Letter to the Editor

Re: Raymond J, Mohr JP, The TEAM-ARUBA Collaborative Groups. The Prevention of Hemorrhagic Stroke: A Review of the Rational and Ethical Principles of Clinical Trials on Unruptured Intracranial Aneurysms and Arteriovenous Malformations. Interventional Neuroradiology 14: 365-373,2008.

We read with interest the article by Drs Raymond and Mohr regarding the ethics of clinical trials on patients with unruptured in- tracranial aneurysms (UIAs) and arteriove- nous malformations (AVMs). Both physicians have obviously given this subject a great deal of thought. However, those without a background in philosophy may find this article confusing and perhaps somewhat troubling.

There can be little doubt that there is uncertainty about whether AVMs and UIAs should be treated. Likewise, some of the existing natural history studies of both entities are fla- wed^1,2. Unless the reader is familiar with the literature, however, the references to existing studies are not enlightening and may mislead the reader into believing that the matter of their validity has been settled. A discussion of the shortcomings of the available evidence would have been both relevant and helpful.

Similarly, it is generally accepted that randomized controlled trials (RCTs) are established methods to address medical uncertainty. But this subject is not without controversy. The literature on the ethics of RCTs is enormous, and it is surprising to see so very little of it is referenced in this article. There are journals (e.g. The American Journal of Bioethics) and entire institutes (e.g. The Hastings Centre) dedicated to studying the kind of issues raised by Drs. Raymond and Mohr. Aristotle, the Greek empiricists and rationalists, Galen and Dewey provide the philosophical framework within which the authors develop their arguments for RCTs. But no matter how instructive and suggestive these debates from the history of philosophy might be, it is important to acknowledge that much relevant material has been written since then. The authors' purpose and the interested reader's understanding would have been better served by references to contemporary writings.

Perhaps most troubling is the almost offhand characterization of medicine as casuistry and most physicians as either cold, detached, scientific academics preoccupied with populations and statistics or pragmatic practitioners treating individuals guided solely by their personal, particularized experience. Casuistry is a complex concept and is essentially the application of a system (e.g. religion, experience) to explain an individual event. The authors link it perilously close to sophistry, which is the use of clever but false arguments to prove a point. In this way they create convenient "straw men" which they can use to caricature various attempts to advance medical research.

Most physicians, whether based at an academic institution or in the community, are a complex blend of many components, both scientific and experiential. To imply that one group is oblivious to, or uninterested in, the knowledge of the other is disingenuous. If the authors are truly interested in recruiting physicians to join TEAM and ARUBA, their case must be made with understandable science and logic, rather than rambles through esoteric reaches of the history of philosophy. Philosophy, like medicine, is a profession with its own history, methods and literature. To persuade physicians as scientists and practitioners, it must be deployed to generate arguments that are accessible and relevant to the contemporary context.