This article touches on a number of interesting topics. It refers to 'orphaned fields' - which include, for example, low back pain; it refers to the 'primary ethical problem' is the lack of attention to the orphaned fields; it refers to additional types of evidence - beyond RCTs - that are relevant to evaluating effective treatments in these fields; it identifies cases that demonstrate the capacity of practitioners in the orphaned fields to take on board evidence-based medicine. An illustratve extract:
…orphaned fields of medicine, that is areas of medicine where medical research is weak and diverse, is lacking financial incentives, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health. In these fields, complex syndromes such as repetitive strain injury syndrome (RSI), whiplash, chronic low back pain, and chronic fatigue syndrome (CFS) are investigated. There is an urgent need for well designed effect studies, preferably randomised clinical trials (RCTs), to distinguish effective from ineffective therapies. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields.
The problem may be diagnosed as a lack of evidence as such or as a lack of evidence that is appropriate to these specific fields and patients. Especially when allocation decisions are linked to the availability of evidence, matters of justice are at stake.
The article identifies two 'ethical ways of reasoning' about EBM in relation to the 'orphaned fields': one treats EBM as 'intrusive' and potentially inappropriate; the authors' prefer a second model that seeks to expand the methodology of EBM to incorporate the considerations that are particularly relevant in the orphaned fields, for example by paying more attention to patient narratives: their approach retains respect for existing EBM approaches such as RCTs.