Abstract
Evidence-based medicine (EBM) transformed modern healthcare by replacing anecdote with rigour and authority with data. Yet an unintended consequence has emerged at the bedside: therapeutic nihilism—the reflexive withholding of care in the face of clinical uncertainty, justified by the absence of definitive evidence. This article argues that therapeutic nihilism represents the dark side of misapplied EBM, arising when population-level data are mistaken for bedside mandates and when decision-making displaces clinical judgement.
Drawing on bedside reasoning, ward-level dilemmas, and patient-centred empirical research, the essay shows that therapeutic nihilism is not an evidentiary failure but a failure of ownership. Evidence informs decisions; judgement owns consequences. When judgement is abdicated, medicine becomes technically defensible yet morally hollow.
1. How Evidence-Based Medicine Quietly Turned Against the Bedside
Evidence-based medicine was never meant to silence clinicians. It was conceived as a synthesis of the best available evidence, clinical expertise, and patient values. At the bedside, however, this synthesis has gradually collapsed into hierarchy. Evidence now often dominates, while clinical expertise and contextual judgement are treated as sources of bias rather than wisdom.
On ward rounds, this appears in familiar phrases: “There’s no strong evidence,” “Guidelines don’t clearly recommend this,” “Let’s wait and watch.” Each statement may be factually correct. The problem lies not in the observation but in the inference that follows: therefore, we should not act. In this way, uncertainty—once the very condition that demanded judgement—has become a reason to retreat from it.
2. Decision-Making vs Clinical Judgement
The dark side of EBM emerges when decision-making is confused with clinical judgement.
Decision-making is procedural, algorithmic, and protocol-driven. It answers the question: What does the guideline allow? It works best when evidence is strong, populations are comparable, and risks are relatively symmetric.
Clinical judgement is interpretive, context-sensitive, and cannot be fully delegated. It answers a different question: given this patient, this uncertainty, and these risks—what should I do? Judgement becomes indispensable precisely when evidence is incomplete.
conflicting when patients in front of us do not resemble trial populations and when benefits and harms are asymmetric.
Protocols can support decisions. They cannot absolve judgement. And when the clinician’s discomfort with uncertainty pushes care toward inaction, therapeutic nihilism begins.
3. Clinical Uncertainty Is Not a Failure State
A central misconception fuelling therapeutic nihilism is the belief that uncertainty reflects inadequate knowledge and therefore inadequate grounds for action. In real-world medicine, uncertainty is often irreducible—frail elderly patients, multimorbidity, competing risks, and social constraints lie beyond the reach of many trials and guidelines.
Waiting for certainty in such contexts is not prudence; it is avoidance. Medicine does not operate in the domain of proof. It operates in the domain of reasonable action under uncertainty. Absence of evidence does not equal evidence of futility. Clinical responsibility persists even when certainty does not.
4. Therapeutic Nihilism at the Bedside: Empirical Reality
Therapeutic nihilism is not merely theoretical. Patient-centred qualitative research in amyotrophic lateral sclerosis (ALS) demonstrates how nihilism manifests once a disease is labelled “incurable”. Patients described being treated as_ “hopeless cases”_, with clinicians focusing narrowly on prognosis while withdrawing from care planning, symptom management, psychological support, and follow-up. Patients reported hearing statements such as “there is nothing more to be done”, leaving them feeling abandoned rather than informed.
Crucially, this withdrawal was not driven by evidence that supportive care causes harm. Rather, it reflected a failure of clinical judgement after recognition of limited disease-modifying options. The absence of a cure was misinterpreted as the absence of therapeutic responsibility. In bedside terms,_ “no cure”_ was misheard as “no care”.
5. The Moral Comfort of Inaction
Therapeutic nihilism persists because inaction can feel safer. Intervening exposes the clinician to complications, scrutiny, regret, and blame. Inaction, when supported by ambiguous evidence or guidelines, feels defensible and less personally risky.
But omission is not neutral. A decision not to act is still a decision, with consequences that unfold in physiology, function, dignity, and trust. The moral burden does not disappear simply because evidence is incomplete; it concentrates at the bedside, on the clinician who chooses.
6. When Caution Becomes Cruelty
There are moments when restraint is wisdom. There are others when restraint becomes neglect. Symptom-relieving therapies may be withheld because mortality benefit is unproven. Heart failure therapies may be underused because trial populations were younger. Patients may be told “nothing more can be done” when uncertainty—not impossibility—is the real barrier.
For clinicians, this posture can appear scientifically mature. For patients, it is experienced as abandonment. When caution becomes a reflex rather than a considered stance, it ceases to be humility and becomes disengagement.
7. Therapeutic Skepticism Is Not Therapeutic Nihilism
Concerns about bias, selective reporting, small effect sizes, and limited generalizability are legitimate. However, these concerns do not logically require therapeutic nihilism. Contemporary analysis of therapeutic skepticism argues for calibrated caution: lowering confidence in effect size estimates and being more critical of study conclusions, while still preserving therapeutic engagement.
In other words, skepticism should refine judgement, not extinguish it. Medicine is a mixed bag of highly effective, moderately effective, and marginal interventions. Broad-brush nihilism fails because it erases that heterogeneity—and because it confuses limitations of evidence with futility of care.
8. The Hidden Curriculum on Ward Rounds
Trainees learn more from what senior clinicians model than from what they teach. When uncertainty repeatedly leads to inaction, the implicit lesson becomes: uncertainty is dangerous, judgement is risky, and protocols are shields.
Over time, clinicians become highly competent at documenting why they did nothing and less comfortable explaining why they acted. This is not clinical humility. It is erosion of professional agency—and it breeds a culture where responsibility is outsourced rather than owned.
9. Reclaiming a Humane Evidence-Based Practice
The solution is not to abandon evidence nor to embrace reckless intervention. It is to restore balance.
A mature evidence-based practice:
Uses evidence to inform decisions
Uses judgement to own consequences
Accepts uncertainty without paralysis
Recognizes that responsibility cannot be delegated to guidelines
Care continues even when a cure does not. Evidence refines medicine. Judgement animates it.
10. Conclusion: Against the Quiet Abdication
Therapeutic nihilism is the dark side of evidence-based medicine, not because EBM is flawed, but because it is misunderstood. When judgement is surrendered in the name of evidence, medicine becomes technically defensible yet morally hollow. At the bedside, uncertainty does not excuse inaction. It demands someone willing to judge—and to stand by that judgement.
Evidence supports decisions. Judgement owns consequences. When uncertainty is greatest, judgement matters most.
Clinical Implications (Ward Teaching)
“No cure” must never become “no care”.
Decisions can be protocolized; judgement cannot.
Uncertainty does not absolve responsibility—it concentrates it.
Symptom relief, planning, dignity, and presence remain therapeutic duties even when disease-modifying options are limited.
References
- Maksymowicz S, Libura M, Malarkiewicz P. Overcoming therapeutic nihilism. Breaking bad news of amyotrophic lateral sclerosis—a patient-centred perspective in rare diseases. Neurological Sciences. 2022;43:4257–4265. 2. Fuller J. Therapeutic skepticism. In: The New Modern Medicine: Disease, Evidence, and Epidemiological Medicine. Oxford University Press; 2025:356–396.
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