A question popped up on MEDLIB-L earlier this week, from a hospital librarian who is concerned that one of her docs is selectively using the information that she is providing. He's a proponent of a number of alternative psychiatry therapies (she mentions T-touch, reiki and suicide assessment scales, in particular) and, in the librarian's view, " the best evidence overwhelmingly points to a lack of efficacy in using any of these techniques".
She goes on to say,
Here's the dilemma. Although I have no way of knowing what this person does with the information I provide, my suspicion is that by the time it gets to people in charge of decision-making, the best evidence is played down, or not addressed at all.
And she wonders if there is something that she ought to do about this.
The follow-up discussion has been pretty good and most of the messages express caution about taking action that might be seen as interfering with the physician's decision making. In response to some of the comments, the original poster says, in part,
I've come to realize that perhaps this discussion is about defining the role of the medical librarian in EBM. Do we believe in it and support it? If so, shouldn't we be concerned about patients being subjected to, and billed for, therapies of any kind, not limited to alternative therapies which just happened to be the topic in my case, that have not borne up under scientific scrutiny?
It's a great question, and I have a great deal of sympathy for this librarian's concerns. But I fear that she is veering close to practicing medicine without a license. While librarians in general are big supporters of EBM, it is worth noting that there is still considerable discussion within the physician community about how one best makes use of evidence, and what role intuition, art, and the fact that the patient in front of you is not a statistic, all play in making treatment decisions. In many cases, the evidence base is weak (or nonexistent) to begin with, and physicians routinely find themselves in situations where the particulars of their case seem to defy a straightforward application of what the evidence seems to imply. This is likely to be particularly the case with alternative therapies which have not received as much objective, systematic study as more conventional therapies.
All librarians are faced with situations in which the information that they provide may be used to do harm. This is probably more often the case for hospital librarians than for those in any other sector. Certainly if a hospital librarian is aware of a situation in which he or she has reason to believe that someone is making treatment decisions that are harming a patient, this should be brought to the attention of the appropriate administrators in the hospital. But that doesn't seem to be the case in this example. In this case, the librarian is putting her judgment about how clinical decisions should be made (based on her evaluation of the evidence base in the literature) ahead of that of the requester. But she is doing this without knowing any of the specifics about the actual cases that may be affected. As a librarian, these are not her decisions to make. She can be an advocate for EBM and strive to provide the best and most comprehensive information resources available on a particular topic. But the judgment of how to make use of the resources, what to consider and what to ignore, and what other factors to bring to play, remain the responsibility of the physician, even in those cases where the librarian is sure that she is right and the physician is wrong.
It's tough one. And it makes me think of the dilemmas that we may find ourselves in where our professional ethics and personal ethics turn out to be not quite aligned, or even in conflict? Consider the situation of pharmacists who are opposed to abortion and feel an ethical responsibility to refuse to provide the morning-after pill? Does this conflict with their professional responsibilities?
In 1993, I was a member of the task force that developed the current MLA Code of Ethics. Even this many years later I think of it as one of the most satisfying experiences of my professional life. It was a wonderful group of people to work with, the discussions were rich and complex and rewarding, and I'm very proud of what we came up with.
But ethical issues aren't necessarily set in stone, and the challenges that we face (both as professionals and as individuals) shift over time, so I was very happy to hear, at the fall Board of Directors meeting, that president-elect Mary Ryan is thinking of including consideration of some ethical issues (in particular those involving conflicts of interest) among her presidential priorities. We'll find out more about that at the February board meeting, but I, for one, would be happy to see it happen.