The Tree of Wisdom: Maintaining epistemological health within an (emerging) evidence-free environment

Abstract

Mounting concerns regarding the corruption of the clinical research enterprise by the pharmaceutical industry, as well as demonstrations of the inappropriateness of traditional research designs and consequent clinical guidelines to direct application to patient care, have led to challenges to the integrity of the evidence-based medicine (EBM) movement. However, the emerging crisis of confidence in clinical research should be seen as a threat to the viability of the entire healthcare system, not simply to EBM. Efforts of the EBM movement to represent itself as the brokers and mediators of the clinical research-healthcare interface are impediments to a full appreciation of the dilemma. Recognizing the implications of contrasting epistemological stances regarding the relationship of clinical research findings to healthcare policy and practice is essential to maximizing the value of research to the healthcare system. A synergy between empiricism-rationalism epistemologies, particularly conspicuous within the EBM movement, is identified as an important philosophical barrier to achievement of this goal. The notion of an evolutionary hierarchy of knowledge and wisdom is proposed as a vehicle to demonstrate a social constructivist alternative to a dualistic epistemology. Contrasting examples of social constructivist and empiricist-rationalist descriptions of integration of research with healthcare practice are provided for purposes of illustration.

From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative

“…Alternatively, large trials may be published but may withhold data on specific outcomes or even suppress the data on large percentages of the included patient populations . Unethical practices such as this constitute the basis for recently voiced expressions of mistrust regarding the integrity of the clinical research enterprise . Hence, difficulties of verification notwithstanding, the GWG wisely decided that it would be a mistake not to mandate active consideration of the possibility of “reporting” or “publication” bias in the course of rating the quality of evidence from clinical research for purposes of developing health care recommendations for large populations.…”

Evidence‐based medicine ‐ 2018.Quo Vadis?

“…This exclusionary position, which continues to privilege scientific evidence hegemonically over all other types and sources of clinical knowledge of relevance to the care of patients, remains a cardinal feature of EBM's defective epistemology. Indeed, despite occasional forays into the philosophy of medicine, EBM has yet to seriously address this terminal shortcoming . This is surely the reason why Djulbegovic and Guyatt refer only to the need for EBM to “raise awareness of the need for consideration of individual patient values and preferences”, and why they fail to present a method to integrate such vital patient factors in practice with a series of case examples in heroic illustration.…”

“…However, while scholarly exchange retains the potential to generate meaningful outcomes, it would appear that a divergence of these respective theses, not convergence, may be the likely result of their individual endeavours. For sure, the radically differing epistemologies of EBM and PCC represent the first critical point of departure from any commonality of thinking . Moreover, as EBM adopts “more sophisticated” evidence hierarchies, the consolidation of its reductionism conflicts badly with PCC's vision of a model of health and social care that embraces the totality of the human person and therefore the totality of ‘what is wrong’.…”

“…30 EBM has yet to seriously address this terminal shortcoming. 32,33 This is surely the reason why Djulbegovic and Guyatt 9 refer only to the need for EBM to "raise awareness of the need for consideration of individual patient values and preferences", and why they fail to present a method to integrate such vital patient factors in practice with a series of case examples in heroic illustration. EBM, then, provides a theoretical 'nod' to patient factors such as values and preferences as part of its thesis, a gesture necessary to project a manufactured respect for patient autonomy and self-determination.…”

“…For sure, the radically differing epistemologies of EBM and PCC represent the first critical point of departure from any commonality of thinking. 32,33 Moreover, as EBM adopts "more sophisticated" evidence hierarchies, 9 the consolidation of its reductionism conflicts badly with PCC's vision of a model of health and social care that embraces the totality of the human person and therefore the totality of 'what is wrong'.…”