Evidence and ethics in occupational therapy.
Reagon, Bellin and Boniface argue that traditional models of
evidence-based practice focus too much on randomised controlled trials
and neglect 'the multiple truths of occupational therapy'
(Reagon et al 2010). This opinion piece points out several flaws in
their argument, and suggests that it is unethical to rely on weaker
evidence sources when higher quality evidence exists. Ironically, the
evidence that they provide to support their argument regarding different
types of evidence is itself very weak.
Evidence, ethics, decision making.
Occupational therapy (Management)
Occupational therapy (Ethical aspects)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: May, 2011 Source Volume: 74 Source Issue: 5|
|Topic:||Event Code: 310 Science & research; 200 Management dynamics; 290 Public affairs Advertising Code: 91 Ethics Computer Subject: Company business management|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Reagon, Bellin and Boniface set out an argument in their opinion piece that the conventional model of evidence-based practice (EBP) is limited and inappropriate to the client-centred approach of occupational therapy; they seek to suggest a different model of EBP 'which is congruent with occupational therapy philosophy' (Reagon et al 2010, p284). They state in their abstract that 'evidence-based practice is the buzzword of policy makers, managers and practitioners alike and yet there is confusion as to what it actually means' (p284). Despite this claim, they then state in their introduction that 'evidence-based health care' (which they treat as a synonymous term) 'is an approach to practice in which clinical decisions are based upon evidence rather than opinion or tradition' (p284). It seems that there is not so much confusion after all, and no evidence is provided to support their assertion in the abstract that anyone has any problem with this definition.
The purported problems with EBP are stated to be 'detachment from the real world, displacement of expertise and undervaluing of information not derived from research' (p284). Given the topic of the opinion piece and the claim that there is confusion about what EBP is, it is unfortunate that Reagon et al (2010) did not see fit to include the evidence-based medicine (EBM) pyramid as an illustration (see Fig. 1). This simple diagram makes the hierarchy of evidence very clear (more on this later). Systematic reviews of research are the best evidence, but expertise and case studies are also relevant, if lower down the pyramid.
The central thesis of the opinion piece is stated as being that 'there is a tension between practice based upon the needs of individuals and practice based upon theories derived from research' (p284). This conclusion is derived from focus groups and interviews with 21 occupational therapists in one primary care trust. Only five quotes are provided from this group, and it is impossible to tell whether they are from five different people or one person whose views support the argument of Reagon et al (2010). Neither is any information provided about the precise topics and questions used in the study.
The first quote states that occupational therapy is 'a very touchy, feely, doing kind of profession. It isn't a pure science that's provable with numbers' (p285). Here one person's opinion about evidence is provided as evidence of the non-evidence-based nature of occupational therapy. It may be true that occupational therapy is a very client-based discipline, but that does not mean that rigorous research cannot be done in the area, as Armstrong (2010) has pointed out. Reagon et al (2010) state that 'research findings are bound to a specific time ... that may have little to do with individual clinical encounters' (p285). This is true to some extent, but randomised controlled trials (RCTs) are a great guarantor of generalisability. More importantly, evidence obtained from one's own professional experience is even less generalisable to other contexts.
[FIGURE 1 OMITTED]
The second quote takes things further: 'Truth is a subjective thing. A lawyer might disagree with me but I think in terms of healthcare it's subjective' (p285). This is a classic example of a self-contradictory statement. The participant is claiming that his or her claim about the subjectivity of truth is objectively true; either way, he or she must be wrong. And once again, one person's assertion of something as fact is scant evidence that it is true. (One would also have thought that a lawyer would be the first person to agree with the statement.) Another participant stated that it might not be possible to find 'a finite idea of truth' (p285), without explaining what this is supposed to mean.
To support this 'evidence' further, Reagon et al (2010) reference several papers, one of which compares medical science to a golem. It is then simply stated that 'This view is very different from the traditional conception of science as a process by which objective facts are steadily accumulated to form an authoritative knowledge base' (p285).
It is indeed very different, but this is simply the opinion of two authors, and that does not make it true. Despite the fact that they point out that evidence trumps opinion, Reagon et al (2010) seek to wield opinion as evidence. Another example is a further quote from the same authors, which is used to claim that 'medical science ... should be approached with "well-informed caution"' (p285). Quoting three words from a paper without providing any reasoning is not evidence-based referencing.
Multiple truths and sources of evidence
Participants stated that there are no 'universal "right" answers to clinical questions; rather, rightness was felt to be dependent upon a range of biopsychosocial and even spiritual considerations' (p285). Once again, stating it does not make it true, and in many cases there is a clear right answer, even if it is difficult to find, and can perhaps only be found in retrospect. Reagon et al (2010) conclude from the responses that 'multiple versions of truth coexist' (p285). Does this mean that there is also a truth in existence that multiple versions of truth do not coexist?
Reagon et al (2010) then go on to link this idea with their proposal that we should 'broaden the definition of evidence to incorporate multiple sources of information, such as research, clinical expertise, client stories, reflections on clinical experience, education/training and clinical outcomes' (p286). However, with the exception of client stories and reflections, all of these are already potential sources of evidence according to the EBM pyramid (Fig. 1). Of course we must consider experience, education, and outcome information when we are trying to reach an evidence-based decision: it is misleading in the extreme to suggest that EBP currently excludes these sources, and it has been recognised for many years that different problems require different types of evidence (Glasziou et al 2004). What about client stories and reflections on clinical experience? Given that clinical expertise is based on experience, the latter is simply repetition. It is not clear quite what is meant by 'client stories'; obviously clients' medical histories are essential, but if the suggestion is that we should base treatment decisions upon clients' stories, which might be no more than anecdotes, this might be stretching the concept of evidence rather too far.
The closest Reagon et al (2010) get to referring to the EBM pyramid is when they state that 'Rather than attempting to rank evidence sources hierarchically as in traditional models, evidence should be critiqued for its reliability and relevance to the clinical encounter at hand' (p286). The reason that systematic reviews and meta-analyses are at the top of the EBM pyramid is because they are more reliable sources of evidence. This is why the hierarchy exists. While other sources are also valuable, it simply does not make sense to consider them as being equal. In fact, the hierarchy is based upon a critique of reliability of the different methods; Reagon et al (2010) seem to be unaware of this. And once again, it is obvious that the relevance of evidence to a particular clinical situation must always be considered: the trouble with relying upon case studies and individual clinical experience is that we often seek to apply lessons learned from one client to another, when each client is different. As Armstrong (2010, p334) has asked in response to the opinion piece in question, 'How can subjective experience control for bias or for other factors that affect the results?' Only through testing different approaches, using the most rigorous methods of EBM, can we be confident that what worked for one client will work for another.
We have already seen that much of the opinion piece is not new, or based on a misunderstanding of EBM, and what is novel in it is mistaken. However, perhaps the most troubling aspect of the opinion piece is its suggestion that ignoring evidence can be good. In addition to the aforementioned claim that there is no such thing as the right answer, 'The participants gave examples of negotiating treatment plans away from the evidence base in order to accommodate individual preference. Often these involved an element of measured risk taking' (p285). Does this mean that occupational therapists put clients at risk despite evidence that there was a better course of action? No detail is given, so we can only speculate.
Note also that the very concept of risk is dependent on evidence; presumably there was also evidence in such cases that the client would benefit. Otherwise, such practice would be in breach of various occupational therapy ethical codes, including, in the United Kingdom, that of the College of Occupational Therapists' (2010) Code of Ethics and Professional Conduct, which states: 'Any advice or intervention provided should be based upon the most recent evidence available, best practice, or local/national guidelines and protocols' (p17). It is simply unethical to provide treatment that is not informed by the evidence base, as doing so increases the risk of harm to the client. Despite the fact that they acknowledge the risk in doing so, Reagon et al (2010) do not seem to realise that what they are advocating is unethical. (Furthermore, organisations such as the National Institute for Health and Clinical Excellence provide clinical guidelines that are based on various sources of evidence, which also state the strengths and weaknesses of such evidence; such guidelines can inform treatment plans without compromising individual preference.)
In her Elizabeth Casson Memorial Lecture, Drummond (2010) spoke out against pseudoscience, which she defined as '... a methodology, belief or practice claiming or appearing to be scientific but which does not adhere to scientific methodology, lacks supporting evidence or plausibility, or otherwise lacks scientific status' (p296). She added that 'bad research often has a very small sample size, [and] cherry picks the people in the study' (p294). This opinion piece has shown that Reagon et al (2010) neglect to mention the EBM pyramid, and that their support for a theory of multiple truths is logically incoherent and derived from a very small sample. However, their opinion piece does make one important contribution: it highlights the fact that some occupational therapists are still unaware that EBM is an essential component of ethical practice within the profession.
The lack of good quality research and evidence for occupational therapists to draw upon in their daily practice may be behind the 'perceived discrepancy' between evidence-based practice and occupational therapy philosophy. Therefore, the solution is not to 'broaden the definition of evidence', as suggested by Reagon et al (2010, p286), but rather to encourage occupational therapists to participate in high quality research, and to raise awareness of the evidence sources currently available and how to incorporate them into everyday practice. Correct use of the current EBM pyramid encourages the use of multiple evidence sources in order to arrive at the most appropriate intervention for the client. Indeed, by taking into account all of the evidence available, more options are created for the client and, in this way, occupational therapists are able to work in a more holistic and client-centred manner. It is essential for occupational therapy to embrace ethical EBP and move away from anecdote-based client care.
Armstrong B (2010) Scientific methods. (Letter.) British Journal of Occupational Therapy, 73(6), 334.
College of Occupational Therapists (2010) Code of ethics and professional conduct. Available at: http://www.cot.org.uk/homepage/publications/ ?l=l&ListItemID=393&ListGroupID=248 Accessed 04.05.11.
Drummond A (2010) The Elizabeth Casson Memorial Lecture 2010: 'Jack of all trades and master of none': the future of occupational therapy? British Journal of Occupational Therapy, 73(7), 292-99.
Glasziou O, Vandenbroucke J, Chalmers I (2004) Assessing the quality of research. British Medical Journal, 328(7430), 39-41.
Glover J, Izzo D, Odato K, Wang L(2006) Evidence-based medicine pyramid. Dartmouth College and Yale University. Available at: http://ebmpyramid. org/preview.php Accessed 21.07.10.
Reagon C, Bellin B, Boniface G (2010) Challenging the dominant voice: the multiple evidence sources of occupational therapy. British Journal of Occupational Therapy, 73(6), 284-86.
Justine Shaw (1) and David Shaw (2)
(1) Occupational therapy student, School of Health, Glasgow Caledonian University, Glasgow.
(2) Lecturer in Ethics, School of Medicine, University of Glasgow, Glasgow.
Corresponding author: Dr David Shaw, Lecturer in Ethics, School of Medicine, University of Glasgow, 378 Sauchiehall Street, Glasgow G2 3JZ.
Reference: Shaw J, Shaw D (2011) Evidence and ethics in occupational therapy. British Journal of Occupational Therapy, 74(5), 254-256.
Submitted: 13 August 2010.
Accepted: 14 April 2011.
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