Djulbegovic Benjamin, Guyatt Gordon H, Ashcroft Richard E
Center for Evidence-Based Medicine and Health Outcomes Research and the Clinical Translational Science Institute at the University of South Florida, Tampa, Florida 33612, USA.
Cancer Control. 2009 Apr;16(2):158-68. doi: 10.1177/107327480901600208.
Since the term "evidence-based medicine" (EBM) first appeared in the scientific literature in 1991, the concept has had considerable influence in many parts of the world. Most professional societies, the public,and funding agencies have accepted EBM with remarkable enthusiasm. The concept of evidence-based practice is now applied in management, education, criminology, and social work. Yet, EBM has attracted controversy: its critics allege that EBM uses a narrow concept of evidence and a naive conception of the relationships between evidence, theory, and practice. They also contend that EBM presents itself as a radical restructuring of medical knowledge that discredits more traditional ways of knowing in medicine, largely in the interests of people with a particular investment in the enterprise of large-scale clinical trials. Because EBM proposes aspecific relationship between theory, evidence, and knowledge, its theoretical basis can be understood as an epistemological system. Undertaking epistemological inquiry is important because the adoption of a particular epistemological view defines how science is conducted.
In this paper, we challenge this critical view of EBM by examining how EBM fits into broad epistemological debates within the philosophy of science. We consider how EBM relates to some classical debates regarding the nature of science and knowledge. We investigate EBM from the perspective of major epistemological theories (logical-positivism/inductivism, deductivism/falsificationism/theory-ladeness of observations, explanationism/holism, instrumentalism, underdetermination theory by evidence).
We first explore the relationship between evidence and knowledge and discuss philosophical support for the main way that evidence is used in medicine: (1) in the philosophical tradition that "rational thinkers respect their evidence," we show that EBM refers to making medical decisions that are consistent with evidence, (2) as a reliable sign, symptom, or mark to enhance reasonableness or truthfulness of some particular claim ("evidence as a guide to truth"), and (3) to serve as a neutral arbiter among competing views. Our analysis indicates that EBM does not have a rigorous epistemological stance. In fact, EBM enthusiastically draws on all major traditions of philosophical theories of scientific evidence.
Our findings indicate that EBM should not be construed as a new scientific or philosophical theory that changes the nature of medicine or our understanding thereof. Rather, we should consider EBM as a continuously evolving heuristic structure for optimizing clinical practice.
自“循证医学”（EBM）这一术语于1991年首次出现在科学文献中以来，该概念在世界许多地区都产生了相当大的影响。大多数专业协会、公众和资助机构都以极高的热情接受了循证医学。循证实践的概念现在已应用于管理、教育、犯罪学和社会工作等领域。然而，循证医学也引发了争议：其批评者称，循证医学使用了狭义的证据概念以及对证据、理论和实践之间关系的幼稚理解。他们还认为，循证医学将自己呈现为医学知识的一种激进重构，这种重构诋毁了医学中更传统的认知方式，主要是为了那些在大规模临床试验企业中有特殊利益的人的利益。由于循证医学提出了理论、证据和知识之间的特定关系，其理论基础可以被理解为一种认识论体系。进行认识论探究很重要，因为采用特定的认识论观点决定了科学的开展方式。
在本文中，我们通过考察循证医学如何融入科学哲学中的广泛认识论辩论，对这种对循证医学的批判性观点提出质疑。我们思考循证医学如何与一些关于科学和知识本质的经典辩论相关联。我们从主要认识论理论（逻辑实证主义/归纳主义、演绎主义/证伪主义/观察的理论负荷、解释主义/整体主义、工具主义、证据的不充分决定性理论）的角度研究循证医学。
我们首先探讨证据与知识之间的关系，并讨论医学中使用证据的主要方式的哲学支持：（1）在“理性思考者尊重其证据”的哲学传统中，我们表明循证医学指的是做出与证据一致的医学决策，（2）作为一种可靠的迹象、症状或标记，以增强某些特定主张的合理性或真实性（“证据作为通向真理的指南”），以及（3）作为相互竞争观点之间的中立仲裁者。我们的分析表明，循证医学没有严谨的认识论立场。事实上，循证医学积极借鉴了科学证据哲学理论的所有主要传统。
我们的研究结果表明，循证医学不应被理解为一种改变医学性质或我们对医学理解的新科学或哲学理论。相反，我们应该将循证医学视为一种不断发展的启发式结构，用于优化临床实践。
