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Doody's Review ServiceReviewer: Lisa Judy Chin, MPH, JD (Columbia University College of Physicians and Surgeons)
Description: This book reviews the historical and conceptual origins of evidence-based healthcare practice and discusses ethical issues that have emerged with the evolution of evidence-based practice.
Purpose: The author examines the professional conflict that clinicians are faced with — the demand that healthcare practice be based on the rigors of science but also needing to maintain their clinical judgment. According to the author, this conflict has created a tension for healthcare providers and resulted in one of the "greatest practical and ethical challenges in the history of the health professions." The author discusses the issue of uncertainty of knowledge in professional practice and yet, in the presence of such uncertainty, healthcare providers should not neglect their professional duty to reduce this uncertainty. The author contends, "that even our best evidence will never be complete or definitive is not in itself a reason to slack off." With that, the book provides a thoughtful discussion regarding the ethical considerations of evidence-based practice, and the provider's ethical obligation in navigating through the world of evidence-based practice, that is, why should healthcare providers adopt evidence-based practice and by doing so, they are not compromising their clinical judgment.
Audience: According to the author, the book is targeted for health professional students studying evidence-based practice, all physicians, and practitioners of epidemiology and public health. I would concur with the author about the intended audience for the book. Although the book has a strong emphasis on clinical medicine, there are critical topics for epidemiologists and public health professionals. The author should be regarded as a credible authority as a bioethicist who holds academic appointments in medicine, philosophy, epidemiology, public health, and nursing.
Features: The first three chapters of the book examine the history of evidence-based practice and the role of meta-analysis and research synthesis as a means to develop evidence-based practice. In chapter 4, the author discusses the use of randomized clinical trials as the "engine of evidence-based practice" and the application of computer informatics in clinical and epidemiological research and the issue of informed consent and confidentiality, as well the potential of uncertainty in conducting research. Also, in this chapter, the author also has a brief critical discussion of emergency public health informatics and uses bioterrorism as a case study. Chapter 5 examines the establishment of evidence-based clinical medicine via the development and use of clinical practice guidelines and the economic and legal consequences of guidelines. Of particular importance in this chapter, the author acknowledges the weaknesses of clinical practice guidelines but reminds us that the role of clinical practice guidelines can be used to reduce the uncertainty factor in the practice of medicine. In chapter 6, the author discusses issues of ethics in epidemiology and creating public health policy based on evidence. In examining the issue of creating evidence-based public health policy, the author uses three different case studies - passive smoking, screening mammography, and otitis media. The author also examines the issue of evidence-based genetics and its implication for designing health interventions. In the final chapter, the author draws together the various elements put forth in the previous chapters to examine the issue of ethics and evidence and the author proposes "ethical best practice" as means to deal "with the practical challenges raised by evidence-based medicine, showing that ethical practice is, in large part, scientifically sound practice." One major drawback of this book is that the author has very little discussion about the impact of evidence-based practice on the provider-patient relationship at the individual level. He argues that one reason why healthcare providers fail to adopt evidence-based practice is that providers don't believe the evidence applies to the individual patient. In making his argument for evidence-based practice, he draws on the broader perspective and why it should be applied to the individual patient. Although the argument is convincing, the discussion could be further enhanced if the provider-patient relationship on the individual level had been examined.
Assessment: Despite this weakness, the author provides a well written and readable work on the ethical issues of evidence-based practice for health professional students, clinical healthcare professionals, and public health professionals. He provides a substantiated argument for adopting evidence-based practice from an ethical perspective that healthcare providers and practitioners should consider.