Evidence based medicine: ideology, hegemony, statistical gaze and beyond (part two) Autonomy and EBM

What gives an action its moral worth? Kant says what makes an action morally worth is not the consequence or the results that flow from that action. It has to do with the motive of the action. The motive confers the moral worth on the action. According to Kant, the only kind of motive that can confers moral worth on an action is the motive of duty and not the inclinations, one's preferences, likes, desires or impulses.


Autonomy and EBM
There is no better philosophy to explore the ethical substructure of the EBM paradigm than the teaching of the philosopher Immanuel Kant. Immanuel Kant (1724-1804) is one of the most influential philosophers in the history of western philosophy, especially in the fields of epistemology and ethics and it seems appropriate to use Kantian philosophy to understand the concept of autonomy.
What gives an action its moral worth? Kant says what makes an action morally worth is not the consequence or the results that flow from that action. It has to do with the motive of the action. The motive confers the moral worth on the action. According to Kant, the only kind of motive that can confers moral worth on an action is the motive of duty and not the inclinations, one's preferences, likes, desires or impulses.
When we seek pleasure and satisfaction we act according to natural necessity and we obey our desires and inclinations. These desires or inclinations are not chosen by us for ourselves but governed and determined by the nature of cause and effect. We act as means to the realization of ends given outside us. We are instruments rather than authors of the purposes we pursuit. That is heteronomous determination of motive or will, Kant claims.
According to Kant, act freely is not to choose the best means to a given end but to choose the end it self for its own sake. To act freely is to act autonomously. To act autonomously is to act according to a law that given to us by ourselves not according to a law of nature with cause and effect which includes our desires to seek pleasure and meet our inclinations.
When we act out of duty, we resist our inclinations and desires and even sympathy and altruism. Only then we are acting freely and autonomously, and only then our will or motive is not determined or governed by external This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
considerations. Autonomy is our capacity to rise above self-interest, inclinations, prudence and act out of duty. In that sense Kantian ethics is very relevant to medical professionals because "duty of care" is a foremost principle of medical profession. If a physician treats a patient her motive should be 'duty'. She is obliged to treat the patient just because as a health care provider it's her duty to treat the patient, not the interest of profiting from the patient or practicing medicine is a noble profession.
Then arises the question what govern our motive or the will to act? Kant claims reason is the law that determines our will. Kant argues humans are all rational beings. They have the capacity of reason and the ability to act and choose freely and seek pleasure and avoid pain. Then will becomes a power to choose independent of the dictates of nature, religious order or authority and above inclinations or circumstance. This is how reason determines the will.
In Kantian ethics commands of reason that determine the will is called an 'imperative'. Kant describes two types of imperatives, categorical and hypothetical. In categorical imperative the action itself has an end 'without reference to' or 'dependence on' any purpose. The categorical imperatives are compulsory moral obligations and are derived from reasoning using the intellect of rational beings. For example "You should not lie", and "you should not steal" are categorical imperatives. To understand a moral worth of an action, whether it is determined by a categorical imperative, Kant has suggested several formulations. According to one formulation human beings should always be treated as ends in themselves never as a mere means [9]. Every human being has dignity, is autonomous, rational and able to set their own goals and work towards them. Individuals are ends in themselves not mere objects to be used by others.

Point of view
EBM has been criticized for reducing the autonomy of the patient and doctor/patient relationship. The opinionbased health care practice is patient centered and respects patient's autonomy, whereas EBM considers health concerns of population rather an individual and there is an implicit conflict between the ethics of individual care and the ethics of population health .
EBM may reduce patient choice through its logical structure and limits the clinical freedom of the doctor. It arguably reduces the role and responsibility of the doctor. One can argue that patient's autonomy is affected since patient may not even know about all his options as "some choices" may have already been eliminated by EBM as "wrong choices".
There may be many situations where evidence of effectiveness of a therapeutic option will not be available anytime in the foreseeable future. The lack of evidence may deny patients of that option and where there is nothing "proven effective" available it could be the most attractive option for the patient. However in EBM hierarchy it may not even be listed and patient may not be given the choice to consider it.
From a Kantian perspective, keeping a patient in the dark about his condition and all his treatment options would tantamount to disrespecting him as an end in himself. He is treated like an object without a free will, unable to make up his own mind, not as a rational autonomous being with capacity to reason. This violates his dignity and thus his autonomy. This is in Kantian's categorical imperative, treating him as a mere means and not as an end in himself.

Deconstruction and EBM
Deconstruction is notoriously difficult to define. Late French philosopher Jacques Derrida who described deconstruction in 1966 always did shy away from defining it. Deconstruction is a form of close reading of a text in order to demonstrate that any given text has irreconcilably contradicting meanings rather than one unified logical meaning. In other words, any text is not stable and provides for more than one legitimate interpretation [10].
In deconstruction we dismantle our excessive loyalty to an idea. EBM gives us a model where deconstruction can be utilized to understand the text fully. During deconstruction, in simplest form, we need to first read the text very closely and identify the binary oppositions hidden in the text. Examples are many. Male versus female, mind versus body, culture versus nature, good versus evil. According to Derrida each binary opposite is implicit in the definition of the other [11]. One has to be there to add value to the other. Derrida argues that within such binaries, one term is always privileged at the expense of the other. Male over female, mind over body etc.
When one attempts to deconstruct EBM, one set of opposite binaries that you find within EBM text is "intuition" and "evidence". In EBM paradigm "evidence" is privileged over "intuition". EBM advocates statistical evidence to back its claims to validate any of their conclusions and recommendations. Intuition of practitioners based on their understanding of basic mechanisms and their own clinical experience is considered "taken for granted guess work". EBM proponents assume "evidence" from clinical trials (mainly RCTs and metaanalyses) will produce better health care outcome than "intuition" from a practice based on clinical experience and understanding of basic pathophysiology. All EBM conclusions are derived based on this assumption. Like any theory, the assumptions have to be validated. However this assumption of "evidence is better than intuition" is not validated at all. There is no "evidence' to say that doctors practicing EBM provide better healthcare than those who follow practice based medicine. Funnily enough, this distinction between 'evidence' and 'intuition' is based on intuition itself. In deconstructing EBM paradigm, we see that very same and lesser privileged binary opposite "intuition" has been used to make the distinction between admissible and inadmissible evidence. This leaves the reader with an open-minded perplexity or an impasse which Derrida named 'Aporia'. Some argue that EBM therefore 'auto-deconstructs' its own paradigm [1].
In the next article we would consider nineteenth century philosopher Michel Foucault's concept of medical gaze and how it is related to EBM paradigm.