Roy Poses and Daniel Sondheimer wrote:
> I don't think EBM is its own foundation. I think the foundation of
> EBM is the notion that applying logical reasoning and the best
> scientific evidence ought to produce optimal results in medicine and
> health care. This further rests on the assumption that the scientific
> method is the best way to find the best approximation of the truth,
> and further, of course, that there is some sort of external truth or
> external reality.
>
> I would love to see the postmodernist argument for how postmodernism
> benefits patients, or anyone else ;-) <<<<<<
> ----------------------------------------------------------------------
> --
> Postmodernism thrives on deconstruction, like this. I think it
> useful,
> because it conitnually makes one wonder "what if they (EBMers, CAMers,
> Liberals, you name it) and everyone have it all wrong?" I think the
> key virtue is to avoid reaching a point where one is pushed the point
> of frustation and futility, and does nothing. I just keep asking the
> question. "truth is many, truth is one"
> ----------------------------------------------------------------------
> - >>>>>> But asking "what if this whole idea is wrong" is also part of
> the scientific tradition. The difference is that scientists try to
> answer these questions with experiments, or at least with the most
> objective data they can collect, rather than with deconstructionist
> mumbo-jumbo. <<<<<<
EBM certainly isn't its own foundation since as far as I'm aware
there is little evidence that practicing EBM improves patient
outcomes. The evidence I'm aware of is relatively weak - I think it
would allow a weak B grade, or a C grade recommendation that
people practice EBM. So obviously, its foundation must be an
appeal to some idea of science or logic. The difficulty is in
deciding why this should mean that we practice EBM and not the
'old way' of trying to predict what will 'work' in clinical practice on
the basis of physiological or other basic science principles. The
old way uses exactly the same appeal to science or logic but,
using the method we call EBM, we can show it to be unreliable.
I think Roy sets up his own false dichotomy by trying to force a
choice between a belief in an objective reality and collection of
objective data on the one hand, and an incoherent mumbo jumbo
called non science on the other. Effectively, it consigns anyone
who questions an objective reality to the outer darkness of
superstition. You can run this dichotomy in reverse as well and
caricature those who do believe in objective realities as denying
people's subjective experience and reducing them to
depersonalised numbers. Is such symmetrical caricaturing really
necessary though?
In some circumstances I can act 'as if' there is an objective reality.
In other circumstances I can act 'as if' certain features of the world I
know are socially constructed. When I see someone with central
gripping chest pain on exertion, part of what I do may assume the
objective reality of disease and treat this pain 'as if' it were a real
thing called angina. When I talk to them about what it feels like to
have angina, it may be less helpful to assume an objective reality -
what matters is their lived experience and therefore in many
senses their own particular reality. There are different ways of
trying to know their lived experience. I can try to measure it, and
this is important. I can also try to understand it using myself as
the instrument, and I believe this is also important. I personally
think it's helpful to consciously use different, sometimes
incompatible or contradictory perspectives to think about difficult
problems. Why should I be constrained to a single world view?
This is a pretty postmodernist idea. It risks incoherence, sloppy
thinking, lack of attention to method and an anything goes mess.
But I don't think these are an inevitable consequence, and natural
scientific thought isn't immune to them either.
Bruce
Bruce Guthrie,
MRC Training Fellow in Health Services Research,
Department of General Practice,
University of Edinburgh,
20 West Richmond Street,
Edinburgh EH8 9DX
Tel 0131 650 9237
e-mail [log in to unmask]
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