Ben,
As usual, your exposition is reasoned, nuanced, and cogent.

Jim

James M. Walker, MD, FACP
Chief Medical Information Officer
Geisinger Health System

>>> "Djulbegovic, Benjamin" <[log in to unmask]> 11/30/2006 12:55
PM >>>
Roy, thanks for the piece. I actually think it is more provocative and
perhaps should not be completely dismissed for the reasons I want to
elaborate here. 

As you well know, a central tension in epistemology has always been a
relationship between observed reality vs. observable reality vs.
unobservable reality. That is, how far we can go beyond our
observations
and arrive at some meaningful inferences. As everyone knows, this
discussion has been going on since David Hume, a great 18 century
empiricist philosopher. 

What EBM has done is to make a necessary correction in the way people
have postulated that any physiological, basic-science theory can be
directly extrapolated to human clinical findings. This practice
appeared
to have been so widely spread in the second part of 20 century that a
reminder that "facts about the world" do matter has been in order. EBM
has pointed out numerous times that if the investigators had paid more
attention to generation of (unbiased) evidence, disasters such as
prescribing estrogen hormone replacement to healthy women, bone marrow
transplant for breast cancer, use of prophylactic antiarrhytmics in
patients with myocardial infarction etc could have been avoided. In
this
sense, EBM indeed resembles logical positivism. 

The reason that logical positivism is dead is because of a grand
ambition to develop overarching rules of figuring out the truth and
positivists' refusal to go beyond observations. I am not aware that
this
has actually been case with EBM (and in fact, many of us agree that
"observation is theory-laden" and that science is "underdetermined by
data", which is one of the reason that people are paying attention to
the totality of evidence etc). However, postmodernists are right that
the practice of science is socially sanctioned phenomenon and it is
determined by prevailing scientific/social consensus, as Thomas Kuhn
clearly elaborated. In fact, the origin of EBM can probably be traced
to
1962 when an administrative decision (passing the FDA law or its
amendment- I forgot) instituted a clinical trial method as the only
permitted method that can be used to determine if a particular drug
can
be used in humans (prior to 1962, doctors were able to treat patients
with any substance they wished to use as long as it was justified by
their tacit expert knowledge and/or experience; the passage of the FDA
law institutionalized knowledge that is publicly shared and easily
understood by all qualified professionals in the field who share
common
set of the tools and values) (see Roger Matthews' book). From 1962 to
date, we are actually witnessing refinement of a clinical trial
method,
which was, as it were, socially institutionalized. The insistence that
only knowledge that can be understood by everyone [who understands
methods of clinical research ("the rules of the game")] is admissible
has been appealing indeed. For example, New York Times (i.e. society
at
large) in 2001 dubbed EBM as one of the "Ideas of the Year". As a
result, EBM has actually been a dramatic democratizing force- anyone
can
challenge anyone (as students often challenge me using the very same
EBM
paradigm) - which is strikingly a postmodernist view. (In addition,
modern proponents of EBM- many of them are members of this list-
endorse
the importance of tacit knowledge, experience, values- again-a very
postmodern view, I would say).

Sorry for a long reply (this has been something on my mind for a long
time, and probably need more articulation) but I would be interested
in
your as well as other folks' thoughts at this "middle ground" view.

ben

Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute at the University of
South Florida Department of Interdisciplinary Oncology, MRC, Floor
2,Rm#
2067H
12902 Magnolia Drive
Tampa, FL 33612

e-mail:[log in to unmask] 
http://www.hsc.usf.edu/~bdjulbeg/ 
phone:(813)972-4673
fax:(813)745-6525




-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Poses, Roy
Sent: Wednesday, November 29, 2006 15:39
To: [log in to unmask] 
Subject: post-modernists take another whack at EBH

A while back, I posted on Health Care Renewal
[http://hcrenewal.blogspot.com/] about post-modernist accusations that
proponents of EBM were "microfascists"
[http://hcrenewal.blogspot.com/2006/08/post-modernist-view-evidence-base
d.html/]
 
Here we go again.  Thanks to a tip from the Capsules blog
[http://blog.meetingsnet.com/capsules/], I found this summary of a
special issue of Social Science Medicine on EBM
[http://annietv600.wordpress.com/2006/11/28/gift-horse-or-trojan-horse-t
he-ebm-debate-continues/].  In it was this article:
[http://dx.doi.org/10.1016/j.socscimed.2005.11.031]

Goldenberg MJ. On evidence and evidence-based medicine: Lessons from
the
philosophy of science
<http://dx.doi.org/10.1016/j.socscimed.2005.11.031> . Social Science &
Medicine 2006; 62(11):2621-2632.

This article has the now familiar attributes of post-modernist
anti-EBM
diatribes:

Misconceptions of EBM 

For example, the author never once acknowledged that EBM takes into
account clinical experience and the clinical context on one hand, and
patients' values on the other hand, in addition to the "evidence." 
That
later allows the author to accuse EBM of being an instrument of "the
institutional power of medicine" that is bad for women patients.

The author also equated EBM with logical positivism, "However, the
apparent obviousness of EBM can and should be challenged on the
grounds
of how 'evidence' has been problematised in the philosophy of science.
In this paper, I argue that evidence-based practices maintain an
antiquated understanding of evidence as "facts" about the world in the
assumption that scientific beliefs stand or fall in light of the
evidence. This understanding of evidence is explicitly positivist...."
The author then argued against logical positivism, and transferred all
criticisms of it to EBM.

Logical Fallacies

The author made particular use of false dichotomies.  She argued that
logical positivism, and hence EBM, are based on the notion that
people's
perceptions of external reality "are supposed to provide a a maximally
certain and conceptually unrevisable foundation of empirical
knowledge,"
i.e., that perceptions of external reality are perfect.  She then
argues, quite unremarkably, that perceptions of reality are imperfect,
but then says imperfect observations are essentially worthless.  So
the
conclusion was that logical positivist science, which again was
equated
with EBM, is based on worthless observations, implying both such
science
and EBM are worthless.

The author made the usual post-modernist appeals to (post-modernist)
authorities.  Since this was a feminist critique, the authorities in
this case were mostly feminists, although of course there was a bow to
the ubiquitous Foucault.  In a particularly impenetrable section on
"feminist epistemologies of science," for example, she asserted

- "Notions of evidence and theories of epistemic agency are,
therefore,
closely related. Haraway (1996)
<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-

1&_coverDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_
qd=1&_cdi=5925&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&
_userid=709070&md5=861b0a5ef32#bib29>  argues that the notion of
'matters of fact' depends on many kinds of transparencies in the grand
narratives of the experimental way of life. The 'modest witness', the
protagonist of the dramas of the Scientific Revolution who testifies
without prejudice to new facts, had to be constructed in sufficiently
detached and abstracted terms to make plausible the unusual situation
where his experiences could somehow represent everyone's and
no-one-in-particular's experiences."

- "Lorraine Code has argued that 'objectivity' is 'a generalization
from
the subjectivity of quite a small group' (1993, p. 22). However, this
group 'has the power, security, and prestige to...generalise its
experiences and normative ideals across the social order thus
producing
a group of like minded practitioners ('we') and dismissing 'others' as
deviant and aberrant ('they')' (Code 1993, p. 22
<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-

1&_coverDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_
qd=1&_cdi=5925&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&
_userid=709070&md5=861b0a5ef32#bib8> ).
 
Setting aside, for a moment, the apparently deliberate obscurity of
these arguments, why should one believe them just because they were
made
by Haraway or Code?  
 
(Perhaps Deliberately) Turgid Writing
 
One wonders whether the editor of this article actually understood it
all.  The writing is full of the clumsy constructions and opaque
jargon
usually favored by post-modernists.  I will save you further quotes.
One wonders, however, whether the purpose was to deliberately confuse
the reader, in the hopes that readers so confused would attribute
their
mental state to the vast erudition of the author.  
 
Finally, the Dire Warning
 
The author finally concluded that EBM is dangerous, at least to women,
"
Feminist critiques of science are driven by a deep concern that the
abstractions made in the names of scientific objectivity,
generalisability, and predictability harm women. These tendencies
appear
to resurface in the practice of EBM."
 
Furthermore, "Feminist insight reveals that the practices of EBM are
marked by potential or actual gender bias, which has led at least one
critic to argue that EBM is bad for women's health."
 
In Conclusion
 
[Borrowing some wording from my post on accusations of "microfascism,"
but with specific quotes from the Goldenberg article referenced
above...
]
 
Recovering from the brain fever induced by reading about "knowers" as
"collaborative agents," "experiential 'givenness,'" and "objectified
body-machines," one might speculate: Has post-modernism been
deliberately encouraged by some academic leaders, possibly those with
the most severe conflicts of interest, to distract us from
concentration
and abuse of power in health care, the pervasiveness of conflicts of
interests in health care organizations, and unethical and even illegal
behavior by health care leaders?

If so, it's working.

 
 
 
 
Roy M. Poses MD
Clinical Associate Professor of Medicine
Brown University School of Medicine 
email: [log in to unmask] 

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