https://www.tabletmag.com/sections/science/articles/randomized-control-tests-doidge
The idea that “only RCTs can decide,” is still the defining attitude, though, of what I shall describe as the RCT fundamentalist. By fundamentalist I here mean someone evincing an unwavering attachment to a set of beliefs and a kind of literal mindedness that lacks nuance—and that, in this case, sees the RCT as the sole source of objective truth in medicine (as fundamentalists often see their own core belief). Like many a fundamentalist, this often involves posing as a purveyor of the authoritative position, but in fact their position may not be. As well, the core belief is repeated, like a catechism, at times ad nauseum, and contrasting beliefs are treated like heresies. What the RCT fundamentalist is peddling is not a scientific attitude, but rather forcing a tool, the RCT, which was designed for a particular kind of problem to become the only tool we use. In this case, RCT is best understood as standing not for Randomized Control Trials, but rather “Rigidly Constrained Thinking” (a phrase coined by the statistician David Streiner in the 1990s).
With such a good technique as RCTs, one might wonder, why do we ever bother with observational studies?
There are a number of situations in medicine in which observational studies are obviously superior to randomized control trials (RCTs), such as when we want to identify the risk factors for an illness. If we suspected that using crack cocaine was bad for the developing brains of children, it would not be acceptable to do an RCT (which would take a large group of kids, and randomly prescribe half of them crack cocaine and the other half a placebo and then see which group did better on tests of brain function). We would instead follow kids who had previously taken crack, and those who never had, in an observational study, and see which group did better. All studies ask questions, and exist in a context, and the moral context is relevant to the choice of the tool you use to answer the question. That is Hippocrates 101: Do no harm.
Similarly, withholding the most promising treatment we have for a lethal illness is also a moral matter. That is precisely the position taken by the French researchers who thought that hydroxychloroquine plus azithromycin was the most promising treatment known for seriously ill COVID-19 patients, and who argued that doing an RCT (which meant withholding the drug from half the patients) was unconscionable. RCT fundamentalists called their study “flawed” and “sloppy,” implying it had a weak methodology. The French researchers responded, in effect saying, we are physicians first; these people are coming to us to help them survive a lethal illness, not to be research subjects. We can’t randomize them and say to half, sorry, this isn’t your lucky day today, you are in the nontreatment group.
I remember there have been several RCT studies that were stopped short of completion when evidence became overwhelming that the treatment worked. The expressed reasoning of the managers of the studies was that is was immoral to withhold a treatment proved efficacious from the placebo group.
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