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HEALTH POLICY AND ETHICS: David R. Buchanan and Franklin G. Miller Justice and Fairness in the Kennedy Krieger Institute Lead Paint Study: the Ethics of Public Health Research on Less Expensive, Less Effective Interventions Am J Public Health 2006; 96: 781-787 [Abstract] [Full text] [PDF]

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Evidence-based ethics?

Jessica M. Robbins   (5 June 2006)

Evidence-based ethics? 5 June 2006
Jessica M. Robbins, epidemiologist Einstein Center for Urban Health Policy and Research Send letter to journal: Re: Evidence-based ethics? jessica.robbins{at}phila.gov Jessica M. Robbins	Buchanan and Miller's article on the ethical questions associated with research into less-expensive alternatives to existing but underutilized treatments lays out an interesting set of conditions under which such research would be ethical. They do not, however, address the question of who determines whether those conditions are met and how. The judgments, for example, that "resource or political constraints ... do not allow full or extensive provision" of a better treatment and that there is "a high degree of likelihood" that the less expensive treatment will be implemented are not simple and not within the professional expertise of most medical or public health researchers. Much of the discussion of these issues reflects conflicting assumptions about empirical questions that are rarely spelled out. Buchanan and Miller assume that the "libertarian conception of justice that would leave social betterment to market forces" not only prevails now but will prevail for the foreseeable future and that in general the pace of social change is "glacial." In this framework, there is no difficulty in concluding that constraints that exist today will continue to exist indefinitely, regardless of whether or not research is done on less- expensive alternatives. Others, however, believe that exploration of less -beneficial treatments reduces the chances of or slows the introduction of the best treatment for all. These are questions for which empirical evidence can and should be explored. The pace of social change in recent years has been rapid, not glacial, and often in directions that are harmful to public health. Some AIDS-related research projects have been launched on the assumption that treatments available in the United States and Europe would not become available in less-developed countries. This assumption has sometimes been proved wrong, at least for some populations. Whether the provision of less-effective treatments actually deters the provision of more-effective treatments is a more complex question. I would welcome evidence-based efforts to answer it. Many ethical questions turn on values, not facts. But many also rest on beliefs about social and political realities, and these beliefs should be defended with evidence, not just assertion.