Q21

[elanaminkoff]

I am having trouble understanding how A is correct.
I felt I had a pretty good understanding of the passage, and my map is as follows-
P1- introduction to concept of equipoise
P2- idea of Theoretical equipoise and why it is too strict and unreasonable for clinical trials
P3 & 4- introduction to clinical equipoise and how it is a more practical solution for clinical trials (this is the side of the scale the author falls on)

So with this question my though it that I am looking for something that would weaken the idea that CE is superior to TE, and the primary reason given for CE's superiority is because it is not based on a single doctors idea of neutrality, but rather the group as a whole. So a dingle doctor can have a preference (since thats human nature) but as long as the group of doctors as a whole does not lean heavily towards on drug we can have CE and carry on with the trial. I just am not seeing how A does this, perhaps it is because I am not understanding the answer correctly. I had selected E thinking that this answer rules out one of the main problems the author had with TE. My thought process was that even though this is not weakening CE, it is strengthening TE, and so it perhaps is undermining the need for CE.

Can someone please help clear this up for me.

Thanks

[ohthatpatrick]

I think you're right that you're 90% there on this passage.

The one piece of tension you omitted from the beginning of the passage is the whole ethical backdrop that makes comparative trials tricky:

We have an ethical rule that says "you should only give the BEST treatment to patients".

Now say there's a comparative trial that compares drug X to drug Y.

Some people in the study only get drug X; some people only get drug Y.

Unless X and Y are equally effective, then one of these groups of people is getting an INFERIOR treatment. So aren't we being unethical in letting one of them get something OTHER THAN the best treatment?

The traditional answer to this dilemma was, "No, we have a mental standpoint of (theoretical) equipose. We have no idea whether X is better than Y, so it's ethical for us to give either drug to each group."

The author is saying, "c'monnnnn, really? You have NO idea whether X is better than Y? That's incredibly rare, for a physician to not already have some evidence/preference for the superiority of one over the other."

So if a physician can only conduct a comparative trial if she is TRULY impartial to the two drugs being compared, then we would hardly ever get to ethically conduct comparative trials.

What is the author's modification/compromise to this problem?

He's saying, let's ditch the standard of theoretical equipoise, which focuses on an individual's lack of preference (and is therefore really rare to find).

Instead, let's invoke the standard of clinical equipoise, which focuses on the overall medical community's lack of preference (which should presumably be much easier to come by).

The author is saying, "clinical trials are thus easier to ethically conduct. We don't have to worry about the physician administering the trial having a clear preference for one drug. We can rely on the idea that the medical community as a whole doesn't have a clear preference for one of the drugs in the study."

So the way (A) weakens the author's argument is by saying "Sorry, buddy. In MOST clinical trials, the medical community as a whole DOES have a clear preference for one of the drugs."

If that's the case, then clinical equipoise does NOT help us to overcome this ethical hurdle to most clinical trials, because clinical equipoise only saves us when we can plausibly argue that there ISN'T yet a consensus in the medical community about which drug in the study is the best.

Does that make sense?

=== other answers ===

(B) We never really cared about whether physicians would stay or leave, just whether they would already think that one of the treatments was BETTER than the other. Also, this is a 2nd paragraph idea. The question asked about the 3rd/4th.

(C) 3rd and 4th paragraphs are building the case for "clinical equipoise as a solution to our ethical problem". If there's less ethical oversight overall, that affects us whether we're using theoretical OR clinical equipoise as our standard. So nothing about this weakens the idea of clinical equipoise, specifically.

(D) The preference of ethicists vs. clinical researchers doesn't really matter to the 3rd/4th paragraph question of "does using the standard of clinical equipoise alleviate the ethical problems we have with theoretical equipoise?" This answer seems largely compatible with the passage to me. Naturally, ethicists would concoct and love the pure ideal of theoretical equipoise. The author, sensing the practical problems this rigid standard imposes on clinical researchers (who would thus not like TE), suggests a modification to the idea.

(E) The author did say that researchers would be liable (likely) to form a preference from early data. But this goes against a 2nd paragraph idea. This has nothing to do with the 3rd/4th paragraph, which are all about using the standard of clinical equipoise.

Hope this helps.

[jm.kahn]

I thought this was a tough question because there were two choices A and E that seemed to weaken the author's argument in 3rd and 4th paragraph. I'd just add a solid reason why E is not correct.

E is about researchers who begin the trial with "no" preference. On its face, it seems to weaken because all clinical equipoise was motivated in part because researchers develop preferences. But reading closely, the passage grants you that researchers "commonly" have preference for one of the treatments from the start, in the 3rd para. So even if E impacted trials where researchers began with "no" preference, it'd only impact a small set of researchers, not the ones for whom clinical equipoise is needed and who "usually" have a preference. So E doesn't really weaken the argument for clinical equipoise.

It's very subtle wording that clearly eliminates E.