EBM and the strawman: a commentary on Devisch and Murray (2009). ‘We hold these truths to be self-evident': deconstructing ‘evidence-based’ medical practice (original) (raw)
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Accounting for EBM: notions of evidence in medicine
Social science & medicine (1982), 2006
This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also ...
'We hold these truths to be self-evident': Deconstructing 'evidence-based' medical practice
Journal of Evaluation in Clinical Practice, 2009
The rationale, aims and objectives Evidence-based medicine (EBM) claims to be based on 'evidence', rather than 'intuition'. However, EBM's fundamental distinction between quantitative 'evidence' and qualitative 'intuition' is not self-evident. The meaning of 'evidence' is unclear and no studies of quality exist to demonstrate the superiority of EBM in health care settings. This paper argues that, despite itself, EBM holds out only the illusion of conclusive scientific rigour for clinical decision making, and that EBM ultimately is unable to fulfil its own structural criteria for 'evidence'. Methods Our deconstructive analysis of EBM draws on the work of the French philosopher , Jacques Derrida. Deconstruction works in the name of justice to lay bare, to expose what has been hidden from view. In plain language, we deconstruct EBM's paradigm of 'evidence', the randomized controlled trial (RCT), to demonstrate that there cannot be incontrovertible evidence for EBM as such. We argue that EBM therefore 'auto-deconstructs' its own paradigm, and that medical practitioners, policymakers and patients alike ought to be aware of this failure within EBM itself. Results EBM's strict distinction between admissible evidence (based on RCTs) and other supposedly inadmissible evidence is not itself based on evidence, but rather, on intuition. In other words, according to EBM's own logic, there can be no 'evidentiary' basis for its distinction between admissible and inadmissible evidence. Ultimately, to uphold this fundamental distinction, EBM must seek recourse in (bio)political ideology and an epistemology akin to faith.
European Journal for Person Centered Healthcare, 2019
Despite many passing references to contemporary frontiers of thought such as cybernetics and complexity theory, Tarnished Gold, a self-published book, leads the reader towards critical visions of clinical research enterprise that are more linked to the past than to the present or the future. Along the way, Evidence Based Medicine is taken as the enemy, but is consistently misrepresented. The authors are seriously under-informed regarding contemporary issues and controversies related to the design of clinical research as well as the cognitive aspects of clinical practice. They ignore the relevance of narrative and relationship-centered medicine to those issues and controversies. The actual challenges of healthcare in our time and its relationship to clinical research are largely avoided. As a result, "Tarnished Gold" fails to illuminate or inform lessons already learned from the controversies that have occurred since the appearance of EBM. More importantly, the authors fail...
EBM: Evidence to practice & practice to evidence
2015
The purpose of this paper is to explore new perspectives about difficulties academicians may have communicating with clinicians, obtaining subjects, and gaining compliance for their research. Sackett et al1 defined evidence-based medicine (EBM) as an integration of best research evidence, clinical expertise, and patient values. However, Guyatt et al2 places clinical observation and experience last in the evidence hierarchy with the randomized controlled trial held as the standard for clinical intervention. The hierarchical discourse of medical knowledge produces opposition rather than collaboration between researcher, clinician, and patient. Foucault gave new perspectives describing how power circulates through individuals within organizational discourse.3 Drawing on literature and experience, this paper describes how the hierarchical model of power in the research community obstructs new areas of knowledge, and how clinicians create resistance. Alleviating perceptions of dominance ...