Evidence-based medicine and equity: The exclusion of disadvantaged groups

Abstract

Being healthy is almost universally acknowledged as a significant good, both in itself and for the instrumental value of good health in achieving other important goals in life. At some periods in history, poor health has been seen as a matter of fate or chance, a natural disaster akin to earthquakes or floods. If this were the case, the moral duty on society would be to help those who were afflicted, but there could be no responsibility to influence the distribution of ifi health as this would be considered to be beyond human control. In the early twenty first century, we have a different view. We know that the burdens of health are unevenly distributed, both within societies and between societies. Poor health is strongly associated with poverty, with disadvantage, with social exclusion. We also know that access to good health care tends to vary inversely with the need for it, and that this Inverse Care Law is as true today as when it was first described thirty years ago (Watt 2002). This information should change the nature of our moral responsibilities with regard to health care; not only should we treat those who are sick, but we should act to prevent this maldistribution of both ill health and health care, and to ensure that the disadvantaged receive the best rather than the worst of our health care. We might do this in a number of ways, for example through individual clinical interventions, through systemic approaches to health care, or by using policy to direct activities in the health sector and beyond. Evidence-based Medicine is an approach to health care that seems to offer multi-level assistance in creating and delivering fairer health care. This implicit promise of fairness operates in at least two ways. First, the processes of EBM are committed to objectivity through the use of strictly standardised methods, thereby eliminating opportunities for subjective decisions and possible discrimination. Second, the findings of EBM can be used to ensure fair distribution of effective interventions across the population, at the individual level through the use of evidence-based practice, and at the population level through the use of evidence-informed health policy and resource-allocation decisions. Avoiding discrimination and ensuring fair distribution of effective treatments are potentially powerful tools in addressing the exclusion of disadvantaged groups and achieving greater equity in health care. This paper explores the effects upon health equity of using EBM as the basis for clinical care and health policy decisions, using a focus on disadvantaged groups. Disadvantaged" is a very general descriptor; here I take the term to include groups subject to social exclusion or deprivation for reasons such as low socio-economic status, ethnicity, age, gender, mental ifi health or similar. If EBM improves the health care (and so health) of those with the greatest burden of ill health, then we are some way towards meeting our responsibilities. The paper is divided into three main sections, looking at the way evidence is created, the way EBM is clinically applied, and the policy uses of EBM. © 2005 Springer-Verlag Berlin Heidelberg.