Medicina

Journal of Evaluation in Clinical Practice ISSN 1356-1294

Ethics and EBM: acknowledging bias, accepting difference and embracing politics
jep_1412 365..373

Ian Kerridge BA BMed(Hons) MPhil(Cantab) FRACP FRCPA
Associate Professor, Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia

Keywords difference, ethics, evidence-basedmedicine, ideology, judgement, politics Correspondence Associate Professor Ian Kerridge Centre for Values, Ethics and the Law in Medicine University of Sydney Sydney, NSW Australia E-mail: kerridge@med.usyd.edu.au Accepted for publication: 17 January 2010 doi:10.1111/j.1365-2753.2010.01412.x

Abstract
Evidence-based medicine (EBM) has been effective because it confers both epistemic and moralauthority, promising that both individual patient care and public health interventions are effective, safe and efficient, that these decisions and standards can be determined (and therefore judged) in a transparent manner and that this form of decision making is reliable, objective and value-free. The problem is that EBM refers to particular, ideologically and philosophically specific concepts ofevidence, medicine and the relationship between them. The analysis of the ‘ethics’ of EBM, therefore, requires not only a critique of its philosophical naïvety and its attachment to modernism and positivism, but a critique of its social, cultural and political implications.

Over the past decade and a half since the inception of evidencebased medicine (EBM), evidence-based principles and practiceshave come to have a profound influence on the setting of biomedical research priorities, the generation of public health and clinical practice guidelines and the implementation of these guidelines in practice. At present, all funders and publishers of biomedical research and all policy makers and practitioners of clinical and public health medicine are expected to understand and implement theprinciples of EBM. Evidence-based medicine (which has variously been described as a paradigm, a methodology, a practice, a system of regulation or audit and a political movement) has been so effective because it has and confers both epistemic and moral authority. It promises that both individual patient care and public health interventions are effective, safe and efficient, that these decisions andstandards can be determined (and therefore judged) in a transparent manner and that this form of decision making is reliable, objective and value-free. There is not and cannot be anything inherently wrong with medicine that incorporates or is based on evidence. On the contrary, that is what we should all be striving for all the time. The problem is that ‘evidence-based medicine’ is different from‘evidence’ ‘based’ ‘medicine’, in that the term refers to particular, ideologically and philosophically specific concepts of evidence, medicine and the relationship between them. The analysis of the ‘ethics’ of EBM, therefore, requires not only a critique of its

philosophical naïvety and its attachment to modernism and positivism, but a critique of its social, cultural and political implications.What is EBM?
One of the difficulties of examining EBM in any substantive way is that it takes many forms and is emergent, like many concepts promulgated through different discourse communities [1]. Evidence-based medicine first emerged from the work of a group of professors of epidemiology, biostatistics and medical informatics at McMaster University in Canada [2]. The initial formulation of EBMwas very clear: it was that medicine should be based upon the ‘conscientious, explicit and judicious use of current best evidence’ [3] and that ‘best evidence’ should be identified using ‘epidemiological and biostatistical ways of thinking.’ [4] Through the methods it privileged, EBM distinguished itself from traditional medicine, which relied on unsystematic observations, medical intuition,...