Shared decision making is the only outcome that matters in evidence based medicine


Over the years I’ve made a variety of arguments about contemporary midwifery and lactivist philosophies:

1. They subvert science by exaggerating benefits of favored treatment options (unmedicated vaginal birth and breastfeeding).

2. They threaten safety by ignoring risks of favored treatment options.

3. They falsely declare favored treatments save money but neglect to include costs.

4. They are multi billion dollar businesses, not selfless provision of care.

5. They are anti-feminist because they judge women by the function of their reproductive organs.

But even if we were to ignore all these faults, we would still be left with the biggest drawback of them all; contemporary midwifery and lactivist philosophy are unethical.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is unethical to use population level outcomes as justification to ignore patient preferences.[/pullquote]


As the authors of Shared decision is the only outcome that matters when it comes to evaluating evidence-based practice explain:

[E]valuations of the impact of evidence-based practice (EBP) are invariably focused on improving population-level health outcomes (overall incidence of heart attacks or hospitalisations) rather than at the individual patient level.

We believe this focus is inappropriate and fundamentally flawed for the following reasons.

Population-level health outcomes rarely if ever take into account patient values and preferences and therefore by definition fly directly in the face of the fundamental goals and definition of EBP. Ignoring patient values and preferences or at least not placing them at the forefront of decision making legitimises the argument that the presence of effects at population levels is sufficient justification for recommending treatments even though the absolute magnitude of these changes clearly may not be important to all individual patients.

The authors are not writing about efforts to promote unmedicated vaginal birth or breastfeeding, but they could be. The problem is:

[A] fundamental misunderstanding many have about EBP: that the rationale and justification for EBP relies on being able to demonstrate that EBP somehow should lead to better clinical outcomes. This common misunderstanding pervades the current scientific discourse around EBP and impedes how, as a society, we should practice medicine. EBP is about taking care of individuals and is not about the insensitive use of population-based evidence. As soon as the question moves to one of clinical outcomes, this individual-to-population frame-shift occurs and clinicians often consider scientific probability at aggregate levels. Looking at outcomes for individuals is entirely different from thinking about evidence from large groups in trials and in cohorts.

In other words, EVEN IF unmedicated vaginal birth or breastfeeding are shown to have population level benefits, that does NOT justify pressuring patients to make those choices. That’s because scientific evidence is a tool akin to a measuring tape to be used to evaluate various treatment options, not a cudgel to be used to beat patients into conformity.

So, for example, we can counsel a patient about the population level outcomes of various treatments for a his metastatic cancer, but it would be unethical to pressure him to choose the option that has the best population benefit if it does not comport with his preferences.

So, for example we can counsel a pregnant woman whose fetus has a severe brain malformation about the dismal population level outcomes for babies like hers, but it would be unethical to pressure her to terminate the pregnancy if that does not comport with her personal beliefs.

So, for example, we can counsel a pregnant woman about increased systemic risks of a C-sections, but it is unethical to refuse maternal request C-sections.

So, for example, we can counsel a new mother that breastfeeding has population level benefits for babies, but it is unethical to pressure her to breastfeed because that is “best.”

The authors include a graphic that offers even more examples of what evidence based practice is NOT.


It’s NOT about saving money so it wouldn’t matter if vaginal births and breastfeeding save money (although they don’t).
It’s NOT only about the results of clinical trials and systematic reviews so no amount of scientific evidence on the “risks” of epidurals or formula feeding should be used to prevent a woman from opting for either one.
It’s NOT about achieving a specific outcome; it’s about achieving the outcome the patient prefers.

It is about using the best available evidence in a hierarchical way to answer clinical questions. But the answer to the clinical question is NOT the ethical determinant of the treatment, the patient’s decision is the determinant.

The authors conclude:

Evaluating evidence based practice decisions — N always=1

As healthcare professionals, we accept the need to explain to patients there is evidence of effective treatments at population levels. However, the decision whether to adopt most treatments at an individual level is a decision that is unique, context-based and derived by careful deliberation about trade-offs. This careful deliberation defines EBP, and in the vast majority of circumstances, the only outcome of relevance for EBP is to measure whether a shared decision was made.

The bottom line is that no amount of population based evidence justifies ignoring the needs and desires of the individual patient.