I haven't read the full paper and found it difficult to decipher the
argument being put forward against EBM in the quotes provided from the
Goldenberg paper by Roy Poses.

Here is my stab at understanding the arguments put forward in the quotes
from the Goldenberg paper.

I think that this paper has infact (unintentionally) put forward the reasons
why objective scientific assessment of health interventions in properly
conducted clinical trials is necessary. The design of clinical trials is
based on an acknowledgement that there is such a thing as 'the placebo
effect' - the human tendency to observe the effect they want to observe. The
objective assessment is carried out in order to AVOID the notion that:


>'... EBM, are based on the notion that people's perceptions of external reality
>"are supposed to provide a a maximally certain and conceptually unrevisable
>foundation of empirical knowledge," i.e., that perceptions of external reality
>are perfect.  She then argues, quite unremarkably, that perceptions of reality
>are imperfect, but then says imperfect observations are essentially worthless.
>So the conclusion was that logical positivist science, which again was equated
>with EBM, is based on worthless observations, implying both such science and
>EBM are worthless.'

I think that there is a basis for the argument for there being an inequality
in acknowledgment of womens 'experiences' in objective assessment of health
intervention steming from the fact that the scientific evidence for most
diseases and health interventions is based on research conducted mainly in
men (because it is easier). This may not always be valid. For example, it is
now becoming apparant with cardiovascular disease trials conducted in women
that the presentation of ischemic disease in women differs from men and is
often missed as the diagnostic tests are based on evidence of disease
presentation from men (see: Women's Ischemia Syndrome Evaluation (WISE).
Journal of the American College of Cardiology, Vol. 47, No.3, Supplement S.
2006. www.onlinejacc.org.

The same ineqality would apply to other under represented groups in clinical
trials i.e - children, elderly, different ethnic groups. Fortunately
attempts are being made to address these ineqalities.

> - "Lorraine Code has argued that 'objectivity' is 'a generalization from the
> subjectivity of quite a small group' (1993, p. 22). However, this group 'has
> the power, security, and prestige to...generalise its experiences and
> normative ideals across the social order thus producing a group of like minded
> practitioners ('we') and dismissing 'others' as deviant and aberrant ('they')'
> (Code 1993, p. 22 .....<"


Anjana








on 29/11/06 8:38 pm, Poses, Roy at [log in to unmask] wrote:

> A while back, I posted on Health Care Renewal [http://hcrenewal.blogspot.com/]
> about post-modernist accusations that proponents of EBM were "microfascists"
> [http://hcrenewal.blogspot.com/2006/08/post-modernist-view-evidence-based.html
> /]
> 
> Here we go again.  Thanks to a tip from the Capsules blog
> [http://blog.meetingsnet.com/capsules/], I found this summary of a special
> issue of Social Science Medicine on EBM
> [http://annietv600.wordpress.com/2006/11/28/gift-horse-or-trojan-horse-the-ebm
> -debate-continues/].  In it was this article:
> [http://dx.doi.org/10.1016/j.socscimed.2005.11.031]
> 
> Goldenberg MJ. On evidence and evidence-based medicine: Lessons from the
> philosophy of science <http://dx.doi.org/10.1016/j.socscimed.2005.11.031> .
> Social Science & Medicine 2006; 62(11):2621-2632.
> 
> This article has the now familiar attributes of post-modernist anti-EBM
> diatribes:
> 
> Misconceptions of EBM
> 
> For example, the author never once acknowledged that EBM takes into account
> clinical experience and the clinical context on one hand, and patients' values
> on the other hand, in addition to the "evidence."  That later allows the
> author to accuse EBM of being an instrument of "the institutional power of
> medicine" that is bad for women patients.
> 
> The author also equated EBM with logical positivism, "However, the apparent
> obviousness of EBM can and should be challenged on the grounds of how
> 'evidence' has been problematised in the philosophy of science. In this paper,
> I argue that evidence-based practices maintain an antiquated understanding of
> evidence as "facts" about the world in the assumption that scientific beliefs
> stand or fall in light of the evidence. This understanding of evidence is
> explicitly positivist...."  The author then argued against logical positivism,
> and transferred all criticisms of it to EBM.
> 
> Logical Fallacies
> 
> The author made particular use of false dichotomies.  She argued that logical
> positivism, and hence EBM, are based on the notion that people's perceptions
> of external reality "are supposed to provide a a maximally certain and
> conceptually unrevisable foundation of empirical knowledge," i.e., that
> perceptions of external reality are perfect.  She then argues, quite
> unremarkably, that perceptions of reality are imperfect, but then says
> imperfect observations are essentially worthless.  So the conclusion was that
> logical positivist science, which again was equated with EBM, is based on
> worthless observations, implying both such science and EBM are worthless.
> 
> The author made the usual post-modernist appeals to (post-modernist)
> authorities.  Since this was a feminist critique, the authorities in this case
> were mostly feminists, although of course there was a bow to the ubiquitous
> Foucault.  In a particularly impenetrable section on "feminist epistemologies
> of science," for example, she asserted
> 
> - "Notions of evidence and theories of epistemic agency are, therefore,
> closely related. Haraway (1996)
> <http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-1&_cov
> erDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=59
> 25&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5
> =861b0a5ef32#bib29>  argues that the notion of  'matters of fact' depends on
> many kinds of transparencies in the grand narratives of the experimental way
> of life. The 'modest witness', the protagonist of the dramas of the Scientific
> Revolution who testifies without prejudice to new facts, had to be constructed
> in sufficiently detached and abstracted terms to make plausible the unusual
> situation where his experiences could somehow represent everyone's and
> no-one-in-particular's experiences."
> 
> - "Lorraine Code has argued that 'objectivity' is 'a generalization from the
> subjectivity of quite a small group' (1993, p. 22). However, this group 'has
> the power, security, and prestige to...generalise its experiences and
> normative ideals across the social order thus producing a group of like minded
> practitioners ('we') and dismissing 'others' as deviant and aberrant ('they')'
> (Code 1993, p. 22
> <http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-1&_cov
> erDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=59
> 25&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5
> =861b0a5ef32#bib8> ).
> 
> Setting aside, for a moment, the apparently deliberate obscurity of these
> arguments, why should one believe them just because they were made by Haraway
> or Code?  
> 
> (Perhaps Deliberately) Turgid Writing
> 
> One wonders whether the editor of this article actually understood it all.
> The writing is full of the clumsy constructions and opaque jargon usually
> favored by post-modernists.  I will save you further quotes.  One wonders,
> however, whether the purpose was to deliberately confuse the reader, in the
> hopes that readers so confused would attribute their mental state to the vast
> erudition of the author.
> 
> Finally, the Dire Warning
> 
> The author finally concluded that EBM is dangerous, at least to women, "
> Feminist critiques of science are driven by a deep concern that the
> abstractions made in the names of scientific objectivity, generalisability,
> and predictability harm women. These tendencies appear to resurface in the
> practice of EBM."
> 
> Furthermore, "Feminist insight reveals that the practices of EBM are marked by
> potential or actual gender bias, which has led at least one critic to argue
> that EBM is bad for women's health."
> 
> In Conclusion
> 
> [Borrowing some wording from my post on accusations of "microfascism," but
> with specific quotes from the Goldenberg article referenced above... ]
> 
> Recovering from the brain fever induced by reading about "knowers" as
> "collaborative agents," "experiential 'givenness,'" and "objectified
> body-machines," one might speculate: Has post-modernism been deliberately
> encouraged by some academic leaders, possibly those with the most severe
> conflicts of interest, to distract us from concentration and abuse of power in
> health care, the pervasiveness of conflicts of interests in health care
> organizations, and unethical and even illegal behavior by health care leaders?
> 
> If so, it's working.
> 
> 
> 
> 
> 
> Roy M. Poses MD
> Clinical Associate Professor of Medicine
> Brown University School of Medicine
> email: [log in to unmask]