Commentary: Shaw's critique of health care is still valid.

Abstract

The preface provided by George Bernard Shaw to The Doctor’s Dilemma 1 is a profoundly insightful and deliberately provocative essay on the short-comings of health care, as provided by doctors who are deficient in scientific thought and are driven by petty profit motives. It is also an eloquent espousal of an ideal public health system, devoid of those flaws. Though Shaw was unduly harsh on Pasteur, improperly critical of the efforts to eliminate smallpox and his prototype of an underpaid doctor driven to malpractice no longer exists in many parts of the world, most of the ideas developed in the preface are of great contemporary relevance. Shaw’s consistent demand for credible evidence is the hallmark of a truly scientific mind. He expresses despair, and even disgust, at the usual medical practitioner not applying the methods of scientific enquiry and the principles of statistical analysis to evaluate the efficacy and safety of the treatment methods which they espouse with ill-informed enthusiasm and willingly inflict on an unsuspecting public. The situation has not improved greatly since Shaw’s time. Even as ‘evidence’ constantly accumulates in the pages of prolific research publications, the average practitioner is often distanced from its message. Even when a part of that message does reach him or her, often through the pharmaceutical industry’s sales promoters or through the lay media, the aptitude and the ability to subject that message to serious scientific scrutiny are severely deficient. Shaw protests against the incorrect use of statistics and the lack of matched comparison groups. He argues convincingly that apparent benefits of interventions are easily demonstrable in the absence of a matched comparison group and cautions that such spurious interpretations ought not to guide medical practice. He makes out a good case for employing the scientific design of a controlled trial for evaluating medical interventions. He is particularly caustic about the ecological fallacies that arise from analyses that depend on time trends and do not take into account the confounding effects of concomitant changes in other determinants. The example he provides, of the relationship between disappearance of typhus and amputation of the little finger, is particularly telling. The clarity with which he identifies and describes confounding as a factor which bedevils ‘causal’