Too much evidence, too little judgment?

by November 16, 2010

A sample hierarchy of evidence

When confronted with the complexity and ambiguity of disease or even of every-day sickness, each of us as patients could hardly be blamed for taking comfort in an approach to medicine that is advertised as scientific, rational, and founded on the most careful of statistical studies. Surely with “evidence-based medicine” — such is the official term — we’re in the safest hands that the modern world can devise, as far away as possible from the aged general practictioner of our childhood memories (and of myth) who somehow got all of his diagnoses wrong and prescribed Aspirin for our every complaint.

Yet though evidence-based medicine (EBM) has enjoyed a stunning rise in influence from its coining in the early 1990s, critics are hot on its trail, arguing (as philosopher Michael Loughlin does in a recent essay in The Philosopher’s Magazine) that EBM dangerously minimizes the importance of non-quantitative elements in clinical decision-making:

Subjective disagreements tend to dissolve, on analysis, into differences of preference. In contrast differences about what constitutes good evidence are real disagreements, not matters of whim or preference. It does seem possible to question the idea that any one source of evidence should be treated as inherently better than others, across a wide range of potentially unique cases. Critics also question the equation of judgement with “opinion”, a term inviting the qualifier “arbitrary”, or “subjective”, when a better account of clinical reasoning might take judgement as the foundational concept and construe the main project of medical epistemology as the inquiry into how to cultivate and support sound or wise judgement. If opinion is then classified as a form of low-grade evidence (as it is in several published hierarchies) then EBM starts to look like a position that devalues professional judgement, replacing the quest for “wisdom” in practice with a type of technical know-how, treating a part of the human reasoning process required for good practice as though it were the whole, or the only part worth discussing.

Read the rest here. A lecture on “The End of Evidence-Based Medicine”, by Mayo Clinic endocrinologist Victor Montori, M.D., is worth viewing for the additional arguments it adds to this debate (view it here).