Sham Surgery: The Problem of Inadequate Medical Evidence

In an ideal word, doctors would choose what medical procedures to use on the basis of rigorous evidence. In reality, medical procedures may diffuse into clinical practice before they are scientifically evaluated. Once a procedure becomes popular, physicians may keep performing it, even after evidence emerges suggesting that it does not work. A leading example is arthroscopy for knee arthritis, which a landmark study has shown works no better than a placebo operation. We use the arthroscopy case as a window into the capacity of American government to serve citizens' shared interest in effective medicine. We identify severe problems at every stage of the policy process, from evaluation to decision making and implementation. Surgeons have attacked the study on questionable methodological grounds yet they have not insisted on the follow-up trials that would address the problems they claim undercut the study's unwelcome conclusions. In deference to expert opinion, the government has maintained broad coverage of the procedure under the Medicare program. These outcomes are unsurprising. Medical procedures are not subject to rigorous scientific evaluation in general. While drugs and devices are routinely tested for efficacy, there is no FDA for surgery. We argue that the systematic underevaluation of medical procedures reflects the simultaneous presence of market failures and government failures, and that this problem is not self-correcting.