Editor's Choice

It’s the evidence, stupid

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2119 (Published 16 October 2008) Cite this as: BMJ 2008;337:a2119
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

    Nearly 20 years ago, the US state of Oregon embarked on a brave experiment to explicitly ration health care. The aim was to create and then whittle away at a prioritised list of treatments covered by the state funded Medicaid programme, so that the available money would cover more people. With the global credit crunch likely to make scarce resources even scarcer, this week’s BMJ looks back at what can be learnt from Oregon and forward to how we should ration health care in the future.

    As Vidhya Alakeson explains (doi:10.1136/bmj.a1563), the unique thing about Oregon’s 1989 health plan was its commitment to being both systematic and transparent. But it hit the rocks of an economic downturn, and almost no other health system has adopted the approach. Oregon’s latest attempt at health reform is more sophisticated, but, says Alakeson, it may prove just as unlucky in its timing. As Doug Kamerow writes (doi:10.1136/bmj.a2093), America’s economic crisis has pushed health care off the agenda. He is scathing about President Bush’s subversion of scientific evidence for political ends. A new president should swiftly recommit to science, transparency, and public scrutiny, he says.

    How then should we move forward in healthcare rationing (or prioritisation, or allocation—whichever word works best for you)? Should clinicians take the lead, as Norheim proposes (doi:10.1136/bmj.a1846)? Can we hold decision makers to account for the “reasonableness” of their decisions, as Daniels and Sabin think is necessary (doi:10.1136/bmj.a1850)? Or should we look to economic frameworks (systematically stopping doing things that don’t work and spending the money on things that do), as Donaldson and colleagues describe (doi:10.1136/bmj.a1872)? Some combination of all three approaches is likely to be the answer.

    It’s interesting that markets don’t get a favourable mention by any of our commentators, as the editorial by Goold and Baum points out (doi:10.1136/bmj.a2047). Donaldson and colleagues contend that incentives don’t deliver rational decisions, and there’s support for this in Keyhani and colleagues’ New York based study of overuse of tympanostomy tubes for otitis media (doi:10.1136/bmj.a1607).

    It comes back to the same old cry—what’s the evidence that something works safely and provides value for money for society and individual patients? The evidence may be weak, but it must always be the starting point for any debate. And that applies to complementary medicine too. I mention this because of a letter this week from Edzard Ernst, the UK’s only professor of complementary medicine (doi:10.1136/bmj.a2063). It seems that sections of the complementary medicine community are less than keen to discuss the science behind their recommendations, resorting instead to lobbying, intimidation, and threats of legal action. Ernst calls the frequency of such events in recent months “downright scary.” We should all be concerned about this. It’s not about protectionism on the part of conventional medicine; it’s about calling all practitioners to account on the same terms and, as with the debate on rationing, honouring our professional commitment to science, transparency, and public scrutiny.


    Cite this as: BMJ 2008;337:a2119

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