ask CWA wrote:

> Social Epistemology: A Journal of Knowledge, Culture and Policy 
> Volume 22 Issue 4 
> (http://www.informaworld.com/openurl?genre=issue&issn=0269-1728&volume=22&issue=4&uno_jumptype=alert&uno_alerttype=new_issue_alert,email) 
> is now available online at informaworld (http://www.informaworld.com).
>
> Special Issue:Evidence in Evidence-Based Medicine

which has generated a lot of commentary.

I'd like to add my two cents to the mix. I believe that many of my 
points have already been made by others, but I couldn't resist the urge 
to say something about all of this.

Much of the commentary has been critical of Post Modern philosophy. I 
gave a talk about this (Stats #76: The post-modern assault on 
evidence-based medicine), which is available on my old website:

http://www.childrensmercy.org/stats/training/hand76.asp

I think that the arguments are definitely worth listening to, as this 
concept in postmodernism that seemingly objective methods can be 
manipulated to reinforce the prevailing perspective of those in power is 
almost certainly true. Witness the attempts (largely successful, sad to 
say) of pharmaceutical companies to promote their products through 
manipulation of the peer-reviewed literature.

Smith R. Medical Journals Are an Extension of the Marketing Arm of 
Pharmaceutical Companies. PLoS Medicine. 2005;2(5):e138 EP -. Available 
at: http://dx.doi.org/10.1371%2Fjournal.pmed.0020138 [Accessed January 
6, 2009].

If you believe Dr. Smith's article, then you have to accept at least 
part of the premises of post modern philosophy. The problem, of course, 
is that post modern philosophers take the argument to such an extreme. 
They also seem to believe that they are the only ones capable of 
recognizing the flaws in these seemingly objective methods.

I believe that the EBM community needs to mount a vigorous response to 
the post modern critics (more than just a few passionate emails on this 
list). Are there any good critiques published in a prominent 
peer-reviewed journal, for example, of the article

Holmes D, Murray SJ, Perron A, Rail G. Deconstructing the evidence-based 
discourse in health sciences: truth, power and fascism. Int J Evid Based 
Healthc 2006; 4: 180-186.

I'd also agree with the comments about complementary and alternative 
medicine (CAM), whose proponents seem to trash randomized trials except 
when those trials show support for CAM. Even so, their critiques are 
still worth reading. It is very difficult to offer holistic treatment 
within the narrow confines of a double blind randomized controlled trial.

To illustrate this, note that the physician patient relationship is so 
important in medicine. Most physicians will present a therapy option in 
a reasonably optimistic tone (for example, "this device seems to work 
well for many of my patients"). The ethical requirements of equipoise 
and informed consent utterly destroy this offering of optimism and hope. 
It's true for both CAM and traditional medicine. I'm glad that we 
respect equipoise and informed consent, but it does carry a high price tag.

You should always remember that the way that medicine is practiced in a 
clinical trial is often far removed with the way medicine is practiced 
in the clinic. That doesn't mean you can ignore randomized trials when 
they present results that are uncomfortable to you. Instead, you should 
use the CAM criticisms of randomized trials to help you remember that 
these methods do have limitations.

I have a seminar that I taught about this (Stats #66: What Can 
Alternative Medicine Teach Us About Evidence-Based Medicine?) also on my 
old website

http://www.childrensmercy.org/stats/training/hand66.asp

And finally, to answer the question of whether evidence or theory should 
dominate, I would suggest that both should be used to reinforce the 
other. Evidence does not trump theory and theory does not trump 
evidence. It's just that evidence without theory requires a higher level 
of evidence (I do like the goat/unicorn analogy) and theory has to be 
extremely compelling to be accepted without any empirical support. We're 
happiest, of course, when theory and evidence are in agreement.
-- 
Steve Simon, Standard Disclaimer.
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