• Why there is – thank goodness – no such thing as “evidence-based health policy”

    The following is a guest post by Keith Humphreys.  Keith is a Professor of Psychiatry at Stanford University and blogs at the Reality-Based Community.  He has worked with state, federal and international policy makers to improve public policies related to addiction and its treatment.

    During my time at the White House and Peter Piot’s at the United Nations, we both heard many activists and academics say that we health policy makers should just “do what the science says”. Policy debates should be free of politics, moral concerns, values, and ideologies, they argued. Instead they believed that health policy (e.g., how to provide health care to the uninsured) could and should be based solely on cold, hard facts. And then they would lay down some facts and tell us what health policy allegedly followed logically from them.

    Peter and I point out the logical and ethical problems with this conceptualization of “evidence-based policy” in BMJ (nee British Medical Journal, partly gated). There is no doubt that science can be extraordinarily useful for informing health policy, for example by evaluating new interventions, developing life-saving medications and identifying new threats to health (e.g., Peter co-discovered the Ebola virus).

    But what we do with scientific evidence is always a political and moral judgment. We don’t provide health care to the sick because the evidence forces us to. We provide health care to the sick because such activity is in keeping with our values. Likewise, we might choose to morally oppose certain policies (e.g., capital punishment) even if there is solid scientific evidence of benefit (e.g., if it is ever shown conclusively that capital punishment reduces crime). It would be dishonest to hide behind the evidence and say, for example, that science made us put a helpless human being to death; that moral judgment falls on all of our heads.

    To drive home the distinction between scientific evidence and its application, consider the strong scientific evidence that risk for addiction is highest in adolescence. It is just as evidence-informed to respond to these data by targeting alcohol and cigarette advertising at adolescents (as some companies have done) as it is to respond to these data by targeting addiction prevention programs at adolescents (as health professionals do). The problem with addiction-promoting companies isn’t their lack of reliance on scientific evidence, but their lack of decency.

    More generally, being good at science doesn’t mean being good at running society (if you don’t believe us, you really ought to sit in on a faculty meeting). That’s why scientists, including me and Peter, get one vote just like everyone else. We scientists of course have the right to push for our values and politics as individual citizens like everyone else, but we cannot claim the mantle of science when we venture beyond our data to our opinions about how other people should live.

    In short, evidence-informed policy is a worthy goal, but value-free evidence-based policy is a wrongheaded concept, and to the extent it allows political agendas to hide behind scientific credentials, it can also be dangerous.

    • A number of wonderful works illustrates this concept perfectly (“And the Band Played On” and “Emperor of All Maladies” comes to mind immediately). On the surface, it seems what drives politics (and thus policy decisions) is money, but underlying this is some sort of moral judgment.

      It’s interesting that the ACA attempts to turn this model on its head and use science to drive policy directions in the right way (PCORI). Is this, too, just a scientific mask for ideological questions? But one with which we happen to agree?

      Thanks for the thought-provoking post.

    • First, this post has an awful title, which doesn’t follow from the text, or from the referenced article. It’s the type of thing you expect to see in a tabloid, but not on TIE.

      It’s a shame that the title of your editorial in the BMJ was not retatined for this post (Scientific evidence alone is not sufficient basis for
      health policy). In a world where ideology and political expedience often trumps evidence collected on intervention research after public values have identified a health problem and menu of acceptable policy options, it’s irresponsible to wage war against evidence based policy writ large.

      Neither this blog post nor the linked publication provides a concrete example of any individual arguing that public health policy should be based solely on ‘science’, without any consideration of values. As such, I can’t help but feel that arguing against ‘value-free evidence based policy’ is a strawman.

      I can imagine political actors or stakeholder advocates choosing to downplay the ambiguity inherent in research results when they happen to have ‘evidence’ on their side, but I think this is an example of the garden variety dishonesty that pervades individuals with an advocacy viewpoint rather than being a serious academic argument.

      • Couldn’t agree more, arrow. One thing is to inform evidence with our moral code, whatever that happens to be, and another thing is to deny/prevent our moral code to be informed by evidence.

        Gart Valenc
        Twitter: @gartvalenc

      • I largely agree as well. The title of the journal article is entirely reasonable. But “evidence based” does not equal “valueless” in either medicine or policy.

    • From the article: “We don’t provide health care to the sick because the evidence forces us to. We provide health care to the sick because such activity is in keeping with our values.”

      In the US, isn’t health care purchased by the sick as well as the healthy who seek to preventive disease and to improve health?

      • Unfortunately, scientific evidence can be used as a justification for a bad policy. In the US, for example, I recall a past-president imply that “if you get sick and can’t obtain health care, it is your own fault and the country cannot be expected to provide you with that health care.”

        Where exactly is the “moral value” in such an idiotic justification for policy?

    • I don’t see how the dichotomy in health policy is any different from, let’s say, psychoanalytic therapy (a value driven placebo) vs. an evidence based/empirically supported treatment. Being scientific and impartial does not imply that one is unaware of the social or economic influences on health policy.

      Weak argument. More science, dude.

      • A. You’ve confused absence of mechanism for absence of utility, a very serious mistake both in science and policy studies.

        B. Mere awareness of social or economic influences doesn’t allow you to elide the fundamental problem, which is that data-gathering is not the same activity as priority-setting.

        More science, yes, always. But science alone? A non-starter, because that can’t work for policymaking.

        • Nope. Psychoanalytic has no mechanism because it works no better than placebo, ie. no utility. Empirically supported treatment generally still has an unknown mechanism, though the effect/utility is known. And again, evidence based treatment may or may not have a known mechanism but has a known effect/utility.

          Generally, the problem in policy making is the absence or misinterpretation of science/data. There will always be concerns from more qualitative perspectives that are voiced, and will generally be overrepresented. Asking for more science, or even daring to say “only science” will simply shift the currently skewed inputs to policy decisions.

          More science, less rhetoric, emotional appeal, and ideology please.

    • Interesting, but I see some irony. If “evidence-based health policy” meant looking at the deadly results of twentieth century experiments with socialized medicine, European social democracy, communism, and so forth–and then doing the opposite–then I’d be all for it!