Trnka Susanna, Stöckelová Tereza
University of Auckland, Auckland, New Zealand.
Institute of Sociology of the Czech Academy of Sciences, Prague, Czech Republic.
Sociol Health Illn. 2019 Feb;41(2):234-248. doi: 10.1111/1467-9566.12817. Epub 2018 Aug 26.
A. L. Cochrane's Effectiveness and Efficiency frequently appears as a key reference in debates over, and a justification for, contemporary evidence-based medicine. Cochrane's concern in this text with the equality of care as the ultimate rationale for why effectiveness and efficiency of cure are needed has, however, largely disappeared from debate. In this article, we reconsider Cochrane's approach through the use of case studies of plural forms of medicine in the Czech Republic, namely traditional Chinese medicine, homeopathy and spa care. In addition to bringing equality back into the picture, we also identify four expansions to Cochrane's original vision arising from the difficulties of separating cure from care; the overlap between prevention and cure; the complex actions of some multi-faceted therapies; and recent reconceptualisations of the placebo effect. In conclusion, we suggest that instead of the widely used strictly vertical "evidence pyramid", a descriptor of the horizontal and additive ordering of evidence might be more appropriate. We also argue that in healthcare systems characterised by a multiplicity of approaches, if we want to truly benefit from this heterogeneity, we must take seriously each medical tradition's approaches to prevention, cure, care, as well as efficiency, efficacy and equality.
A. L. 科克伦的《有效性与效率》在当代循证医学的辩论中经常作为关键参考文献出现，也是其正当理由。然而，科克伦在本文中所关注的医疗平等作为需要治疗有效性和效率的最终理由，在很大程度上已从辩论中消失。在本文中，我们通过捷克共和国多种医学形式的案例研究来重新审视科克伦的方法，这些医学形式包括传统中医、顺势疗法和温泉疗法。除了将平等重新纳入视野，我们还从将治疗与护理分离的困难、预防与治疗的重叠、一些多方面疗法的复杂作用以及安慰剂效应的最新概念化中，识别出对科克伦原愿景的四点扩展。总之，我们建议，与其使用广泛应用的严格垂直的“证据金字塔”，对证据进行水平和累加排序的描述可能更合适。我们还认为，在以多种方法为特征的医疗体系中，如果我们想真正从这种异质性中受益，就必须认真对待每种医学传统在预防、治疗、护理以及效率、疗效和平等方面的方法。
