Evidence Based Medicine
Here Trisha Greenhalgh, an actual expert, writes what I have been trying to write. In a Twitter thread.
Please click the link.
Two key tweets
But the principle of waiting for the definitive RCT [randomized controlled Trial] before taking action should not be seen as inviolable, or as always defining good science. On the contrary, this principle, inappropriately applied, will distort our perception of what “good science” is.
This explains with less than 280 characters what I was trying to say in “What has science established”. I am quite sure that she is correctly desscribing a widespred view that “waiting for a definitive RCT” defines “good science”. Clearly this is a category error. Science does not tell us what to do. It might tell us what will happen if we do things, but it is not a moral code. “First do no harm” is ethics not science. Good science requires recognizing what is not known, it does not have anything to do with the argument “we don’t know and therefore we should”. The principle however applied is not consistent with knowing what science is let alone knowing what good science is.
The scientific method, professional ethics and the Federal Food, Drug, and Cosmetic Act are all sets of rules that some people should follow. But they aren’t different aspects of the same entity, they aren’t different parts of one organic whole. Following Adam Smith, I think laws have been internalized to fear and obedience, then respect, then internaliztion so what was the letter of law becomes the voice of concience.
But, of course, the main point is
More specifically, taking a “primum non nocere” (= don’t act till we’ve got RCT certainty) stance when hundreds are dying daily makes no scientific or moral sense. It is neither scientifically nor morally reckless to try out policies that have a plausible chance of working
“…a widespred view that ‘waiting for a definitive RCT’ defines ‘good scicne’…”
[Aside from the typos, which are also a ubiquitous artifact of excessive mindless media, the desire to speak up in the midst of crisis is a ubiquitous means of doing something about things for which there is nothing that we can do anything about. Thanks to the Internet and alternative broadcasting means the self-absorbed ruminations of individuals discontent with their own immediate circumstance in life are in endless supply, albeit when emanating from elites then necessarily framed in some seemingly objective and academically relevant critique of those that are actually doing something responsible about our shared peril. The need to not disappear into the morass is even more compelling than our own self-pity.
Too cynical? Wait a while and see. ]
Robert,
BTW, I totally agree with you regarding the distinctions that you make among science, ethics, and morals. How could one not? Nonetheless, many that should know better will still say otherwise not necessarily because of their semantics disability per se, but rather because their understanding of the correct semantics does not adequately fulfill their inner needs to be seen and heard, which is best served by the illusion of informed dissent. Whether such protestations are a matter of simple insecurity or conforming to one’s priors can only be assessed individually.
I’m not sure about the point of this argument. All sorts of new treatments are being tried for COVID and with various levels of effectiveness. Just follow news oor, even better, the scientific literature, particularly the prerprints which often appear online as soon as the spell checker is done with them. Right now, no one has found a silver bullet, and, as always happens in the clinic, promising leads typically fail to reproduce reliably. Clinical data is noisy, but it’s the only data we’ve got.
In computer science, a big issue is scaling. It’s relatively easy to come up with a nice prototype, but getting it to work well for a million users is where the science and reproducibility come in. It’s like this is medicine. Doctors and others in the clinic have a lot of freedom to try things and observe the results. Rolling that result out as general practice is where the science comes in.
The kind of software I write for use around the house doesn’t need a QA department, bug tracking or source control. You really don’t want to manage your unemployment insurance web site this way for a reason, and it’s he same reason you don’t want every patient dosed with every online influencer’s nostrum de jour. We tried that kind of medicine. We tried it for thousands of years, and medical treatment was of limited value for tthousands of years. What changed? What changed was all that science-y stuff with controlled experiments and clinical trials.
Kaleberg Dude,
I can only believe that “the point of this argument” has to do with taking sides in the battle of the armchair quarterbacks over the orthodoxy of accelerated approval of Covid-19 treatment drugs. One such drug, remdesivir, really should not even be considered in such a context. There have been precedents in cancer chemo. If the drug is only administered in a clinical setting to patients with an extremely high probability of dying without such treatment then the rules are different. OTOH, boredom and helplessness are epidemic on a larger scale than Covid-19 thus far and armchair quarterbacking is a long established albeit temporary remedy for those afflictions.
Even in science there is sometimes a substantial separation between theoretical and applied disciplines, but in application development that separation can be huge. The science part of computers is mostly in the hardware engineering first and the OS second, placing queueing theory and serialization in the OS although they are essential and relevant to applications. For instance, how many different implementations of Agile Software Development exist? The same answer would apply to the question “How many firms using Agile Software Development exist?” This is comparable to so-called management sciences disciplines such as TQM.
My wife is a business systems analyst at Anthem, which uses Agile which she calls “Anthem Agile” rather than “Agile Agile.” I have been retired since June 2015, so I traded in SAS coding for a collection of hand tools. While she telecommutes sitting at our corner nook table in the kitchen, I shop for groceries, clean our pool, and this week complete the transplanting of our patio garden bell peppers into large pots. Every two or three weeks I plant two or three heads of Boston lettuce in 2 foot X 10 inch planters. Neither boredom nor helplessness have visited me.
Sometimes emergencies justify setting the rule book aside.
But not always and not for every instance. Tough calls I am glad I am not making.
Were I the patient, I would probably try just about anything (well except hydroxy and Lysol injections).
I would try hydroxychloroquine based on improved sumptoms on the single large RCT. Also in vitro evidence (it blocks infection in vitro).
@kaleberg I know what is being tried (see clinicaltrials.gov). I also know that deployment of Remdesivir came more than 2 months and tens of thosands of deaths after I called for it March 2 2020.
I also know that there are now dozens of candidate vaccines at least 2 of which are kmown to be safe yet I am told we will have to wait months before a vaccine is deployed.
I read you telling me to calm down as things are fine while thousands die a day and the caseload is frowing exponentially in Brazil and India.
I know resaerch is peoceeding at an incredible rate. I also know that the FDA is not sticking to business as usual. I am also sure that their caution is killing people.
Always I say RCT yes, but extreme expanded access while the trials are ongoing (eligibility for a trial being an exclusion criterion).