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)

The public rejection of scientific claims is widely recognized by scientific and governmental institutions to be threatening to modern democratic societies. Intense conflict between science and the public over diverse health and environmental issues have invited speculation by concerned officials regarding both the source of and the solution to the problem of public resistance towards scientific and policy positions on such hot-button issues as global warming, genetically modified crops, environmental toxins, and nuclear waste disposal. The London Royal Society’s influential report (...) “Public Understanding of Science”, which spearheaded the now-thriving area of science... (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)

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

With twentieth- and twenty-first-century philosophy of science’s unfolding acceptance of the nature of scientific inquiry being value-laden, the persistent worry has been that there are no means for legitimate negotiation of the social or non-epistemic values that enter into science. The rejection of the value-free ideal in science has thereby been coupled with the spectres of indiscriminate relativism and bias in scientific inquiry. I challenge this view in the context of recently expressed concerns regarding Canada's death of evidence controversy. The (...) worry, raised by Stathis Psillos, is that as constructivist accounts of science demoted the previously secure status of evidence for drawing justified conclusions in science, we were left with no rational delineation between the right and wrong values for science. The implication for the death of evidence controversy is that we may have no rational grounds for claiming that the Canadian Government is wrong to interfere with scientific enterprise. But he does offer another avenue for reaching the conclusion that the wrong social values are directing the current stifling of some sectors of Canadian science. Psillos draws from standpoint epistemologies to devise a salient defence of ‘valuing evidence’ as a universalizable social value. That is, government bodies ought to enable scientific research via adequate funding as well as political non-interference. In this paper, I counter that non-epistemic values can be rationally evaluated and that standpoint epistemology’s universalizable standpoint provides an inadequate framework for negotiating social values in science. Regarding, I draw from the evidence-based medicine debate in philosophy of medicine and from feminist empiricist investigations into the science–values relationship in order to make the argument for empirically driven value arbitration. If social values can be rationally chosen in the context of justification, then we can have grounds for charging the Canadian leadership with being ‘at war with science’. I further argue that my recommended empiricist methodology is preferable to Psillos’s search for universalizable perspectives for negotiating social values in science because the latter method permits little more than the trivial conclusion that evidence is valuable to science. (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)

The once animated efforts in medical phenomenology to integrate the art and science of medicine (or to humanize scientific medicine) have fallen out of philosophical fashion. Yet the current competing medical discourses of evidencebased medicine and patient-centered care suggest that this theoretical endeavor requires renewed attention. In this paper, I attempt to enliven the debate by discussing theoretical weaknesses in the way the “lived body” has operated in the medical phenomenology literature—the problem of the absent body—and highlight how evidence-based medicine (...) has refigured medical phenomenology’s historical nemesis, “biomedicine.” What we now need is a phenomenology of the embodied subject in the age of evidence-based medicine. (shrink)

The precondition of any feminist politics – a usable category of ‘woman’ – has proved to be difficult to construct, even proposed to be impossible, given the ‘problem of exclusion’. This is the inevitable exclusion of at least some women, as their lives or experiences do not fit into the necessary and sufficient condition(s) that denotes group membership. In this paper, I propose that the problem of exclusion arises not because of inappropriate category membership criteria, but because of the presumption (...) that categories can only be organised by identity relations or shared properties among their members. This criterion of sameness as well as the characterisation of this exclusion as essentialism attests to a metaphysics that is not conducive to resistance and liberatory projects. Following a strain of hybrid thinking in feminist and post-colonial theory, I outline an alternative pluralist logic that confronts oppressive binaries that impede theory work in gender, sexuality, and race theory, and limit political action and resistance. The problem of exclusion is neither irresolvable nor is it essentialism. Instead it is a denial of subjectivity due to pseudodualistic self/Other dichotomies that can be resisted by adopting a new categorial logic. While this paper focuses on the specific problem of formulating a category of ‘woman’, it has implications for other areas of gender, critical race, and postcolonial theory. Rather than working toward an inclusive category founded on sameness, theorists need to develop independent and positive categories grounded in difference. Our current categorial logic does not permit such a project, and therefore a new metaphysics must be adopted. (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)

In Clough’s reply paper to me (http://wp.me/p1Bfg0-1aN), she laments how feminist calls for diversity within scientific communities are inadvertently sidelined by our shared feminist empiricist prescriptions. She offers a novel justification for diversity within epistemic communities and challenges me to accept this addendum to my prior prescriptions for biomedical research communities (Goldenberg 2013) on the grounds that they are consistent with the epistemic commitments that I already endorse. In this response, I evaluate and accept her challenge.

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)

In accordance with the critical women’s health literature recounting the ways that women are encouraged to submit themselves to various sorts of health “imperatives”, I investigate the messages tacitly conveyed to women in “campaigns for the cure” and breast cancer awareness efforts, which, I argue, overemphasizes a “positive attitude”, healthy lifestyle, and cure rather than prevention of this life-threatening disease. I challenge that the message of hope pervading breast cancer discourse silences the despair felt by many women, furthers a tacit (...) blaming for disease infliction via a rhetoric of personal responsibility, underemphasizes other cogent health determinants like environmental toxicity, and undermines legitimate critiques of current biomedical practices like widespread mammography. While finding a cure for breast cancer is a laudable and worthwhile healthcare goal that can understandably be shared by women’s health activists, corporate sponsors, and the medical community, this paper resists the current formation of campaigns for the cure and “pink ribbon activism” in general. (shrink)