Is evidence an ethic?

Abstract

Recently, when asked why “cosmetogynecology” was wrong a colleague retorted, “Because there is no evidence.” The response poses an interesting question in whether evidence renders an ethic since ethics are dedicated to right conduct and correspondingly assign the labels right and wrong or good and bad. The outcry for restraint in the adoption of new pelvic floor repair kits or cosmetogynecology largely stems from the lack of evidence [1–3]. While evidence-based medical practice is certainly ethical, evidence is not an ethic, and if evidence is not an ethic, but a compliment to an ethic, how do we judge medical practice? Medicine is not ethically neutral. When we identify disease as “bad” and health as “good” we pronounce judgment on equally natural processes. While it is true that medicine can borrow ethical principles from a physician’s individual world-view, medicine has an intrinsic ethic. It can be convincingly argued that the Hippocratic Oath captures the salient features of this intrinsic ethic [4]. What is the fundamental goal of medicine? According to the Hippocratic oath a physician intervenes to “benefit the sick.” In essence physicians restore health, since this is what will benefit the sick. Who and in what ways an individual is sick can be reasonably debated, but physician duties are restorative. In one sense health is a unidirectional concept (e.g., healthy bowel function cannot be improved) and as such physicians do not apply therapies to create super-normal function. The ethics of medical enhancement to otherwise normal human function is ethically and culturally charged [5] and beyond this editorial. It will suffice to say that evidence can aid in defining normal, and with this medical practice, but the evidence only informs the overarching ethical principle to restore health; not included, as a first principle, is remuneration, ego, or personal advancement. It has been said that management of pelvic floor dysfunction is not about what could be done but what should be done. This is not a neutral statement. Questions of “should” bespeak judgments that are rooted in ethics. If physicians regularly practice interventions that evidence has consistently shown to be ineffective, this is fraud. Conversely, if a practice has abundant evidence documenting efficacy, is it de facto ethical? Obviously not, since harvesting organs from non-consenting trauma victims is wrong despite the evidence that organ transplantation can be highly effective (it is worth noting the presently simmering issue of presumed consent in organ donation). Ignorance can soften the first situation but the latter arises from a darkened world-view that is outside of any intrinsic medical ethic. When looking for a rule for practice and likewise rules to judge the ethics of any practice in medicine, we must recognize that individual world-views, in cooperation with the intrinsic medical ethic, can underlie the process. Such individual world-views can reorder care priorities to where the ends justify the means. If evidence demonstrated a therapy ineffective, yet it was practiced routinely, this would be bad. As stated above the situation is at least dishonest, but why is dishonesty bad? If self-interest is the prevailing human ethic then would not any medical practice that does not majority benefit the physician be bad? In 1991 Dr. L.D. Rue proposed at the American Academy for the Advancement of Science that modern culture needed a “noble lie” to foster moral behavior. The “lie” would be necessary as an authority to impart value to the universe and ourselves. While medicine Int Urogynecol J (2008) 19:745–746 DOI 10.1007/s00192-008-0617-8