Evidence based medicine (EBM) is under critical debate, and person centered healthcare (PCH) has been proposed as an improvement. But is PCH offered as a supplement or as a replacement of EBM? Prima facie PCH only concerns the practice of medicine, while the contended features of EBM also include methods and medical model. I here argue that there are good philosophical reasons to see PCH as a radical alternative to the existing medical paradigm of EBM, since the (...) two seem committed to conflicting ontologies. This paper aims to make explicit some of the most fundamental assumptions that motivate EBM and PCH, respectively, in order to show that the choice between them ultimately comes down to ontological preference. While EBM has a solid foundation in positivism, or what I here call Humeanism, PCH is more consistent with causal dispositionalism. I conclude that if there is a paradigmatic revolution on the way in medicine, it is first of all one of ontology. (shrink)

Proponents of evidence-based medicine have argued convincingly for applying this scientific method to medicine. However, the current methodological framework of the EBM movement has recently been called into question, especially in epidemiology and the philosophy of science. The debate has focused on whether the methodology of randomized controlled trials provides the best evidence available. This paper attempts to shift the focus of the debate by arguing that clinical reasoning involves a patchwork of evidential approaches and that the (...) emphasis on evidence hierarchies of methodology fails to lend credence to the common practice of corroboration in medicine. I argue that the strength of evidence lies in the evidence itself, and not the methodology used to obtain that evidence. Ultimately, when it comes to evaluating the effectiveness of medical interventions, it is the evidence obtained from the methodology rather than the methodology that should establish the strength of the evidence. (shrink)

Given the unprecedented novel nature and scale of coronavirus and the global nature of this public health crisis, which upended many public/environmental research norms almost overnight. However, with further waves of the virus expected and more pandemics anticipated. The COVID-19 pandemic of 2020 opened our eyes to the ever-changing conditions and uncertainty that exists in our world today, particularly with regards to environmental and public health practices disruption. This paper explores environmental and public health evidence-based practices toward responding (...) to Covid-19. A literature review tried to do a deep dive through the use of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward retrieving research publications, “gray literature” as well as reports from expert working groups. To achieve enhanced population health, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain time. As only together can evidence-informed decision-making (EIDM) can become a reality which include effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production as well as use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-production. Co-production (or co-creation or co-design) of environmental/public health evidence considered as a key tool for addressing complex global crises such as the high risk of severe COVID-19 in different nations. A significant evidence-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy-making; conducting sound evaluation; do a thorough program-planning frameworks; as well as disseminating what is being learned. As researchers, scientists, statisticians, journal editors, practitioners, as well as decision makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel research findings serving as the foundation for intervention as well as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a “Plan B” of effective behavioral, environmental, social as well as systems interventions (BESSI) toward reducing transmission. (shrink)

The evidence-based medicine (EBM) movement is touted as a new paradigm in medical education and practice, a description that carries with it an enthusiasm for science that has not been seen since logical positivism flourished (circa 1920–1950). At the same time, the term ‘‘evidence-based medicine’’ has a ring of obviousness to it, as few physicians, one suspects, would claim that they do not attempt to base their clinical decision-making on available evidence. However, the apparent (...) obviousness of EBM can and should be challenged on the grounds of how ‘evidence’ has been problematised in the philosophy of science. EBM enthusiasm, it follows, ought to be tempered. The post-positivist, feminist, and phenomenological philosophies of science that are examined in this paper contest the seemingly unproblematic nature of evidence that underlies EBM by emphasizing different features of the social nature of science. The appeal to the authority of evidence that characterizes evidence-based practices does not increase objectivity but rather obscures the subjective elements that inescapably enter all forms of human inquiry. The seeming common sense of EBM only occurs because of its assumed removal from the social context of medical practice. In the current age where the institutional power of medicine is suspect, a model that represents biomedicine as politically disinterested or merely scientific should give pause. (shrink)

Since its introduction just over two decades ago, evidence-based medicine (EBM) has come to dominate medical practice, teaching, and policy. There are a growing number of textbooks, journals, and websites dedicated to EBM research, teaching, and evidence dissemination. EBM was most recently defined as a method that integrates best research evidence with clinical expertise and patient values and circumstances in the treatment of patients. There have been debates throughout the early 21st century about what counts (...) as good research evidence between EBM proponents and philosophical critics and even within the EBM community itself. Similar controversy arises about the relative worth of patient values and clinical expertise (and how these can be integrated). EBM has also evolved in ways that have come under scrutiny. Specifically, policymakers have used EBM research methodology to increase the relative importance of clinical guidelines that some clinicians have argued are tyrannical. Philosophers have addressed all of these controversies, and with very few exceptions have been critical of EBM. In addition most philosophical attention has been on the epistemic role of Randomization and evidence hierarchies, with relatively little attention being paid to the role of Diagnosis, expertise, patient values, and Systematic Reviews within EBM. (shrink)

We live in an age of evidence-based healthcare, where the concept of evidence has been avidly and often uncritically embraced as a symbol of legitimacy, truth, and justice. By letting the evidence dictate healthcare decision making from the bedside to the policy level, the normative claims that inform decision making appear to be negotiated fairly—without subjectivity, prejudice, or bias. Thus, the term ‘‘evidence-based’’ is typically read in the health sciences as the empirically adequate standard (...) of reasonable practice and a means for increasing certainty. Supporters believe that evidence-based medicine (EBM) can introduce rational order to the deliberative processes of healthcare decision making. It is perhaps puzzling, then, to come across critical perspectives (typically arising from the humanities and the more theory-driven social sciences) raising concerns about a seeming technogovernance being introduced by this deferral to the evidence where power interests can be obfuscated by way of technical resolve. The critics holding this minority view argue that technological solutions to problems of knowledge and practice cannot replace medicine’s normative content. Against EBM’s democratic leanings toward transparency and accountability, medical criteria alone cannot decide valueladen ethically charged decisions. This paper attempts to explain and evaluate this important debate in the philosophy of medicine, focusing specifically on the dispute over 'evidence-based women's health'. (shrink)

Thirty years after the rise of the evidence-based medicine (EBM) movement, formal training in philosophy remains poorly represented among medical students and their educators. In this paper, I argue that EBM’s reception in this context has resulted in a privileging of empiricism over rationalism in clinical reasoning with unintended consequences for medical practice. After a limited review of the history of medical epistemology, I argue that a solution to this problem can be found in the method of (...) the 2nd-century Roman physician Galen, who brought empiricism and rationalism together in a synthesis anticipating the scientific method. Next, I review several of the problems that have been identified as resulting from a staunch commitment to empiricism in medical practice. Finally, I conclude that greater epistemological awareness in the medical community would precipitate a Galenic shift toward a more epistemically balanced, scientific approach to clinical research. (shrink)

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism (...) would respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (shrink)

This thesis examines philosophical controversies surrounding the evaluation of medical treatments, with a focus on the evidential roles of randomised trials and mechanisms in Evidence-Based Medicine. Current 'best practice' usually involves excluding non-randomised trial evidence from systematic reviews in cases where randomised trials are available for inclusion in the reviews. The first paper challenges this practice and evaluates whether adding of evidence from non-randomised trials might improve the quality and precision of some systematic reviews. (...) The second paper compares the alleged methodological benefits of randomised trials over observational studies for investigating treatment benefits. It suggests that claims about the superiority of well-conducted randomised controlled trials over well-conducted observational studies are justified, especially when results from the two methods are contradictory. The third paper argues that postulating the unpredictability paradox in systematic reviews when no detectable empirical differences can be found requires further justification. The fourth paper examines the problem of absence causation in the context of explaining causal mechanisms and argues that a recent solution is incomplete and requires further justification. Solving the problem by describing absences as causes of 'mechanism failure' fails to take into account the effects of absences that lead to vacillating levels of mechanism functionality. The fifth paper criticises literature that has emphasised functioning versus 'broken' or 'non-functioning' mechanisms emphasising that many diseases result from increased or decreased mechanism function, rather than complete loss of function. Mechanistic explanations must account for differences in the effectiveness of performed functions, yet current philosophical mechanistic explanations do not achieve this. The last paper argues that the standard of evidence embodied in the ICE theory of technological function is too permissive for evaluating whether the proposed functions of medical technologies have been adequately assessed and correctly ascribed. It argues that high-quality evidence from clinical studies is necessary to justify functional ascriptions to health care technologies. (shrink)

As a way to make medical decisions, Evidence-Based Medicine (EBM) has failed. EBM's failure arises from not being founded on real-world decision-making. EBM aspires to a scientific standard for the best way to treat a disease and determine its cause, but it fails to recognise that the scientific method is inapplicable to medical and other real-world decision-making. EBM also wrongly assumes that evidence can be marshaled and applied according to an hierarchy that is determined in an argument (...) by authority to the method by which it has been obtained. If EBM had valid theoretical, practical or empirical foundations, there would be no hierarchy of evidence. In all real-world decision-making, evidence stands or falls on its inherent reliability. This has to be and can only be assessed on a case-by-case basis applying understanding and wisdom against the background of all available facts—the "factual matrix." EBM's failure is structural and was inevitable from its inception. EBM confuses the inherent reliability and probative value of evidence with the means by which it is obtained. -/- EBM is therefore an ad hoc construct and is not a valid basis for medical decision-making. This is further demonstrated by its exclusion of relevant scientific and probative real-world decision-making evidence and processes. It draws upon a narrow evidence base that is itself inherently unreliable. It fails to take adequate account of the nature of causation, the full range of evidence relevant to its determination, and differing approaches to determining cause and effect in real-world decision-making. EBM also makes a muddled attempt to emulate the scientific method and it does not acknowledge the role of experience, understanding and wisdom in making medical decisions. (shrink)

Evidence-based medicine is a clinical decision-making framework which makes claims about what physicians ought to do. Though heralded as the cutting edge of medical science, evidence-based medicine is a value-laden normative theory which implicitly depends on substantive views regarding what is morally good or right. In this paper, I provide an ethical analysis of evidence-based medicine. I consider its normative underpinnings in three ethical theories: utilitarianism, Kantian deontology, and virtue ethics. In the face of (...) uncertainty, evidence-based medicine endorses expected utility theory using the best available evidence in order to avoid doing more harm than good. In accordance with the Kantian respect for individuals as ends in themselves, evidence-based medicine calls for integrating the values and preferences of the patient. De-emphasizing intuition, clinical expertise, and pathophysiologic rationale emphasizes the need for the intellectual virtues of curiosity, critical thinking, and courage. Evidence-based medicine is a successful clinical practice that can be morally justified by all three major ethical theories. Although its focus on maximizing good health outcomes and integrating respect for individual patients has been emphasized, the role of the intellectual virtues in evidence-based medicine remains highly under-explored. (shrink)

Evidence-based medicine is a clinical decision making framework which makes claims about what physicians ought to do. Though heralded as the cutting edge of medical science evidence-based medicine is a value laden normative theory which implicitly depends on substantive views regarding what is morally good or right. In this paper, I provide an ethical analysis of evidence-based medicine. I consider its normative underpinnings in three ethical theories: utilitarianism, Kantian deontology, and virtue ethics. In the (...) face of uncertainty, evidence-based medicine endorses expected utility theory using the best available evidence in order to avoid doing more harm than good. In accordance with the Kantian respect for individuals as ends in themselves, evidence-based medicine calls for integrating the values and preferences of the patient. De-emphasizing intuition, clinical expertise, and pathophysiologic rationale emphasizes the need for the intellectual virtues of curiosity, critical thinking, and courage. Evidence-based medicine is a successful clinical practice that can be morally justified by all three major ethical theories. Although its focus on maximizing good health outcomes and integrating respect for individual patients has been emphasized, the role of the intellectual virtues in evidence- based medicine remains highly under-explored. (shrink)

In this article, we explicate evidence-based nursing (EBN), critically appraise its framework and respond to nurses’ concern that EBN sidelines the caring elements of nursing practice. We use resources from care ethics, especially Vrinda Dalmiya’s work that considers care as crucial for both epistemology and ethics, to show how EBN is compatible with, and indeed can be enhanced by, the caring aspects of nursing practice. We demonstrate that caring can act as a bridge between ‘external’ (...) class='Hi'>evidence and the other pillars of the EBN framework: clinical expertise; patient preferences and values. Drawing on an influential EBN handbook, section 1 presents the aims and features of EBN, including the normative principle that EBN should take place within a ‘context of caring’. We aim to understand this context and whether it can be neatly detached from the EBN framework, as the handbook seems to suggest. In section 2, we highlight the grounds for resistance to EBN from the nursing community, before mounting the argument that nursing practices can be understood fruitfully through feminist care ethics and/or virtue ethics lenses. In section 3, we deepen that analysis using Dalmiya’s concepts of care-knowing and care as a hybrid ethico-epistemic virtue, which are ideally suited to the complex practices of nursing. In section 4, we bring this rich understanding of care into conversation with EBN, showing that its framework cannot be adequately theorised without paying proper attention to care. Caring can be neither an innocuous background assumption of nor an afterthought to the EBN framework. (shrink)

COVID-19 demonstrated a global catastrophe that touched everybody, including the scientific community. As we respond and recover rapidly from this pandemic, there is an opportunity to guarantee that the fabric of our society includes sustainability, fairness, and care. However, approaches to environmental health attempt to decrease the population burden of COVID-19, toward saving patients from becoming ill along with preserving the allocation of clinical resources and public safety standards. This paper explores environmental and public health evidence-based practices toward (...) responding to Covid-19. A literature review tried to do a deep dive through the use of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward reretrieving research publications, “grey literature” as well as reports from expert working groups. To achieve enhanced population health, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain time. As only together can evidence-informed decision-making (EIDM) can become a reality which includes effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production as well as use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-production. Co-production (or co-creation or co-design) of environmental/public health evidence considered as a key tool for addressing complex global crises such as the high risk of severe COVID-19 in different nations. A significant evidence-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy making; conducting sound evaluation; do thorough program-planning frameworks; as well as disseminating what is being learned. As researchers, scientists, statisticians, journal editors, practitioners, as well as decision-makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel research findings serving as the foundation for intervention as well as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a “Plan B” of effective behavioural, environmental, social as well as systems interventions (BESSI) toward reducing transmission. (shrink)

Introduction: Clinical practice guidelines (CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale: I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated (...) aims of these CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis: The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial (RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion: The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. (shrink)

While most of healthcare research and practice fully endorses evidence-based healthcare, a minority view borrows popular themes from philosophy of science like underdetermination and value-ladenness to question the legitimacy of the evidence-based movement’s philosophical underpinnings. While the feminist origins go unacknowledged, those critics adopt a feminist reading of the “gap argument” to challenge the perceived objectivism of evidence-based practice. From there, the critics seem to despair over the “subjective elements” that values introduce (...) to clinical reasoning, demonstrating that they do not subscribe to feminist science studies’ normative program——where contextual values can enable good science and justified decisions. In this paper, I investigate why it is that the critics of evidence-based medicine adopt feminist science’s characterization of the problem but resist the productive solutions offered by those same theorists. I suggest that the common feminist empiricist appeal to idealized epistemic communities is impractical for those working within the current biomedical context and instead offer an alternate stream of feminist research into the empirical content of values (found in the work of Elizabeth Anderson and Sharyn Clough) as a more helpful recourse for facilitating the important task of legitimate and justified clinical decision-making. I use a case study on clinical decision-making to illustrate the fruitfulness of the latter feminist empiricist framework. -/- See response by Sharyn Clough: http://wp.me/p1Bfg0-1aN See reply by Maya Goldenberg: http://wp.me/p1Bfg0-1oY. (shrink)

Medicine, like law, is a pragmatic, probabilistic activity. Both require that decisions be made on the basis of available evidence, within a limited time. In contrast to law, medicine, particularly evidence-based medicine as it is currently practiced, aspires to a scientific standard of proof, one that is more certain than the standards of proof courts apply in civil and criminal proceedings. But medicine, as Dr. William Osler put it, is an "art of probabilities," or at best, a (...) "science of uncertainty." One can better practice medicine by using other evidentiary standards in addition to the "scientific." To employ only the scientific standard of proof is inappropriate, if not impossible; furthermore, as this review will show, its application in medicine is fraught with bias. Evidence is information. It supports or undermines a proposition, whether a hypothesis in science, a diagnosis in medicine, or a fact or point in question in a legal investigation. In medicine, physicians marshal evidence to make decisions on how to best prevent, diagnose, and treat disease, and improve health. In law, courts decide the facts and render justice. Judges and juries assess evidence to establish liability, to settle custody and medical issues, and to determine a defendant's guilt or innocence. (shrink)

Because “evidence” is at issue in evidence-based medicine (EBM), the critical responses to the movement have taken up themes from post-positivist philosophy of science to demonstrate the untenability of the objectivist account of evidence. While these post-positivist critiques seem largely correct, I propose that when they focus their analyses on what counts as evidence, the critics miss important and desirable pragmatic features of the evidence-based approach. This article redirects critical attention toward EBM’s rigid (...) hierarchy of evidence as the culprit of its objectionable epistemic practices. It reframes the EBM discourse in light of a distinction between objectivist and pragmatic epistemology, which allows for a more nuanced analysis of EBM than previously offered: one that is not either/or in its evaluation of the decision-making technology as either iconoclastic or creedal. -/- . (shrink)

The investigation of the degree of amotivation and subsequent intervention towards the motivation of undergraduate vocational and technical education (VTE) students has not received the same amount of attention as other disciplines. Despite the negative impact of a lack of volitional drive on students' practical skills learning, there is scarcity of literature on amotivation among VTE undergraduate students. This study aimed to demonstrate the effectiveness of problem-based learning (PBL) in transitioning undergraduate students from a state of being amotivated to (...) motivated. The study utilized a quasi-experimental research design and selected 168 students in their penultimate and final years majoring in agricultural education, business education, computer education, home economics, and industrial technical education who met the study's inclusion criteria. The intervention consisted of eight weeks of treatment and four weeks of follow-up meetings. An existing academic motivation scale was adapted for use, and data was collected through a self-report questionnaire. Data analysis was conducted using independent sample t-tests, and paired sample t-tests. The findings revealed that the level of amotivation among the students was high, and PBL had a significant impact on transitioning VTE students from being amotivated to motivated in the treatment group compared to those in the control group. Furthermore, the positive gains were maintained by the treatment group at follow-up. The study suggests that a PBL program can effectively address students' lack of volitional drive to engage in academic activities among undergraduate students majoring in agricultural education, business education, computer education, home economics, and industrial technical in Nigeria. (shrink)

Over the past several decades, we devoted much energy to generating, reviewing and summarizing evidence. We have given far less attention to the issue of how to thoughtfully apply the evidence once we have it. That’s fine if all we care about is that our clinical decisions are evidence-based, but not so good if we also want them to be well-reasoned. Let us not forget that evidence based medicine (EBM) grew out of an interest (...) in making medicine ‘rational’, with the idea that rational clinical evaluations should be evidence-based. I agree with the uncontroversial statement that the best decision is supported, at least in part, by the best available evidence. Rationality, however, is constituted by reasoning, not evidence. Complete arguments are necessary for rational evaluations, arguments that begin with general evidence and end in a conclusion about a particular patient. In order to traverse these inferential gaps, medicine must address the issue of how to establish, as an intermediate premise, what the evidence has to say about the efficacy of an intervention for particular patients in a particular practice setting. (shrink)

Evidence-based medicine relies on the execution of clinical practice guidelines and protocols. A great deal of of effort has been invested in the development of various tools which automate the representation and execution of the recommendations contained within such guidelines and protocols by creating Computer Interpretable Guideline Models (CIGMs). Context-based task ontologies (CTOs), based on standard terminology systems like UMLS, form one of the core components of such a model. We have created DAML+OIL-based CTOs (...) for the tasks mentioned in the WHO guideline for hypertension management, drawing comparisons also with other related guidelines. The advantages of CTOs include: contextualization of ontologies, providing ontologies tailored to specific aspects of the phenomena of interest, dividing the complexity involved in creating ontologies into different levels, providing a methodology by means of which the task recommendations contained within guidelines can be integrated into the clinical practices of a health care set-up. (shrink)

According to factive accounts of the norm of belief and decision-making, you should not believe or base decisions on a falsehood. Even when the evidence misleadingly suggests that a false proposition is true, you should not believe it or base decisions on it. Critics claim that factive accounts are counterintuitive and badly mischaracterize our ordinary practice of evaluating beliefs and decisions. This paper reports four experiments that rigorously test the critic’s accusations and the viability of factive accounts. The (...) results undermine the accusations and provide the best evidence yet of factive norms of belief and decision-making. The results also help discriminate between two leading candidates for a factive norm: truth and knowledge. Knowledge is the superior candidate. (shrink)

The evidence based medicine movement has championed the need for objective and transparent methods of clinical guideline development. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was developed for that purpose. Central to this framework is criteria for assessing the quality of evidence from clinical studies and the impact that body of evidence should have on our confidence in the clinical effectiveness of a therapy under examination. Grades of Recommendation, Assessment, Development, and Evaluation has (...) been adopted by a number of professional medical societies and organizations as a means for orienting the development of clinical guidelines. As a result, the method of GRADE has implications on how health care is delivered and patient outcomes. In this paper, we reveal several issues with the underlying logic of GRADE that warrant further discussion. First, the definitions of the “grades of evidence” provided by GRADE, while explicit, are functionally vague. Second, the “criteria for assigning grade of evidence” is seemingly arbitrary and arguably logically incoherent. Finally, the GRADE method is unclear on how to integrate evidence grades with other important factors, such as patient preferences, and trade‐offs between costs, benefits, and harms when proposing a clinical practice recommendation. Much of the GRADE method requires judgement on the part of the user, making it unclear as to how the framework reduces bias in recommendations or makes them more transparent—both goals of the programme. It is our view that the issues presented in this paper undermine GRADE's justificatory scheme, thereby limiting the usefulness of GRADE as a tool for developing clinical recommendations. (shrink)

How do archaeologists make effective use of physical traces and material culture as repositories of evidence? Material Evidence is a collection of 19 essays that take a resolutely case-based approach to this question, exploring key instances of exemplary practice, instructive failures, and innovative developments in the use of archaeological data as evidence. The goal is to bring to the surface the wisdom of practice, teasing out norms of archaeological reasoning from evidence. -/- Archaeologists (...) make compelling use of an enormously diverse range of material evidence, from garbage dumps to monuments, from finely crafted artifacts rich with cultural significance to the inadvertent transformation of landscapes over the long term. Each contributor to Material Evidence identifies a particular type of evidence with which they grapple and considers, with reference to concrete examples, how archaeologists construct evidential claims, critically assess them, and bring them to bear on pivotal questions about the cultural past. -/- Historians, cultural anthropologists, philosophers, and science studies scholars are increasingly interested in working with material "things" as objects of inquiry and as evidence – and they acknowledge on all sides just how challenging this is. One of the central messages of the book is that close analysis of archaeological best practice can yield constructive guidelines for practice that have much to offer practitioners within archaeology and well beyond. (shrink)

Clinical psychology is characterized by persistent disagreement about fundamental aspects of the discipline ranging from what mental disorders are to what constitutes effective treatment. Attempts to address the problem of epistemic disagreement have been frequently based on establishing the correct answer by fiat without identifying and addressing the sources of the disagreement. We argue that this strategy has not worked very well and the result is frequently ongoing and intractable disagreement, with each side in an argument convinced they are (...) correct. In this paper, we outline an epistemic disagreement procedural model intended to assist researchers and clinicians in the field of clinical psychology to identify, explore, and develop inquiry strategies that capitalize on situations where competing knowledge claims are made. The result is a flexible conceptual framework committed to a defensible epistemic pluralism, fallibilism, and contextualism, across the various research tasks constituting the field of clinical psychology. (shrink)

On a standard view about reasons, evidence, and justification, there is justification for you to believe all and only what your evidence supports and the reasons that determine whether there is justification to believe are all just pieces of evidence. This view is mistaken about two things. It is mistaken about the rational role of evidence. It is also mistaken about the rational role of reasons. To show this, I present two basis problems for the standard (...) view and argue that it lacks the resources to solve these problems. It is easy to spot these mistakes once we are clear on the ontology of reasons and have a better understanding of the role that belief plays in the theory of possessed evidence. After attacking the standard view, I offer an alternative account of justification. On this view, the justificatory status of a belief is not a function of the reasons/evidence on which it is based (it might not be based on any) but is instead a function of the basis that it can provide. (shrink)

In everyday life and in science we acquire evidence of evidence and based on this new evidence we often change our epistemic states. An assumption underlying such practice is that the following EEE Slogan is correct: 'evidence of evidence is evidence' (Feldman 2007, p. 208). We suggest that evidence of evidence is best understood as higher-order evidence about the epistemic state of agents. In order to model evidence of (...) evidence we introduce a new powerful framework for modelling epistemic states, Dyadic Bayesianism. Based on this framework, we then discuss characterizations of evidence of evidence and argue for one of them. Finally, we show that whether the EEE Slogan holds, depends on the specific kind of evidence of evidence. (shrink)

Evidence-based medicine (EBM) calls for medical practitioners to “integrate” our best available evidence into clinical practice. A significant amount of the literature on EBM takes this integration to be unproblematic, focusing on questions like how to interpret evidence and engage with patient values, rather than critically looking at how these features of EBM can be implemented together. Other authors have also commented on this gap in the literature, for example, identifying the lack of clarity about (...) how patient preferences and evidence from trials is supposed to be integrated in practice. In this paper, I look at this issue from an epistemological perspective, (looking at how different types of knowledge in EBM can be used to make sounds judgements). In particular, I introduce an epistemological issue for this integration problem, which I call the epistemic integration problem. This is essentially the problem of how we can use information that is both general (eg, about a population sample) and descriptive (eg, about what expected outcomes are) to reach clinical judgements that are individualized (applying to a particular patient) and normative (about what is best for their health). (shrink)

In this paper, I examined whether evidence from the neuroscience of morality supports the standard models of phronesis, i.e., Jubilee and Aretai Centre Models. The standard models explain phronesis as a multifaceted construct based on interaction and coordination among functional components. I reviewed recent neuroscience studies focusing on brain networks associated with morality and their connectivity to examine the validity of the models. Simultaneously, I discussed whether the evidence helps the models address challenges, particularly those from the (...) phronesis eliminativism. Neuroscientific evidence supported the importance of brain networks, i.e., the default mode, salience, and central executive functioning networks, in moral functioning in general. The findings favorably supported the multifaceted and integrative nature of phronesis proposed by the standard models. Finally, I considered how the two models could explain the mechanisms of phronesis more integratively based on neuroscientific findings. At the end of this paper, with the evidence, I proposed several practical ideas to promote the cultivation of phronesis, e.g., the consideration of coordination among components for moral functioning and the use of moral exemplars. (shrink)

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability (...) to improve quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

This philosophical article critically examines Ayurveda, highlighting its classification as a pseudoscientific practice and questioning its place in modern medicine. By integrating both Indian and Western philosophical perspectives, the article contributes to the broader discourse on tradition versus empirical science. It challenges the authority of ancient knowledge in the face of modern scientific rigor, while also exploring the potential for dialogue between holistic practices and evidence-based medicine. This work adds depth to the literature on alternative medicine, skepticism, (...) and the philosophy of science, encouraging critical reflection on the role of Ayurveda today. (shrink)

Clinical practice is a part of the integral learning method in nursing education. The use of information and communication technologies (ICT) in clinical learning is highly encouraged among nursing students to support evidence-based nursing and student-centered learning. Through the information-processing lens of the mindsponge theory, this study views performance expectancy (or perceived usefulness) and effort expectancy (or perceived ease of use) as results of subjective benefit and cost judgments determining the students’ ICT using intention for supporting clinical (...) learning, respectively. Therefore, the study examines whether effort expectancy moderates the relationship between performance expectancy and the intention to use ICT among Moroccan nursing students. The Bayesian Mindsponge Framework (BMF) analytics was employed on a dataset of 702 Moroccan nursing students. We found that nursing students’ performance expectancy is positively associated with the intention to adopt ICT and social media, while effort expectancy positively moderates this relationship. Moreover, the model with effort expectancy as the moderator was discovered to have a significantly larger weight than the model with effort expectancy as the direct predictor, validating our information-processing reasoning. This study provides a new perspective on the interplay between the benefit and cost perceptions of ICT use to support clinical learning methods in nursing education. Moreover, given the limited education resources, especially in developing countries like Morocco, we recommend nursing education and training prioritize communicating the benefits of ICTs and social media over ease of use. Doing so would help improve the effectiveness and efficiency of nursing education and training while lowering costs. (shrink)

Some prominent evidentialists argue that practical considerations cannot be normative reasons for belief because they can’t be motivating reasons for belief. Existing pragmatist responses turn out to depend on the assumption that it’s possible to believe in the absence of evidence. The evidentialist may deny this, at which point the debate ends in an impasse. I propose a new strategy for the pragmatist. This involves conceding that belief in the absence of evidence is impossible. We then argue that (...) evidence can play a role in bringing about belief without being a motivating reason for belief, thereby leaving room for practical considerations to serve as motivating reasons. I present two ways in which this can happen. First, agents can use evidence as a mere means by which to believe, with practical considerations serving as motivating reasons for belief, just as we use tools (e.g. a brake pedal) as mere means by which to do something (e.g. slow down) which we are motivated to do for practical reasons. Second, evidence can make it possible for one to choose whether or not to believe – a choice one can then make for practical reasons. These arguments push the debate between the evidentialist and the pragmatist into new territory. It is no longer enough for an evidentialist to insist that belief is impossible without evidence. Even if this is right, the outcome of the debate remains unsettled. It will hang on the ability of the evidentialist to respond to the new pragmatist strategy presented here. (shrink)

In recent years, the idea has been gaining ground that our traditional conceptions of knowledge and cognition are unduly limiting, in that they privilege what goes on inside the ‘skin and skull’ of an individual reasoner. Instead, it has been argued, knowledge and cognition need to be understood as embodied, situated, and extended. Whether these various interrelations and dependencies are ‘merely’ causal, or are in a more fundamental sense constitutive of knowledge and cognition, is as much a matter of controversy (...) as the degree to which they pose a challenge to ‘traditional’ conceptions of cognition, knowledge and the mind. In this paper we argue that when the idea of ‘extendedness’ is applied to a core concept in epistemology and the philosophy of science—namely, scientific evidence—things appear to be on a much surer footing. The evidential status of data gathered through extended processes—including its utility as justification or warrant—do not seem to be weakened by virtue of being extended, but instead are often strengthened because of it. Indeed, it is often precisely by virtue of this extendedness that scientific evidence grounds knowledge claims, which individuals may subsequently ascribe to themselves. The functional equivalence between machine-based gathering, filtering, and processing of data and human interpretation and assessment is the crucial factor in deciding whether evidence has been gathered, rather than the distinction between intra- and extracranial processes or individual and social processes. To prioritize biological processes here, and to assert the superiority of human cognitive capacities seems both arbitrary and unwarranted with respect to gathering evidence, and ultimately would lead to an unattractive skepticism about many of the methods used in science to gather evidence. In other words, conceiving of scientific evidence as ‘impersonal’ not only better captures the character of evidence-gathering in practice, but also makes sense of a large amount of evidence-gathering that ‘personal’ accounts fail to either acknowledge or accurately describe. Whilst we suggest it is likely that all internally-distributed evidence-gathering processes are merely contingently internal processes, a significant number of externally-distributed evidence-gathering processes are necessarily externally-distributed. Some evidence can only be gathered by extended epistemic agents. (shrink)

Considerations of nonhuman animal moral agency typically base their reasoning and (very often negative) verdict on a capacity‐focused approach to moral agency. According to this approach, an entity is a moral agent if it has certain intrapersonal features or capacities, typically in terms of conscious reflection and deliberation. According to a practice‐focused notion of moral agency, however, an entity is a moral agent in virtue of being a participant of a moral responsibility practice (MRP). I argue that a (...) practice‐focused approach to moral agency, combined with empirical evidence from research on canid social play and cognition, with support from The Function Argument, makes the notion of nonhuman animal moral agency more likely than usually indicated. However, the support is not absolute, as the practice‐focused approach itself may be put into question. I describe how this objection prompts us to critically assess any empirical, metaethical, or normative assumptions on these matters. These questions, in turn, raise a number of further questions of how we should conceive of, use, and evaluate whatever standards of moral agency we adopt. (shrink)

While children’s interaction with digital technologies is a matter of interest around the world, evidence based on nationally representative data about how integrated these tools are in children’s everyday life is still limited in New Zealand. This research report presents findings from a study that explores children’s internet access, online skills, practices, and opportunities. This report is part of Netsafe’s research project Ngā taiohi matihiko o Aotearoa - New Zealand Kids Online, and our first publication as a member (...) of Global Kids Online. Generating insightful, reliable evidence about New Zealand children’s online experiences is vital to develop adequate support that reflects children’s experiences and needs. This, in turn, will help them to manage online risks and potential harm from behaviours such as cyberbullying, harassment, and other forms of abuse and intimidation. (shrink)

In the first part of this investigation we highlight two, seemingly irreconcilable, beliefs that suggest an impending crisis in the teaching, research, and practice of—primarily state-supported—mathematics: (a) the belief, with increasing, essentially faith-based, conviction and authority amongst academics that first-order Set Theory can be treated as the lingua franca of mathematics, since its theorems—even if unfalsifiable—can be treated as ‘knowledge’ because they are finite proof sequences which are entailed finitarily by self-evidently Justified True Beliefs; and (b) the slowly (...) emerging, but powerfully rooted in economic imperatives, belief that only those Justified True Beliefs can be treated as ‘knowledge’ which are, further, categorically communicable as Factually Grounded Beliefs—hence as comprehensible pre-formal ‘mathematical truths’—by any intelligence that lays claims to a mathematical lingua franca. We argue that this seeming irreconcilability merely reflects a widening chasm between an increasing under-estimation of the value to society of ‘semantic arithmetical truth’, and an increasing over-estimation of the value to society of ‘syntactic set-theoretical provability’; a chasm which must be narrowed and bridged explicitly. We thus proffer a Complementarity Thesis which seeks to recognize that mathematical ‘provability’ and mathematical ‘truth’ need to be interdependent and complementary, ‘evidence-based’, assignments-by-convention to the formulas of a formal mathematical language; where (a) the goal of mathematical ‘proofs’ may be viewed as seeking to ensure that any mathematical language intended to formally represent our pre-formal conceptual metaphors and their inter-relatedness is unambiguous, and free from contradiction; whilst (b) the goal of mathematical ‘truths’ must be viewed as seeking to ensure that any such representation does, indeed, uniquely identify and adequately represent such metaphors and their inter-relatedness. Our thesis is that, by universally ignoring the need to introduce goal (b) in our curriculum, the teaching of, and research in, mathematics at the post-graduate level cannnot justify its value to society beyond the mere intellectual stimulation of individual minds. In the second part we appeal to some recent—and hitherto unsuspected—unarguably constructive Tarskian interpretations, of the first-order Peano Arithmetic PA, which establish PA as both finitarily consistent, and categorical. Since we also show that the second order subsystem ACA0 of Peano Arithmetic and PA cannot both be assumed provably consistent, we conclude that there can be no mathematical, or meta-mathematical, proof of consistency for Set Theory. Hence the theorems of any Set Theory are not sufficient for distinguishing between (i) what we can believe to be a ‘mathematical truth’; (ii) what we can evidence as a ‘mathematical truth’; and (iii) what we ought not to believe is a ‘mathematical truth’; whilst the theorems of the first-order Peano Arithmetic PA are sufficient for distinguishing between (i), (ii) and (iii). We conclude from this that the holy grail of mathematics ought to be ‘arithmetical truth’, not ‘set-theoretical proof’. (shrink)

Innovative modes of collaboration between archaeologists and Indigenous communities are taking shape in a great many contexts, in the process transforming conventional research practice. While critics object that these partnerships cannot but compromise the objectivity of archaeological science, many of the archaeologists involved argue that their research is substantially enriched by them. I counter objections raised by internal critics and crystalized in philosophical terms by Boghossian, disentangling several different kinds of pluralism evident in these projects and offering an analysis (...) of why they are epistemically productive when they succeed. My central thesis is that they illustrate the virtues of epistemic inclusion central to proceduralist accounts of objectivity, but I draw on the resources of feminist standpoint theory to motivate the extension of these social -cognitive norms beyond the confines of the scientific community. (shrink)

Using placebos in day-to-day practice is an ethical problem. This paper summarises the available epidemiological evidence to support this difficult decision. Based on these data we propose to differentiate between placebo and “knowledge framing”. While the use of placebo should be confined to experimental settings in clinical trials, knowledge framing — which is only conceptually different from placebo — is a desired, expected and necessary component of any doctor-patient encounter. Examples from daily practice demonstrate both, the (...) need to investigate the effects of knowledge framing and its impact on ethical, medical, economical and legal decisions. (shrink)

Plausible probabilistic accounts of evidential support entail that every true proposition is evidence for itself. This paper defends this surprising principle against a series of recent objections from Jessica Brown. Specifically, the paper argues that: (i) explanationist accounts of evidential support convergently entail that every true proposition is self-evident, and (ii) it is often felicitous to cite a true proposition as evidence for itself, just not under that description. The paper also develops an objection involving the apparent impossibility (...) of believing P on the evidential basis of P itself, but gives a reason not to be too worried about this objection. Establishing that every true proposition is self-evident saves probabilistic accounts of evidential support from absurdity, paves the way for a non-sceptical infallibilist theory of knowledge and has distinctive practical consequences. (shrink)

We propose a qualitatively new kind of governance for the emerging need to efficiently guide the densely interconnected, ever more complex world development, which is based on explicit and openly presented problem solutions and their interactive implementation practice within the versatile, but unified professional analysis of complex real-world dynamics, involving both the powerful central units and the attached creative worldwide network of professional representatives. We provide fundamental and rigorous scientific arguments in favour of introduction of just that kind (...) of governance at the modern development stage, after the complexity threshold in the real world dynamics evolution (sometimes intuitively designated as "globalisation"), where the traditional spontaneous-empirical kind of development and related administrative governance lose dramatically and inevitably their efficiency and the necessity of explicit consistent understanding and guidance of complex real-world dynamics becomes evident. (shrink)

Editors' introduction to 3rd thematic issue on philosophy of medicine.

Community-based participatory research (CBPR) and community engaged research (CEnR) are key to promoting community and patient engagement in actionable evidence-based strategies to improve research for health equity. Rapid growth of CBPR/CEnR research projects have led to the broad adoption of partnering principles in community-academic partnerships and among some health and academic organizations. Yet, transformation of principles into best practices that foster trust, shared power, and equity outcomes still remain fragmented, are dependent on individuals with long term projects, (...) or are non-existent. This paper describes how we designed our Engage for Equity PLUS intervention that leverages the leadership and membership of champion teams (including community-engaged faculty, community partners and patient advocates) to improve organizational policies and practices to support equity based CBPR/CEnR. (shrink)

While children’s experiences of online risks and harm is a growing area of research in New Zealand, public discussion on the matter has largely been informed by mainstream media’s fixation on the dangers of technology. At best, debate on risks online has relied on overseas evidence. However, insights reflecting the New Zealand context and based on representative data are still needed to guide policy discussion, create awareness, and inform the implementation of prevention and support programmes for children. This (...) research report presents findings from a quantitative study regarding different aspects related to risks and online safety. It looks at the online experiences that children find bothersome and upsetting and explores the hurtful behaviours they encounter or engage in, both online and in person. Evidence regarding exposure to different types of potentially harmful online content is also presented. Another relevant contribution is the insights related to excessive internet use.The findings presented in this report are based on data from 2,061 New Zealand children aged 9-17. We hope the findings will contribute to the development of policies, practices and services designed to support New Zealand children to safely take advantage of the opportunities available to them online. (shrink)

In a recent paper, Levy, Gadd, Kerridge, and Komesaroff attempt to defend the ethicality of homeopathy by attacking the utilitarian ethical framework as a basis for medical ethics and by introducing a distinction between evidence-based medicine and modern science. This paper demonstrates that their argumentation is not only insufficient to achieve that goal but also incorrect. Utilitarianism is not required to show that homeopathic practice is unethical; indeed, any normative basis of medical ethics will make it unethical, (...) as a defence of homeopathic practice requires the rejection of modern natural sciences, which are an integral part of medical ethics systems. This paper also points out that evidence-based medicine lies at the very core of modern science. Particular arguments made by Levy et al. within the principlist medical ethics normative system are also shown to be wrong. (shrink)

It is widely held that our beliefs can be epistemically faultless despite being morally flawed. Theories of moral encroachment challenge this, holding that moral considerations bear on the epistemic status of our attitudes. According to attitude-based theories of moral encroachment, morality encroaches upon the epistemic standing of our attitudes on the grounds that we can morally injure others with our epistemic practices. In this paper, I aim to show that current attitude-based theories have asymmetric mechanisms: moral features only (...) make it harder for attitudes to secure epistemic merits. I argue that, if attitudes can incur moral injury, failure to form attitudes can too. To make sense of this, I contend, attitude-based accounts require symmetric mechanisms, allowing that moral considerations make it both harder and easier for attitudes to attain epistemic merits. I maintain that, once we recognize this, attitude-based encroachment views must soon concede that they sometimes demand we believe against the evidence. (shrink)

This theoretical paper explores the application of Hegelian inferentialism combined with contemporary quantitative methods to enhance decision-making in healthcare leadership. It proposes a novel conceptual framework that integrates Hegel’s inferentialism with Bayesian analysis and epistemic justice indices to offer a new approach for understanding complex decision processes in healthcare settings. The paper develops theoretical constructs such as the Decision Quality Index (DQI) and the Epistemic Justice Quotient (EJQ), which aim to quantitatively assess leadership effectiveness and ethical considerations in decision-making processes. (...) The discussion includes mathematical proofs for these proposed indices and examines the potential practical implications of this integrated approach, emphasizing its theoretical potential to improve healthcare leadership through more inclusive and evidence-based practices. This work provides a conceptual foundation for future empirical research in healthcare leadership and decision-making. (shrink)

Background: Smart sensors have been developed as diagnostic tools for rehabilitation to cover an increasing number of geriatric patients. They promise to enable an objective assessment of complex movement patterns. -/- Objective: This research aimed to identify and analyze the conflicting ethical values associated with smart sensors in geriatric rehabilitation and provide ethical guidance on the best use of smart sensors to all stakeholders, including technology developers, health professionals, patients, and health authorities. -/- Methods: On the basis of a systematic (...) literature search of the scientific databases PubMed and ScienceDirect, we conducted a qualitative document analysis to identify evidence-based practical implications of ethical relevance. We included 33 articles in the analysis. The practical implications were extracted inductively. Finally, we carried out an ethical analysis based on the 4 principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. The results are reported in categories based on these 4 principles. -/- Results: We identified 8 conflicting aims for using smart sensors. Gains in autonomy come at the cost of patient privacy. Smart sensors at home increase the independence of patients but may reduce social interactions. Independent measurements performed by patients may result in lower diagnostic accuracy. Although smart sensors could provide cost-effective and high-quality diagnostics for most patients, minorities could end up with suboptimal treatment owing to their underrepresentation in training data and studies. This could lead to algorithmic biases that would not be recognized by medical professionals when treating patients. -/- Conclusions: The application of smart sensors has the potential to improve the rehabilitation of geriatric patients in several ways. It is important that patients do not have to choose between autonomy and privacy and are well informed about the insights that can be gained from the data. Smart sensors should support and not replace interactions with medical professionals. Patients and medical professionals should be educated about the correct application and the limitations of smart sensors. Smart sensors should include an adequate representation of minorities in their training data and should be covered by health insurance to guarantee fair access. (shrink)