RCTs are fine but the obsession with them is overwrought and counterproductive. My own drum to beat on this is regarding clinical trials for fatal diagnoses like cancer: https://jakeseliger.com/2024/01/29/the-dead-and-dying-at-the.... We have Kaplan-Meier curves for fatal diagnoses. We know what happens (the tumors grow and metastasize. One doesn't need elaborate phase 3 RCTs to figure out if there's a good shot that a treatment is working; one can see it in tumor response and comparison to known KMCs. The existing system raises costs and causes people to die while waiting a decade or more for exciting treatments: https://atelfo.github.io/2023/12/23/biopharma-from-janssen-t...
Moderna's mRNA-4157 is a current example of this: https://jakeseliger.com/2024/04/12/moderna-mrna-4157-v90-new..., although it may be held up by lack of manufacturing capacity as well.