Perspective: Second-Class Medicine – Implications of Evidence-Based Medicine for Improving Minority Access to Health Care

Abstract

The Promise of Evidence-Based Medicine. The spectacular ascent of medical science at the dawn of the twenty-first century trumpets a new era in US health care and great possibilities for preserving human health. At the same time, it poses serious challenges for policymakers who must make crucial decisions about the safety, efficacy, and affordability of medical technologies. One of the most difficult and contentious matters confronting decision-makers is the question of how to ensure the delivery of lifesaving technologies to low-income and minority patient populations, whereas simultaneously controlling ever-rising health-care costs. In theory, the increasingly popular concept of evidence-based medicine (EBM) suggests a potential tool for both cost containment and the reduction of severe racial and ethnic disparities in health-care delivery. Drawn from systematic reviews of studies that use rigorous research methods, particularly the randomized controlled trial, the "evidence" guiding EBM protocols informs treatment decisions made by physicians, as well as policy decisions regarding the allocation of health technologies at the population level. Operating largely out of the "average" American's view, EBM protocols are policy devices that set the rules for who gets what medical care and on what terms. The foremost claim of some advocates of EBM is that it serves this function well by providing the best available "evidence" about therapeutic interventions, thereby enhancing the capacity of policymakers and physicians to make sound, defensible decisions. At least in theory, the use of EBM should lead invariably to rational decisions so that patients with the same illnesses and clinical indications receive appropriate interventions regardless of race or ethnicity. Again in theory, policy decisions made within EBM frameworks should lead to evenhandedness in the allocation of therapeutic interventions at the population level. Thus, EBM offers the "implicit promise of greater fairness than previously existed" (Poolsup et al., J Clin Pharm Ther 25:197-220, 2000; Taylor et al., N Engl J Med 351:2049-2057, 2004; Yancy, J Card Fail 6:183-186, 2000; Rogers, J Med Ethics 30(2):141-145, 2004).