Striking the Balance: Evidence-Based versus Defensive Medicine

In modern medicine, physicians promote the use of evidence-based practice, making clinical decisions rooted in tested research and guidelines. Pragmatically, many still default to license-protection care: ordering extra tests, extending antibiotic use post-surgery, or avoiding riskier treatments primarily to shield themselves from potential liability. This tension between ideal evidence-based interventions and defensive management affects real decisions that impact patients, physicians, and the entire health care system.^1,2

Evidence-based medicine is built on a simple idea: let science guide the care. It means trusting the weight of clinical trials, systematic reviews, and well-vetted guidelines to make decisions that best serve each patient. License-protection care, also called defensive medicine, comes from a different instinct entirely. It’s driven less by evidence and more by fear of lawsuits, board complaints, or professional scrutiny. Residents are exposed to defensive medicine earlier in their careers and encouraged to consider malpractice liability in their medical decisions. So, while both claim to protect patients, only one is truly anchored in science. The other is a shield, meant to protect the clinician and not necessarily to advance care.^1,2

Although it may sound easier to practice evidence-based medicine, recent studies suggest the contrary. Three out of 4 physicians engaged in a license-protection approach to treat patients, according to Zheng et al. in a meta-analysis published in 2023.³ Qualitative reviews show that defensive practice is often not just a reaction to explicit legal threats but is woven into a broader sense of risk, institutional culture, and uncertainty in care.⁴ For many clinicians, even if a guideline is reasonable, the fear of complications or a lawsuit in a particular patient scenario pushes them toward over-testing or overtreating as a safety buffer.

The fear is not irrational because clinical guidelines are a double-edged sword. In some jurisdictions and legal analyses, they are considered persuasive but not dispositive. The American Law Institute’s 2024 statement of medical negligence shifts away from rigid reliance on customary practice and opens the door for courts to consider evidence-based guidelines, though it doesn’t guarantee that following a guideline is a complete defense.⁴ In older discussions, scholars have debated whether following guidelines should establish a “safe harbor” from liability, but many caution that guidelines vary in quality and may not fit every clinical context. In short, guidelines can help support a physician’s defense by showing alignment with accepted practices, but they rarely serve as an absolute legal shield.

Interestingly, insurers and policymakers favor evidence-based care. The reason lies with cost control, quality metrics, and minimizing unnecessary interventions, although they also know that physicians lean defensively under pressure. From a management perspective, some literature argues that organizational policies, performance metrics, and risk management incentives inadvertently encourage defensive behavior. Thus, even if the institutional preference is evidence-based care, the interplay of legal risk, institutional culture, and reimbursement pressures often pushes decisions toward the more cautious side.^5-8

Clinicians, health institutions, and the legal system need to move in a direction where evidence-based practice is trusted, supported, and legally defensible. That means improving the quality and adaptability of guidelines, promoting legal reforms that recognize reasonable uncertainty, and creating institutional cultures where clinicians aren’t penalized for following good evidence. If we succeed, patients will receive better-targeted care, clinicians will feel safer practicing scientifically grounded medicine, and the system as a whole may become more sustainable.

REFERENCES

1. Vento, S., Cainelli, F., & Vallone, A. (2018). Defensive medicine: It is time to finally slow down an epidemic. World journal of clinical cases, 6(11), 406–409. https://doi.org/10.12998/wjcc.v6.i11.406

2. Sekhar, M. S., & Vyas, N. (2013). Defensive medicine: a bane to healthcare. Annals of medical and health sciences research, 3(2), 295–296. https://doi.org/10.4103/2141-9248.113688

3. Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care. 2023 Dec 7;35(4):mzad096. doi: 10.1093/intqhc/mzad096. PMID: 38060672.

4. Lorenc, T., Khouja, C., Harden, M., Fulbright, H., & Thomas, J. (2024). Defensive healthcare practice: systematic review of qualitative evidence. BMJ open, 14(7), e085673. https://doi.org/10.1136/bmjopen-2024-085673

5. Shenoy, A., Shenoy, G. N., & Shenoy, G. G. (2022). Patient safety assurance in the age of defensive medicine: a review. Patient safety in surgery, 16(1), 10. https://doi.org/10.1186/s13037-022-00319-8

6. Katz E. D. (2019). Defensive Medicine: A Case and Review of Its Status and Possible Solutions. Clinical practice and cases in emergency medicine, 3(4), 329–332. https://doi.org/10.5811/cpcem.2019.9.43975

7. Aaron DG, Robertson CT, King LP, Sage WM. A New Legal Standard for Medical Malpractice. JAMA. 2025;333(13):1161–1165. doi:10.1001/jama.2025.0097

8. Pischedda, G., Marinò, L. & Corsi, K. Defensive medicine through the lens of the managerial perspective: a literature review. BMC Health Serv Res 23, 1104 (2023). https://doi.org/10.1186/s12913-023-10089-3