Evidence based medicine: pragmatic, objective, or authoritarian?

In the spring issue of Perspectives in Biology and Medicine, Maya Goldenberg dissects the contradictions of evidence-based medicine (EBM). (I found the article through philpapers.org, which I didn't know about before.) On the one hand, EBM's commitments to pragmatism
are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.

On the other hand, EBM lays claim to the marble statuary of objectivism, which is problematic.
[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.

But EBM's hierarchy of evidence, with the randomized controlled trial (RCT) at the top, rests on shaky grounds itself:

From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.

EBM's certainty in its own objectivism leads to a blindness: "[t]he hierarchy of evidence is the point at which evidence-based methodology can be charged with authoritarianism." There are some juicy accusations in this article, which I didn't know before, about the financial relationship between EBM "producers" and the editorial boards of certain journals, e.g., BMJ.

However, in her conclusions, Goldenberg is fittingly pragmatic:

In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.

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