Perspectives in Biology and Medicine

William Harvey, the 17th-century English physician and champion of Enlightenment ideals, captured the intellectual passage from medievalism to modernity with this instructive remark: “It is base to receive instructions from others’ comments without examination of the objects themselves, especially as the book of nature lies so open and is so easy of consultation” (quoted in Rawlins 2008, p. 1). Today, the Harveian appeal to empirical evidence and the critical examination of conventional practices still resonates among health researchers and practitioners; however, the alleged ease of access to the empirical world has proven more constrained than Harvey suggested.

The introduction of evidence-based medicine (EBM) to the medical world initially reflected an anti-authoritarian spirit similar to Harvey’s. In the Evidence Based Medicine Working Group’s programmatic 1992 JAMA article, “Evidence Based Medicine: A New Way of Teaching the Practice of Medicine,” EBM was framed as “the way of the future”: a radical new framework for clinical medicine, where junior clinicians would eschew the advice of senior colleagues and instead directly consult the research literature in order to inform [End Page 164] their clinical decision making (EBMWG 1992). Following the precepts of EBM was supposed to improve clinical practice and, by extension, patient care.

Over the past 17 years, EBM has come to influence all areas of clinical practice. In addition, it has influenced the development of institutional and professional guidelines in areas from nursing to health promotion and moved beyond medicine to other disciplines. But direct examination of “the objects themselves,” or at least the results of empirical research gathered by others, soon proved to be too burdensome a task for busy clinicians. The sheer volume of available medical research made EBM’s initial effort to have the next generation of physicians reading and critically assessing the medical literature seem impractical. Useful time-saving techniques were devised, most notably clinical summaries and protocols, which were created and proliferated by an impressive international consortium of research institutions (for instance, the Cochrane Collaboration). It did not take long, however, before there were so many different hierarchies, summaries, and recommendations in circulation that an official working group—cleverly named “GRADE” (Grading of Recommendations, Assessment, Development and Evaluation)—was convened in order to address this heterogeneity (GRADE 2004).

This shift toward standardized clinical summaries and guidelines indicates that EBM has diverged from its early anti-authoritarian practices. EBM now bypasses the need for critical evaluation at the level of individual physicians and instead relies on specialized experts to do much of the critical work. In addition, proponents of EBM claim that the approach is less rigidly “based” on research evidence, especially the data derived from randomized controlled trials, and is now more open to the integration of different forms of evidence. There appears to have been a slow evolution in the assumptions and practices of EBM. The question facing theoreticians and clinicians today is whether these changes have been significant, and if so whether the newest form of EBM has overcome the critiques levelled against the earlier forms. Even if it has, the newest form of EBM is in need of independent evaluation. We believe the time is right to provide this sort of thoughtful scrutiny.

The latest investigation into the assumptions and limitations of EBM proceeds in several directions and is captured by the scholarly contributions to this special issue. First, EBM’s approach to rating evidence is still open to question. In this new age of EBM, philosophical questions about the nature of evidence and its role in justifying knowledge claims, once solely the intellectual domain of epistemology and philosophy of science, have become the subject of critical discussion in a wide range of health professional journals. Sir Michael Rawlins, Chair of Britain’s National Institute for Health and Clinical Excellence (NICE), recently argued that algorithmic approaches to applying the evidence to therapeutics are misguided, because no one form of evidence will consistently trump others. Hierarchies, he explains, “attempt to replace judgement with an over-simplistic, pseudoquantitative assessment of the quality of the available evidence” [End Page 165] (Rawlins 2008, p...