Philosophy of Evidence-Based Medicine

by

Jeremy Howick, Ashley Graham Kennedy, Alexander Mebius

• LAST REVIEWED: 15 January 2015
• LAST MODIFIED: 15 January 2015
• DOI: 10.1093/obo/9780195396577-0253

Introduction

Since its introduction just over two decades ago, evidence-based medicine (EBM) has come to dominate medical practice, teaching, and policy. There are a growing number of textbooks, journals, and websites dedicated to EBM research, teaching, and evidence dissemination. EBM was most recently defined as a method that integrates best research evidence with clinical expertise and patient values and circumstances in the treatment of patients. There have been debates throughout the early 21st century about what counts as good research evidence between EBM proponents and philosophical critics and even within the EBM community itself. Similar controversy arises about the relative worth of patient values and clinical expertise (and how these can be integrated). EBM has also evolved in ways that have come under scrutiny. Specifically, policymakers have used EBM research methodology to increase the relative importance of clinical guidelines that some clinicians have argued are tyrannical. Philosophers have addressed all of these controversies, and with very few exceptions have been critical of EBM. In addition most philosophical attention has been on the epistemic role of Randomization and evidence hierarchies, with relatively little attention being paid to the role of Diagnosis, expertise, patient values, and Systematic Reviews within EBM.

General Overviews

Great places to start for concise overviews of many philosophical issues surrounding evidence-based medicine (EBM) are Bluhm and Borgerson 2011 and Ashcroft 2004. Worrall 2002 arguably sparked more widespread philosophical interest in EBM although it focuses specifically on randomization. Howick 2011 provides a more comprehensive overview that is critical but supportive of EBM. Sehon and Stanley 2003 considers (among other things) the issue of whether EBM is a new Kuhnian paradigm.

• Ashcroft, Richard. “Current Epistemological Problems in Evidence-Based Medicine.” Journal of Medical Ethics 30.2 (2004): 131–135.

  DOI: 10.1136/jme.2003.007039

  This paper covers various epistemological issues raised by evidence-based medicine and provides a balanced critique of its current practice. The author thus establishes a good starting point for future discussion of the nature of clinical evidence.

• Bluhm, Robyn, and Kirstin Borgerson. “Evidence-Based Medicine.” In The Philosophy of Medicine. Edited by Dov M. Gabbay, Paul Thagard, John Woods, and Fred Gifford, 203–238. Handbook of the Philosophy of Science 16. Boston: Kluwer Academic, 2011.

  A fantastic philosophical/historical overview.

• Howick, Jeremy. The Philosophy of Evidence-Based Medicine. Chichester, UK: Wiley-Blackwell, 2011.

  DOI: 10.1002/9781444342673

  Howick defends many aspects of evidence-based medicine, including the use of Systematic Reviews and the superiority of comparative clinical studies (including observational studies and randomized trials) over pathophysiologic rationale and expert judgment.

• Sehon, Scott R., and Donald E. Stanley. “A Philosophical Analysis of the Evidence-Based Medicine Debate.” BMC Health Services Research 3.1 (2003): 3–14.

  DOI: 10.1186/1472-6963-3-14

  Examines various philosophical issues that arise in EBM, including whether EBM is a new Kuhnian paradigm.

• Worrall, John. “What Evidence in Evidence-Based Medicine?” Philosophy of Science 69.Part 3 supp (2002): S316–S330.

  Taking the evidence-based medicine view of such evidence as involving primarily the view that Randomization provides better evidence than observational studies, Worrall attacks evidence-based medicine from a Bayesian perspective.