Is Evidence-based Psychiatric Practice, Ethical Practice?: A Conceptual and Qualitative Study

Since its addition to the medical lexicon in 1992, the concept of ‘evidence-based medicine’ (EBM) has captured the imagination of the medical world, attracting both passionate advocates and ardent opponents. EBM is defined clinically as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Yet, its boldest claim is an ethical one: that EBM, rather than any other method, is the most effective way to fulfill our moral duty to help patients achieve better health. Academic debate on this point has been deeply polarized, from those who assert that ethical practice is evidence-based practice to those who argue that evidence-based practice impoverishes practice and robs it of ethical substance. Mainstream psychiatrists have endorsed EBM which holds out the promise of greater ethical legitimacy for psychiatric disorders and treatments through improved scientific substantiation. Evidence-based psychiatry arises through the straightforward application of EBM to the practice of psychiatry and thus shares the same ethical goal of EBM, to improve patients’ health. Given the ethical debates that have framed psychiatry since its inception as a medical specialty, and the particular nature of mental disorders and their treatments, it is unclear if EBM can be applied to psychiatry, and therefore, whether it can deliver on its ethical promises. This thesis project involved two phases. The first, a conceptual phase, included an analysis of EBM’s ethical commitments as they are represented in its two authoritative textbooks (‘literal’ EBM). This provisional analysis was then extended by a qualitative analysis of the views of three groups of participants concerning the ethics of EBM: 1) EBM developers; 2) mental health practitioners; and 3) philosophers or bioethicists. Combining the analyses from both phases, a more complete depiction of the ethics of EBM was developed in order to address the main thesis question. Evidence-based psychiatric practice cannot be ethical practice by itself. Instead, it can play a small ethical role in clinical practice, only if it is situated within the larger value structure of contemporary medicine and psychiatry.Ph