Yup, in the grand scheme of things I think that Sackett et al. were on the right side of history to advocate for RCTs and there are few things we disagree with. But I do suspect that if he was aware of Fisher’s versus Neyman’s work on RCTs and the related nuances vis-a-vis how they were incorporated in medicine, he might have been a less enthusiastic proponent, e.g., of NNTs. A stronger emphasis on quantifying uncertainty estimates versus point estimates of comparative metrics reveal the deficiencies of NNTs, at least during the time Sackett was advocating for them.
Perfection of course is the enemy of good. But as evidenced by Matthews’s article series, at some point in the past few decades this distortion ultimately led to the rise of randomized non-comparative trials (RNCTs). Our group of clinicians just had a strong debate with biostatisticians of an outside trial sponsor insisting on using an RNCT design. This culminated with one of our clinicians (who helped lead the development of the related agent and study) resigning from participating in the RNCT portion of the study. There is something fundamentally wrong in medicine when we are forced to resort to such measures over a trial design flaw that should be obvious to all stakeholders.