The criticism of EBM would be that science
is always political, it is just that some approaches explicitly recognise
the political and ideological nature of what they are doing while others
do not. There is more to this than just being biased.
Re: post-modernists take another whack
at EBH...EBM: between logical positivism and postmodernism
Very well said. I would urge Dr Djulbegovic
to enlarge on this and submit
it for publication.
However, please note that there is very little resemblance to what he said
and anything I could find in the Goldenberg article. Furthermore,
as
mentioned previously, the Goldenberg article was more than a critique of
EBM: it accused EBM of being actively harmful.
One clue as to why may be found in a part of the article I did not
previously mention. The article called explicitly for science to
be
politicized:
"A feminist philosophy of science is explicitly political, as science
is
recognised to be a vehicle for feminism's emancipatory programme."
I have said before that I think a lot of the opposition to EBM comes from
people who have vested interests, economic or political. EBM, by
striving
to be unbiased (but of course attaining that goal imperfectly) is a threat
to people who are promoting specific economic or political interests,
including "feminism's emancipatory programme" among others.
Finally, a note to Helen Prosser: I don't think I ever denied that EBM
has
limitations, problems, and challenges. If I did, I did not mean to.
And
of course it is true that the current version of EBM has not really figured
out a great way to incorporate patients' values into decision making.
(Although there is a considerable literature on this, much of it labelled
"medical decision making," rather than EBM. See, in particular,
all that
has appeared about measuring patients' utilities and incorporating them
into decisions in the journal Medical Decision Making.) But I did
not see
a reasoned critique of this issue in the Goldenberg paper.
At 12:55 PM 11/30/2006, Djulbegovic, Benjamin wrote:
>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).
>
Roy M. Poses MD
Clinical Associate Professor
Brown University School of Medicine
<[log in to unmask]>
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