Narrative evidence and evidence‐based medicine

Abstract

I argue that evidence-based medicine (EBM) imposes methodological limits that constrain the practice and study of medicine in unfortunate ways. EBM attempts to rid the study of medicine of the subjectivity of individual judgements, while in fact, any use of any kind of evidence requires judgement. On this basis, I argue that there are compelling reasons to broaden the range of evidence employed in EBM, and in particular, to include both straightforward and evaluative narratives. This would mark a shift from the current focus of EBM on purely quantitative data to the inclusion of qualitative data as well. I conclude by emphasizing that objectivity in medicine must come not from the exclusion of wide swaths of potentially valuable evidence, but from the careful application of our critical practices.

Clinical judgement in the era of big data and predictive analytics

“…In this book, she argues that clinical reasoning requires “narrative skills of recognizing, absorbing, interpreting, and being moved by the stories of illness.” Narrative accounts of clinical judgement focus on the patient narrative as an individual encounter with illness. They emphasize the subjectivity of narrative, its situatedness within a lifeworld, and entanglement with “history, culture and life‐meaning.” Narrative epistemologies acknowledge the complex and contingent nature of narratives, and how narrative knowledge is local and defeasible . In this way, these approaches recognize medicine's irreducible uncertainty, but nonetheless strive to negotiate this uncertainty through an interpretive, hermeneutical process.…”

“…The concept of evidence is central to EBM's statistical approach to clinical reasoning. Several authors have attempted to bring together EBM and narrative approaches, some by introducing the concept of “narrative evidence.” We explored this topic in a previous issue, in which we argued that the concept of “historical evidence” proposed by R.G. Collingwood offers a potential means of bridging the divide between EBM and narrative approaches to clinical judgement.…”

“…57 Narrative epistemologies acknowledge the complex and contingent nature of narratives, and how narrative knowledge is local and defeasible. 58 In this way, these approaches recognize medicine's irreducible uncertainty, but nonetheless strive to negotiate this uncertainty through an interpretive, hermeneutical process. This may be achieved through a phenomenological approach, by which the physician attempts to reconstruct the patient's experience by "bridging" with their lifeworld, enabling them to arrive at hermeneutic understanding.…”

Philosophy, ethics, medicine and health care: the urgent need for critical practice

“…This first thematic edition of the Journal devoted explicitly to philosophy in medicine and health care continues this tradition. We present contributions from some of the most incisive, exciting and rigorous thinkers the discipline has to offer on a broad range of subjects of urgent practical import [33–61]. The key goal is to bring depth and clarity to the discussion of topics too often addressed superficially, even in some respected mainstream medical media 3 .…”

“…This special edition also incorporates the papers resulting from a ground‐breaking, 3‐day workshop entitled ‘Critical Debates in Evidence‐based Medicine: Where we've been and where we're going’ that was held in Toronto, Canada, 14–16 November 2008 5 [52–61]. The workshop brought together participants from a variety of disciplines (including medicine, health policy, history, philosophy, bioethics, sociology, epidemiology and biostatistics) and from a number of countries (including Canada, the USA, Australia and Great Britain).…”