Can Pragma defeat Dogma?

All great human endeavours carry with them a dogma, a philosophy, a kind of spiritual guidance. Manifest Destiny, American Exceptionalism, the “lucky country” down under—each rested on such a foundation.

In the case of medicine, and healthcare more broadly, the guiding spiritual force has become a paradigm known as Evidence-Based Medicine and its offspring, Clinical Practice Guidelines. Emerging in the 1990s from biomedical thought centres in North America and Europe, EBM was motivated by the hope of reducing variability in clinical decision-making, increasing objectivity, and ultimately improving outcomes.

Nothing could be further from the truth.

Over the past three decades, the centralisation of clinical decision-making has created perverse incentives and opened the door for the co-opting of the very process it sought to purify. Established with the best of intentions, the EBM-CPG paradigm has presided over the greatest decline in human health outside of wartime.

The enshrining of EBM as an unassailable moral doctrine—a sacred cow to which healthcare must pay homage—must itself be interrogated. It deserves to be a topic of open, rigorous, and outcome-based analysis amongst clinicians, researchers, and policymakers.

When I conducted such an analysis, what emerged was sobering: a system designed to elevate quality instead producing poor outcomes, inefficient resource distribution, and serving as the justification to suppress alternative and innovative technologies—technologies that could have been far better suited to addressing the chronic health crisis in which we now find ourselves.