Wieringa Sietse, Engebretsen Eivind, Heggen Kristin, Greenhalgh Trish
Medical Faculty, Institute of Health and Society, University of Oslo, Oslo, Norway.
Department of Continuing Education/Evidence-based Health Care, University of Oxford, Oxford, UK.
J Eval Clin Pract. 2017 Oct;23(5):964-970. doi: 10.1111/jep.12752. Epub 2017 May 16.
Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to "purify" clinical reality into a dichotomy of objective "evidence" from nature and subjective "preferences" from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit and undertheorized-that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a "situated practice" rather than as a sequence of research-driven abstract decisions.
循证医疗保健（EBHC），以前称为循证医学（EBM），被许多人认为已使医疗保健现代化，并将其从基于权威的过去带入了一个更加理性、科学的基础。但最近的担忧和批评提出了严峻挑战，并促使我们审视不断变化的循证医疗保健的基础。在本文中，我们介绍法国哲学家布鲁诺·拉图尔对现代性的看法，以此作为讨论循证医疗保健/循证医学话语当前变化的框架。借鉴拉图尔的著作，我们认为早期的循证医学运动有一个强烈的现代主义议程，旨在将临床现实“提纯”为来自自然的客观“证据”与来自人类社会和文化的主观“偏好”的二分法。然而，我们认为这种转变在现实中已证明是无法实现的。最近的一些发展似乎表明，在循证医疗保健话语中，提纯证据已走向消亡，并且越来越多的人——尽管是隐含的且理论不足——认识到临床决策中的证据始终是有情境的且与背景相关。独特的个体患者，而非来自遥远研究的抽象真理，必须成为临床实践的起点。因此，循证医疗保健界需要重新考虑科学应与文化相分离的假设，并承认来自人类文化和自然的知识都需要翻译和解释。这对临床推理的影响是深远的。我们提出了一些初步原则，将循证医疗保健概念化为一种“情境化实践”，而不是一系列由研究驱动的抽象决策。
