Scientific Empiricism and Clinical Medicine: A Discussion Paper1

Ethical and scientific decision making in distraction osteogenesis

OBJECTIVE

To propose a prospective registry for distraction osteogenesis research.

RESULTS

The search strategy identified 82 reports, of which 11 were review articles, 17 were animal studies, 5 were theoretical models, and 49 were case reports/series.

CONCLUSIONS

So far, the literature concerning distraction osteogenesis does not allow reliable choices to be made on the most appropriate form of distraction osteogenesis in different clinical decisions or whether it is superior to osteotomy or nontreatment. A prospective registry is proposed to hasten critical appraisal of distraction osteogenesis.

Unique methodological issues facing randomized controlled trials of endourologic procedures

Randomized controlled trials provide the optimal design for evaluating the effectiveness of treatment but have not been widely accepted by surgical investigators. Although there are several methodological and ethical difficulties, none is insurmountable. In the United Kingdom, a regulatory agency has been established to supervise the introduction of new medical procedures, and something similar might be seen in the United States, particularly given the pressure from the government and third-party payors for proof of efficacy and cost effectiveness. Endourologists have responded to similar challenges in the past and must continue to do so.

The challenge of evaluating surgical procedures

All new interventions and procedures must be properly assessed in comparison to the currently accepted method(s). It is unethical not to do so. The optimum method is by Randomised Controlled Trial (RCT). This is ideally suited to the testing of drugs because the trial can usually be double blind and placebo controlled. RCTs are less commonly used for the evaluation of new surgical techniques. There are valid and invalid reasons for this and these are discussed.

The practical and ethical defects of surgical randomised prospective trials

This paper presents a strong criticism of the current enthusiasm for clinical randomised prospective studies in surgery. In the process, the author probes the 'intellectualism' or lack thereof in present day surgical attitudes. The subjects are examined against a framework of ethics and inescapable dilemmas. Ways of correcting the more obvious weaknesses are suggested. The manuscript is, and is meant to be, provocative and is particularly aimed at the academic audience served by this journal.