Sangtaeck Lim, MPH
Health Economics & Outcomes Research Fellow
Jefferson School of Population Health
Anthony Culyer, a professor of Economics at University of York, started his speech at the annual meeting of Society for Medical Decision Making on October 25th in Toronto by using an interesting analogy between the medieval map and heath technology assessment (HTA). He said “in the wonderful medieval map, there was an unexplained territory, Hic Sunt Dracones, around the edge, which nobody was sure about, and terrifying figures like dragons were out there. I see the similarity between this medieval map and HTA.” The audience chuckled.
Three keynote speakers at the meeting – Daniel Callahan, a philosopher in biomedical ethics and President Emeritus at the Hastings Center, Paul Glasziou, a director of the Center for Evidence-based Medicine at the University of Oxford, and Tony Culyer – shared their perspectives on the recent political turmoil around HTA. They talked about the research community’s recent struggles in building ethically acceptable and methodologically objective studies in the HTA realm.
Dr. Callahan ignited the debate by mentioning the recent controversy over the government’s recommendation that women in their 40s forego routine mammograms. He stated his belief that furious reactions from interest groups and the public were not only due to the ethical concerns, such as government’s interference over sacred doctor-patient relationship or individual’s freedom of choice, but also the fundamental mistrust in HTA research evidence.
Professor Culyer attributed this mistrust to two main “dragons” (factors the researchers are uncomfortable with) in the map of HTA: processes for (1) combining different types of evidence and (2) embodying equity concerns. To address these problems, he stressed that the research process be carried out transparently and researchers have ethical confidence that the final outcomes represent the best evidence, and the best experts, and that all the resources were used appropriately.
On the other hand, Paul Glasziou questioned if there has been overuse of HTA, which along with “dragons” increased public mistrust towards HTA. He pointed out that most technologies were simply no better than the existing ones. “For example, the simple mother’s kiss technique for removing foreign bodies from her baby’s nostril is no worse than any kind of current high-tech surgery. For some technologies like that, randomized trials or HTA are not even necessary.”
As a researcher, I do agree the recent public mistrust or uproar toward HTA has resulted from some researchers’ “sloppy” evidence generation and natural lag between new technology and the researcher’s understanding of it. But also as a former journalist, I believe it is a researcher’s duty to convey the new idea to the public in the plainest language and with the most transparent evidence.
Nonetheless, the tension between researchers and the public will continue as long as innovative technologies are being developed. Likewise HTA will certainly continue to struggle and be put to the test in the future. As Professor Cuyler appropriately used it in his speech, I would like to quote the former Labor Health minister in England, Frank Dobson’s line for researchers not to be too discouraged while pursuing the success of HTA:
“Probably not, but it’s worth a bloody good try.”