Sorry for this far too long post. But the energy to engage emerged so here we go:

First thanks for great comments from Ranjan and Klaus.
 
Dear Ken and Mike and others
When you say you disagree with me I am uncertain what this means. Do you disagree with what I said, that EBD is not a singular approach that can dominate design and that it is merely one of many needed approaches, or do you argue against the total rejection of EBD, which I never said?

I argued earlier in a paper for such a position of regarding design and design research as a field where many different theories and methods, perspectives and skills live side by side (https://journals.hioa.no/index.php/formakademisk/article/view/137/134 ). My main message was that we should appreciate this pluralistic world and embrace the big advantages and challenges this pluralism provides. I did not include EBD at that time but certainly would now. My argument is that none of those singular components will provide a safe haven for designers to rest in and to feel confident and secure.  The ethics of design imply inescapable uncertainty, as I see it. EBD is good for some things but it does not work for others. In fact I think we need a pragmatic / eclectic approach to the diversity of theories and approaches in design. The diversity and criticality in implementing a perspective is to my mind a potential strength of the design field. Such an approach is nothing new or strange but it has been argued for earlier e.g. in critical systems thinking by Ulrich, Midgley and others. (Not the same Ulrich as in EBD). 

I assume you do not think EBD is the only viable approach and therefore I continue my argumentation.

So lets start to discuss EBD. But first I want to excuse my lack of deep insight in the field and I am gladly caught in errors and corrected. Not all I state here is well reflected but I take the risk because its time to give EBD a proper critique, to improve it and to learn from it.
There is no doubt that EBD has done great work in improving the quality of health care architecture in some hospital contexts. It remains to see how it can be beneficial for the public sector. At least I could not see the implementations from my net searches into a really broad and penetrating modus.

When looking at EBD it is really applied in a very narrow field, in architecture and especially interiors of hospitals and similar, with a special attention to patients rooms. Though there are a few applications outside this area it’s still very little. It is not given that this context is easily translated to others. The translation of evidence based medicine to education has not gone without very heavy and fundamental critique. This special setting, the patient room, provides easier access to data than many other areas and the data are quantitative and measurable. (e.g. Patient recovery measured in days). Still the research in the field is problematic. There is a lot of badly argued evidence of EBD. In an article from 2007 Schwarz and Stankos, though appreciating the value of EBD, point to many of the problems. I think this article is pretty solid and it seems it still holds ground.

http://test.spokane.wsu.edu/academics/Design/IDRP2/Vol_1/stankos.pdf 
 
It is ironic that EBD has a deficit on rigorous research while it is fronted as a rigorous approach in the design research community. 
Especially interesting is their criticism of EBD as rhetoric and persuasion in a market-strategy perspective. They state that EBD is at risk to be considered a design polemic. Yes, I would say it is to a large degree. It is fronted in a way that it is more robust, better and superior to the other approaches which are regarded as flimsy, personal, normative and based on tradition etc. I think this is sometimes misuse of power language and lack of respect and openness to the diversity and richness in the design field. But I understand it sells well to people who have a limited understanding of design and who have neither time nor insight to engage in cumbersome dialogic processes.

Another problem is its heritage from Evidence Based Medicine. EBM rejects qualitative data. This makes sort of sense in medical research but sounds like madness in design. EBD seems unable to really escape this heritage.

EBD is limited for several reasons. To mention a few:
- Fragmentation: It suffers from the same as does all other positive science, from fragmentation. The echoes from the old positivism debate are apparent. 
- Lack of systemics: As an effect of the fragmentation there is very little evidence of systemic thinking in EBD. The examples are taken out of context. This also explains the high interest in the patient room. It is a framed comparable limited unit.
- Synthesis: From the above follows that EBD does not have a good answer to processes of synthesis and creativity. It’s pretty much strait forward: evidence shows that pictures are good so let’s add pictures. Evidence shows floors should be soft so let’s put in soft floors. This is design at its most primitive.
- Lack of social dynamics: EBD is not user oriented on an individual level. It seeks the common denominators form statistics but does not cater for individual variations.
- How to produce evidence: In EBD design should be based on evidence but to produce the evidence one needs to design in large scale. E.g. Ulrich demonstrated that certain types of pictures on the walls in patient rooms produced faster recovery (I still doubt this but let’s accept it for a moment). But to find this evidence they needed to place such pictures at a large number of rooms.  So there needs to be some sort of design idea first to initiate the research. What is this idea based on?
- Practical problems: In many cases it is just not practical possible to produce the evidence. 
- The time and context error: Preferences in culture are not stable and change relative rapidly over time and vary geographically and with sub cultures. Pictures that produce well-being in one setting / time might well produce stress and unease in others. So the evidence is drifting constantly. Though it is portrayed as stable and solid in EBD.
- The wisdom brake down: Basing design on data like it is done in EBD does not nurture a higher level of operating as a reflective designer. Data is not evidence but needs an argument attached to it to become evidence. Evidence is not knowledge. Evidence needs to be implemented in context and interpreted to a situation to be useful. Knowledge is not wisdom. Wisdom is the sum of knowledge, skills and experiences gathered during a long time while becoming an expert. Intuition is the hallmark of the expert. (See the Dreyfus and Dreyfus skill acquisition model http://en.wikipedia.org/wiki/Dreyfus_model_of_skill_acquisition )
- The descriptive-generative leap problem: Medical science is mostly based on descriptive approaches. Design is generative. While one can argue that EBD is moving medicine into a more generative mode, the methodology is resting in a descriptive approach.

Another complicating discussion lays in the tension between medicine being generative (the invention of new surgery techniques and tools), becoming design (plastic surgery and prostheses) and the notion that all science fundamentally can be regarded as design (Glanville).

There is a way to cater for the above mentioned weaknesses of EBD. We need to appreciate and cultivate the diversity in design research. This would help to triangulate between the different approaches. It would be useful to have some meta-frameworks that establish a mode of design that is able to operate in a pluralistic design world. Systems Oriented Design and Systemic Design provide such a frameworks. EBD finds a natural place within that framework where building knowledge is seen rather as a design task. (www.systemsorienteddesign.net, www.systemic-design.net )

Peter Jones discusses on a similar bases, when reflecting upon many different components, including EBD in his book Design for Care. http://rosenfeldmedia.com/books/design-for-care/ 

I have the feeling EBD is getting softer and gives more leeway to diverse approaches. Somebody who knows this better should give us that overview of how it develops.

Reviewing superficially the research in EBD it does not seem very sound. E.g. in Ulrichs metastudy form 2008  (Ulrich is the Swedish founder and guru of EBD) (https://smartech.gatech.edu/bitstream/handle/1853/25676/zimring_HERD_2008_researchlitreview.pdf?sequence=1 ) there is a table systematizing the findings from a relative large number of studies. It is a bit exotic how this circles around the one unit, the patient room. Looking at this in the perspective of service design would change that picture totally. Also there are obvious methodical problems with the table. On line 7, Reducing depression, the single patient room does not score. There is a systematic error in this way of posting the variables because this does not show if single patient rooms might actually increase depression. It is fair and sensible to ask if the more isolated situation in single rooms increses depression. This is such a grave error that in a discussion where EBD is promoted as better as and more reliable than other approaches, it deflates to me a lot of credibility. None of my students would ever miss that important point. So does evidence based thinking in design produce a certain type of alianation from common sense?

Finally some remarks to Mike and Ken:

Mike you say that medicine was also on unstable ground, similar as design is today and that it has moved to a stable ground. This can be debated, but let’s agree. Your argument implies that design also will reach a similar stable ground. This is where we part. I don’t believe it will. The reason is that design is about and for people and they change much faster than the physiology of the human body. Therefore Design is an adaptive profession built on adaptive expertise. Just think of the dramatic changes in the last ten to twenty years in the design profession. Who could foresee it accurately? I believe that this change and constant redefinition of design is a core feature of design. This list and its discussions washing back and forth are an example. I don’t think it will ever settle. Medicine is a system responding to what is While design is responding to what ought to be or what could be. This goes also to Ken since he thinks the same way. (Is plastic surgery medicine or design?)

To Ken: You make an argument that things are pretty stable. This must be answered in a different way than agreeing or disagreeing. The answer is a simultaneous Yes and NO. It depends. It is a truly relative issue. We are constantly redesigning known stuff. But we are also constantly designing for uniqueness. Being embedded in human culture this uniqueness can seem small sometimes but yet it is there. As long as we don’t rip off each other we constantly build on others work and experiences and we constantly make smaller or bigger adjustments. Design is subscribed by many seemingly contradictory perspectives. We are both repetitive and unique. We design for unique situations. Unfortunately many designers do not understand this and therefore design sometimes tends to be rather fascistic. Architects who design for certain fixed moments in time and fixed spatial ideas disregarding change tend to do this. E.g. our own school building at AHO. We live in this tension caged in our cultural context but aware that we are and that we cannot escape it. All that is new is within that context mostly. But the point is that there is a pretty big difference from practicing medicine to design when it comes to the question of creating something new and unique. That is my argument and it still stands.



Birger Sevaldson (PhD, MNIL) 
Professor at Institute of Design
Oslo School of Architecture and Design
Norway
Phone (0047) 9118 9544
www.birger-sevaldson.no
www.systemsorienteddesign.net
www.ocean-designresearch.net
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