Since its inception in the early 1990's, evidence based medicine (EBM) has been promoted as a way to make clinical practice more scientific. Exponents have appropriated concepts and terminology from the philosophy of science to explain the nature and appeal of EBM. Such appeals range from references to scientific revolutions and paradigms (accompanied by references to Kuhn) to claims of a more clearly empiricist and positivist nature, including the idea that empirical evidence can be a ‘neutral arbiter’ between competing explanatory approaches. EBM famously ‘de-emphasises’ intuition, clinical experience and pathophysiologic rationale in favour of objective evidence from RCTs and their statistical analysis. Critics of EBM have questioned the consistency of these appeals to diverse and incompatible traditions in the philosophy of science, and challenged the naive positivism of the idea that we do not need to know ‘why’ something works but simply ‘what works’. EBM is said to be based on a narrow view of science, focusing on quantitative, clinical evidence and rule-following instead of basic science, theories and judgments, and a narrow view of what it means to be ill, focusing on what can be known of disease instead of how disease is experienced by patients.
These criticisms raise a wide range of questions about the value of EBM and its alternatives. Are they well-placed, and what alternatives exist? Does a return to emphasising judgement and ‘discernment on a case-by-case basis’ represent a return to an uncritical acceptance of authority-based decision making, which EBM set out to replace? Does a return to emphasising the importance of underlying theoretical perspectives and explanatory mechanisms represent a return to a clinical science in which treatments are introduced based on a theoretical, molecular or causal explanations rather than some evidence of their value in practice? Until we have a clearer sense of what we mean by science, and the sense in which clinical practice ought to be ‘scientific’, we cannot develop a viable account that considers clinical trial methodology and how doctors can best incorporate scientific evidence in clinical decision-making and reasoning, taking into account the individual and personal nature of decision-making in clinical practice. Philosophy of science can make a valuable contribution to medical science and practice by understanding and improving medical research methodology, but also by developing an account of medical reasoning, and guiding clinicians in the use, appraisal and integration of information from different sources. A special role is reserved for “philosophy of science in practice”, as the specific tasks and limitations of clinical practice should be taken into account. In this symposium, we would like to explore how philosophy of science can improve the epistemological work in the clinical (research) practice.
Evidence-Based Medicine (EBM) was introduced in the early 1990s as a ‘radical’ and ‘revolutionary’ new ‘paradigm’, a ‘movement’ destined to remodel medicine, which henceforth would be ‘based on evidence’. In the new ‘era’, objective science in the form of Randomised Controlled Trials and their systematic analysis would replace the medieval quackery of the past as the ‘base’ for medical practice. Yet from the outset there was a tension between the apparently contentious nature of any ‘revolutionary’ doctrine and the assumption of protagonists that the case for EBM was so ‘unquestionable’ as to permit no credible opposition. Following critical interrogations of what exponents meant by ‘evidence’, and the plausibility of ‘basing’ all practice upon this conception of evidence, key defenders of EBM produced various ‘clarifications’, effectively redefining EBM in terms so ‘unquestionable’ as to be platitudinous. When critics focussed on EBM's implications for the role of judgement, value and context-specificity in clinical decision-making, protagonists continued to ‘clarify’, rather than retract or modify any substantive claims, speaking of ‘integrating’ these factors (though typically without providing an account of how precisely they would be integrated). Now a new ‘EBM Renaissance Group’ calls for a return to ‘real EBM’, which incorporates ‘expert judgement’, ‘individualised evidence’ and which ‘makes the ethical care of the patient its top priority’.
The '‘brand name’ theory of EBM is the view that, throughout the 22 year history of the EBM ‘movement’, critics made the error of treating as a thesis or proposal what is in fact a brand name, associated with a range of products and publications as well as career and funding opportunities for its exponents. While it is difficult to assess the causal role of EBM in improving outcomes for patients, EBM is nonetheless an extremely successful academic movement. As one of its founders commented in 2009, ‘funding agencies have accepted EBM with remarkable enthusiasm’ and its terminology has spread ‘like fire’, way beyond the medical arena into areas as diverse as education and social work. This success can be analysed with reference to methods employed by other academic movements purporting to discover the ‘base’ or ‘centre’ for practices, including the quality movement in management theory. Ironically, willingness to commit certain basic rhetorical fallacies seems to be the key to establishing longevity in an academic movement of this sort.
Philosophers and scientists often pride themselves on being party to a discourse more rational than popular debate. However, all attempts by theorists to make a positive impact on practice are mediated by the economic and political contexts in which theoretical and practical debates interact. Research in this area needs to acknowledge the difficulties in balancing meeting the demands of the policy agenda with retaining intellectual integrity and making contributions which are of genuine use to practitioners.
Scientific methods are supposed to guarantee the quality of our research. But they do more than this. They define what counts as evidence, what counts as a cause, and what counts as a result. Any science that looks for causes must therefore do so with a pre-understanding of what causation is. This understanding if often tacit and unexamined, yet it forms the basis of our scientific practice. In medicine, for instance, population studies such as randomised controlled trials (RCTs) are thought to offer the strongest evidence of causation. But this method is based on a difference-making notion of causation and also on a frequentist interpretation of probability. These are not neutral or unchallenged philosophical theories.
Does it matter scientifically how we understand causation philosophically? To a great extent, I argue. About 30 percent of all symptoms reported to doctors in Europe and other industrialised countries today are so-called medically unexplained (MUS). These include conditions such as chronic fatigue syndrome (CFS/ME), irritable bowel syndrome (IBS), low back pain (LBP) and fibromyalgia (FM). MUS researchers have not been able to find a common set of causes, a definite psyche-soma division, or even clear-cut classifications for these conditions. Each patient seems to have a complex and unique combination of symptoms and a unique expression of the condition.
These conditions are often depicted as outliers: atypical illnesses where standard causal explanation fails. They are then approached as epistemic problems, where a solution can be found by doing more of the same. In contrast, we take the problem of MUS to be a symptom of a deeper philosophical problem: how to detect causation in cases of complexity and heterogeneity.
Hume thought we could only understand causation as a relation of regularity between discrete, essentially unconnected types of event. From this, an orthodoxy has developed which has affected the way causation is understood within the medical model: 1) robust correlations, 2) difference-making, 3) probability raising, 4) same cause, same effect. This paradigm is tacitly accepted in many scientific methodologies, especially in the health sciences. Evidence based medicine is premised on the idea that what is true of a given population should be directly applicable in individual clinical decisions. What works for most people should also work for the patient. Such external validity only holds if we assume that individual propensities can be derived directly from statistical frequencies.
An alternative to this orthodoxy is a recently developed theory of causation, called causal dispositionalism. This theory emphasises complexity, context-sensitivity, tendency, singularism and holism. While these features are problematic for the orthodox understanding of causation, they are central to MUS and other complex diseases. By changing our philosophical framework for understanding causation, we must also change our scientific practice. This includes upgrading the status of clinical experience and mechanistic knowledge. Methodologically, this means that experimental methods and N of 1 studies should be favoured over statistical methods.
Breathing is ubiquitous and an often neglected aspect of embodied life. It is only when breathing turns into breathlessness that it becomes noticeable, and, if acute or chronic, a medical problem. This paper examines how current critical medical humanities research can shed new light on the symptom of breathlessness. I suggest that there is an epistemic gap between clinical knowledge about the physiology of breathing and breathlessness and the cultural significance of breath and breathing which seeps into the clinic in ways hitherto unexamined. In a project which has been funded by the Wellcome Trust at the Universities of Durham and Bristol (UK) we propose to bring the two forms of knowledge into dialogue, by engaging clinicians with knowledge gleaned by medical humanities, humanities and social science work on breathing and breathlessness. This project suggests that an understanding of the complex cultural, existential and spiritual meanings of breath will contribute to better clinical understanding of this common yet neglected symptom.
There are significant challenges presented by attempting practically to engage clinicians in what the humanities (literary/cultural insights as well as philosophical) have to offer their science and practice, and the first of these is actually finding and route of entry through questions that the epistemic approach of biomedicine has found it difficult to answer. In the case of breathlessness, there are three key issues that are of concern to clinicians. First, conditions causing breathlessness are a significant global health burden. Chronic obstructive pulmonary disease (for example) is currently the 4th largest cause of death in developed countries. Crucially, in the UK at least, a significant number of those who suffer from this condition remain undiagnosed and untreated for a range of reasons, including stigma associated with smoking. Second, breathlessness as a symptom has very few treatment options when therapy for the underlying cause has been exhausted. This is partly because the clinical approach focuses not on the symptom (what is experienced by the patient) but on the pathological cause (what can be demonstrated by clinical science and investigation). There is a clear mismatch between measured lung function and experienced breathlessness, which puzzles clinicians, but which has led to new modeling of the mechanisms of breathlessness through neuroimaging. This takes me to the third issue of focus for clinicians: the neuroscience of breathlessness. This relatively new science is predicated on the fact that breathlessness is under not only involuntary but also voluntary control, and that sites of interest must be sought not only in the brain stem but also in the cortex in functional MRI studies. The route map for this science has so far been pain studies, but there are significant phenomenological differences between pain and breathlessness that may mean this approach may not yield accurate results.
This paper will give an overview of how the humanities (in a broad sense) can become entangled with clinical science and in particular enable more accurate approaches to brain imaging in the field of breathlessness research.
Evidence Based Medicine (EBM) was introduced with the aim to make clinical decisions more “scientific.” One way to realize this is the “hierarchy of evidence,” in which evidence obtained from (systematic review of) randomized controlled trials (RCT’s) is placed on top, and “basic science” and “expert opinion” below. Recently, we have argued that knowledge from basic sciences is crucial in clinical decision making, as it allows doctors to bring together heterogeneous pieces of information (including outcomes from RCT’s and specificities of the patient) to construct a coherent “picture” of the individual (Baalen and Boon, 2014). We consider this ability one of the key intellectual challenges of doctors. The constructed “picture” is consequently used as an epistemic tool in reasoning about the diagnosis and treatment of that patient. Furthermore, instead of deferring their responsibility to rule-based reasoning and strict clinical guidelines, as promoted by EBM, doctors have epistemological responsibility (van Baalen and Boon, 2014).
In this paper, I will argue that, instead of referring the professional expertise of doctors to the bottom of the hierarchy, their specific expertise should be given a central role in thinking about their epistemological responsibility. First, I will claim that constructing a coherent “picture” requires a great deal of expertise. The danger of this claim is that it might initiate a return to “authority-based” decision making. Therefore, secondly, I claim that thinking about this “picture” as an epistemic tool for reasoning about diagnosis and treatment enables to clarify what the professional expertise of doctors consists of, avoiding that too much emphasis is put on “authority”.
Collins and Evans (2007) argue that an important aspect of expertise is “tacit knowledge”, which cannot be expressed in formal language, but has to be attained through “enculturation”. The structure of medical education (formal education in basic knowledge of the human body, diseases and treatment, followed by years of apprenticeship learning as intern, resident or fellow) reveals that medicine should also be considered an expertise of this kind. Nevertheless, to ensure a certain quality of clinical decision making, referring to tacit knowledge is not enough, and a closer examination of the professional expertise of doctors is needed.
Besides skills (e.g. communication and surgical skills) and epistemic content (e.g. basic knowledge, knowledge of treatments and up-to-date knowledge of medical science), thinking about epistemic challenges and epistemic tools reveals that another aspect of expertise is crucial for medical professionals, namely, epistemic actions. This includes the gathering of relevant information from the patient, literature and other sources, critical assessment of information, and medical reasoning. Therefore, I will argue that epistemic actions are crucial for constructing a coherent picture.
In this paper, I will argue that explicating the tacit aspect of expertise through analysis of epistemic actions allows to assign expertise a central role in clinical decision-making, without having to refer to “subjective” qualities, like “intuition” or “authority”. Secondly, it allows to teach young doctors relevant skills to become medical experts. Last, it offers a viable alternative to EBM that warrants a certain quality of clinical decision-making by developing the epistemological responsibility of doctors, instead of prescribing algorithmic reasoning.