Department of Philosophy, Macquarie University, Sydney, Australia.
J Eval Clin Pract. 2012 Oct;18(5):984-91. doi: 10.1111/j.1365-2753.2012.01905.x.
This paper raises questions about the epistemological foundations of evidence-based medicine (EBM). We argue that EBM is based upon reliabilist epistemological assumptions, and that this is appropriate - we should focus on identifying the most reliable processes for generating and collecting medical knowledge. However, we note that this should not be reduced to narrow questions about which research methodologies are the best for gathering evidence. Reliable processes for generating medical evidence might lie outside of formal research methods. We also question the notion of the knower that is assumed by EBM. We argue that EBM assumes an enlightenment conception of knowers as autonomous, substitutable individuals. This conception is troubled by the way that clinicians learn the role of anecdote in health care and the role of patient choice, all of which bring into play features of clinicians and patients as situated individuals with particular backgrounds and experiences. EBM's enlightenment conception of the knower is also troubled by aspects of the way evidence is produced. Given these limitations, we argue that EBM should retain its reliabilist bent, but should look beyond formal research methodologies in identifying processes that yield reliable evidence for clinical practice. We suggest looking to feminist epistemology, with its focus on the standpoints of individual situated knowers, and the role of social context in determining what counts as knowledge.
本文对循证医学（EBM）的认识论基础提出了质疑。我们认为，EBM 是基于可靠主义认识论假设的，这是合适的——我们应该专注于确定生成和收集医学知识的最可靠过程。然而，我们注意到，这不应该简化为关于哪种研究方法最适合收集证据的狭隘问题。生成医学证据的可靠过程可能超出了正式的研究方法。我们还对 EBM 所假设的知识者概念提出了质疑。我们认为，EBM 假设了知识者作为自主、可替代个体的启蒙概念。这种观念受到了临床医生学习轶事在医疗保健中的作用以及患者选择的作用的困扰，所有这些都发挥了临床医生和患者作为具有特定背景和经验的特定个体的作用。EBM 对知识者的启蒙观念也受到证据产生方式的某些方面的困扰。鉴于这些局限性，我们认为 EBM 应该保留其可靠主义倾向，但应该超越正式的研究方法，以确定为临床实践提供可靠证据的过程。我们建议关注女性主义认识论，关注个体情境知识者的立场，以及社会背景在确定什么算作知识方面的作用。
