicists should be concerned.

Evidence-based medicine purports to be the integration of three prongs; best research evidence, clinical expertise, and patient values and preferences. Controversy still surrounds the application of evidence-based medicine and undoubtedly controversy will persist in the treatment of specific diseases, thus allowing for some flexibility in decision-making. Yet, the idea that variation is expensive has gained wide acceptance and variation can best be controlled through rigid systems. So given the financial constraints facing healthcare organizations, as well as pressure from such august organizations like the Institute of Medicine to implement evidence-based medicine, flexibility in decision-making may ultimately become the exception rather than the rule. Certainly, in the short-term, the advantages of a rigid system, notably its cost advantage, overwhelm the advantages of a more naturally adaptive system--and so where possible evidence-based medicine will probably be implemented within a rigid context. Rigidity in system design will affect the activities of clinical ethics. To be effective in such a system, clinical ethicists will need an understanding of the system within which they practice including its values, goals, operations, and tools. This is a knowledge area which few in this field currently have and which they may not wish to acquire. But, if clinical ethicists expect to have credibility in responding to these changes, they must understand the values, goals, processes and outcomes of the system in place and be able to advocate for greater flexibility and greater attention to patient values and preferences even within a rigid mechanical system.