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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. Sign up for my brand new newsletter, The Monthly Mean, at www.pmean.com/news