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Dear Donald My point exactly - EBM ignores the role that strong feelings have on how people make decisions. The values are often implicit rather than explicit. How people make decisions depends on two things. First the likelihood of any consequences of that decision and secondly the values they place on the different outcomes. It seems to me that EBM is good on the first part and poor on the second. Cheers Simon Senior Lecturer in Psychiatry University of Auckland -------Original Message------- From: Donald E. Stanley Date: 11/30/04 03:07:51 To: Simon Hatcher Subject: Re: Epistemology and EBM If what you take to be the case, ie that EBM does not contain implicit values, then I would disagree. If the mammographic screening debate is not value-laden: psychological suffering, unwanted surgical biopsy, follow-up on a non-diagnostic biopsy, opportunity costs, then just imagine what will happen when the few RCTs on PSA screening are reported! I don’t believe there is evidence and over there, in the consulting room, value. The second distinction you make is more in line with what I think is the case: whatever evidence we use in the non-professional setting is not different in kind, but only degree. The distinction between fact/value goes on, and am currently trying to use Hilary Putnam’s arguments to show better what I mean. Dr. Donald E. Stanley Associates in Pathology 500 West Neck Road Nobleboro, ME 04555 207-563-1560 [log in to unmask] From: Simon Hatcher <[log in to unmask]> Reply-To: Simon Hatcher <[log in to unmask]> Date: Mon, 29 Nov 2004 22:38:27 +1300 To: [log in to unmask] Subject: Re: Epistemology and EBM Dear Ted One of the aspects that EBM seems to have missed is the whole database/evidence around how people make decisions. There is a vast amount of evidence on decision making in health care which isn't incorporated into current models of EBM. Much of which reflects the discussion in this thread to date. For example how precisely do you incorporate a patients values into decision making when you are having a conversation with them? How you frame a choice - in terms of benefits or harms - makes a big difference to what people decide. The second point, I would suggest, is that EBM applies to medicine in a professional sense. It doesn't seem to apply to informal health care decisions made outside a professional context - that is there are boundaries beyond which EBM doesn't apply. Not all health care decisions are made in a professional setting - some especially involving "informal" treatments such as going to bed to rest, drinking plenty of fluids, etc are essential preliminaries that happen before someone sees a health professional. Essentially these are not "technical matters". The negative consequences of these interventions are minor and they work in most cases - a situation which may well have applied to the herbal remedy suggested by the trainee at your workshop. Cheers Simon Dr. Simon Hatcher Senior Lecturer in Psychiatry University of Auckland -------Original Message------- From: Ted Harding <mailto:[log in to unmask]> Date: 11/27/04 04:56:48 To: [log in to unmask] Subject: Re: Epistemology and EBM Hi Ronan, On 26-Nov-04 Ronán Conroy wrote: > Fascinating how a moral dimension immediately enters. People > ought to think, and to base their actions on the conclusions > of logical thinking. Why should this be so? Would anyone ever > fall in love, or play a Beethoven sonata again if this were so? Your point is good, but you are arguing somewhat outside the domain I had in mind. I'm not saying that people should base all their actions, or even attitudes, on the conclusions of logical thinking. I can grant that epistemology, etymologically and in the dictionary, means the study of "what we know and how we know it" -- or, more abstractly "the theory of knowledge", though it has itself to grapple with the meaning of "know" and "knowledge". (In so far as it remains descriptive, the latter can to some extent be avoided.) Action is a response to an urge or to a need, the consequence of a decision or of following a rational or irrational preference, or even "involuntary". This can be *influenced* by the conclusions of logical thinking, but in real life (as you exemplify) is often not *governed* by it. Even after falling in love (which can be involuntary) one may still agonise quite logically over whether one should allow oneself to pursue that state to its natural conclusions. A part of the "data" in this agony will be the powerful urge arising from the state, and one may yield to this despite powerful logical misgivings. I play Beethoven sonatas because I enjoy doing so, but would (without great agony) avoid doing so at 3 a.m. in the morning if it would be likely to wake the neighbours. My judgment on that likelihood would be, broadly speaking, evidence-based (either based on my knowledge of the behaviour of sound in the building where I live, or even on the outcome of a visit from the neighbour ... ). The situation I was addressing was one where, in that example, a young doctor had consciously, therefore potentially rationally, contemplated a problem described by her neighbour, and had deliberately proposed a course of action. In that case, one would expect that rationality was playing a substantial part. Unless of course that young doctor was somehow "in love" with herbal remedies ... A physician is in the position of an "authority" -- someone expected to be well informed about what's good to do, or at least be aware that they're not well informed, and reliable in their judgment. > [...] > The idea that human behaviour is shaped by the application > of logic to knowledge is a comfortable fib for which there > is no evidence. Learning logic does not make humans wiser or > act more compassionately. But a lobby of the medical profession > sometimes seems to believe that logic and rational behaviour > should be promoted with the vigour of a religion. I would not, any more than you, go along with the proposition that "logic and rational behaviour should be promoted with the vigour of a religion." It's entirely natural for behaviour to be irrational: indeed one may naturally act contrary to the dictates of logic, and I would not necessarily say that this was wrong. But to draw from this the conclusion that logic should generally not be taken into account would be to condone acting recklessly . In a context where there are aspects which (in principle) are based on logical principles, then one should, for the sake of one's own efficacy, examine if one can the logical aspects in order to evaluate them. But logic can only be guaranteed to give the right answer (if then) when it is based on all relevant available information. When based on incomplete (or, even worse, irrelevant) information, apparently "logical" conclusions can be false. When you are aware that the information is incomplete (and often it is simply not available) then it is good to be aware that one's beliefs about the situation are uncertain. To come back to the playing of Beethoven sonatas, there is a logic (mechanical and musical) to the execution of the performance. I wouldn't object to someone who had neither any mechanical technique nor yet good musical appreciation sitting down at a piano and laboriously and painfully trying to pick out the notes: if they're enjoying themselves that's OK, and the experience may lead on to learning the skills and appreciating the music better. Indeed, I would hope that this would lead them to the conclusion that they could usefully take lessons to improve their technique and understanding, for the sake of producing something that's closer to the performance thay have in their head. As anyone who's been through that will know, there's a very strong logical aspect to this process: you have to do a lot of working out, in your head, before it begins to become fluent. However, if someone who claimed to be a trained pianist played in a way which indicated that they didn't care about these things, then I think I'd be offended by it (even if it did sound better than the clumsy fumblings of the complete beginner). The point is that it's not only a question of pure musical experience: it's also, intricately, a technical matter. Likewise, I believe, for medicine in its scientific aspects. I'm not excluding "human-based medicine". A shrewd physician could in certain cases solve a problem by pure sympathy. But that's not going to cure a case of syphilis on its own (even if it helps the patient to maintain contact and stick to the treatment). When it comes to technical matters, there are right ways and wrong ways, and these are what are amenable, in principle, to rigorous examination and the application of logic. Best wishes to all, Ted. -------------------------------------------------------------------- E-Mail: (Ted Harding) <[log in to unmask]> Fax-to-email: +44 (0)870 094 0861 [NB: New number!] Date: 26-Nov-04 Time: 15:49:29 ------------------------------ XFMail ------------------------------ <http://www.incredimail.com/index.asp?id=54475>