University of Cambridge, UK
I would like to thank psicoevidencias the possibility of writing this editorial. 'The evidence-based medicine' (EBM) is an area where I have worked for years. The MBE but goodwill and seemingly innocent way has become a trap that destroys confidence and needs a serious review before being adopted by developing countries. The damage caused by the MBE to the practice of psychiatry in the developing world could be irreparable.
Since the MBE came on the scene, its concept has been analyzed. Although unreservedly adopted by those who believe that to be scientific, and therefore ethics, clinical practice, should be governed exclusively by clinical guidelines, from the etymological and semantic perspectives the study shows that significant "evidence" refers to an ambiguous meaning, turning it into a confused and confusing fashion.
This criticism is useful but not sufficient. The Achilles heel of the MBE is more profound and pervasive, linked to the concept of science as information flows and associated with the subculture of trade that has been the engine from the beginning. Not only does the MEB adversely affect the quality of the relationship clinician-patient but reduces it to a tactic neocapitalist to do business.
The roots of the problem
There is little 'evidence' available to demonstrate that medicine based on the principles of evidence has significant advantages over the previous system which seeks to replace that call based on medical expertise, authority, and the placebo effect generated within the clinician-patient relationship. After all, the "evidence" could only be obtained with a "trial" to compare the two systems and most scholars believe that this test would be virtually impossible performing. We face a paradoxical situation in which clinicians are asked to accept a radical change in the way it develops its work (eg, leaving the wise counsel of his own experience and follow the dictates of impersonal statistics) . Thus the current basis of "evidence" are nothing other than what they say statisticians, theorists, managers, companies (like high school Cochrane) and capital investors, who are precisely those who say where the money goes .
The truth about the term 'evidence'
Among previous criticism is the fact that the multiple meanings the term 'evidence' to make something complex SEM work. His studio is like a package that must be sliding. In English 'evidence' has two main meanings. Use 'ontological' (the oldest) refers to 'Energeia', one of the Greek terms used to refer to 'Truth' and 'objectivity'. 'Energeia' referred to situations where an object is presented in full and obvious to the observer's perception. Given the metaphysics of the predominant perception at the time, this meant a contact 'physical' between the object and the person, being primary evidence and not influenced by the existence of the object.
The second meaning in English is epistemological and relates to the 'reasons to believe' in something. That is, what actually constitutes 'have grounds for saying this and that ...', has never been part of the 'definition' of evidence. The reason is obvious: through history, the causes have been negotiated and have relied on the epistemological fashion of the time. So, in relation to its etymology is not that the term "evidence" is confusing, but its proper application requires an epistemic apparatus whose specification varies over the years.
This is true in some contexts (eg a court) where the epistemological use is based on a putative ontological meaning (the fact that a witness see 'X' performing an action can be taken to the field of evidence and believe that 'X' is a murderer "). In the case of the MBE that is not assumed. The 'necessary reasons to believe that T treatment works (epistemological use) is not based on any objective view (ontological meaning) but in a numerical trick. For example, when reaching a statistical significance level (say 5%) that was chosen arbitrarily, this becomes an `object 'defined as real or true.
The Achilles heel of the MEB
To cope with these difficulties is necessary to have enough information about the history of the SEM. Began in the 1920's when the old definition of 'scientific objectivity' (based on the philosophical led by Bacon in the seventeenth century and the positivism of Comte in the nineteenth I) was in crisis. Both strands were based on different forms of inductivism and experimentalism, ie the two argue that nature can be questioned or even tricked into giving answers - Galileo, Newton, and the movement of the picture in full support this trend. Finally, the 1840, John Stuart Mill finalized all these aspects in an inductive text that listed the laws of logic which could be obtained from general knowledge of the study of a sample. In fact, what Mill did was to redefine the way the mind of any expert (either doctor, plumber, lawyer or engineer) works to remove 'general information' of their experience.
late nineteenth century, Mill developed everything began to be attacked. For the new philosophy of science (developed by Frege, Russell, etc.) Idea that knowledge could be based on the `experience 'personal (psychological concept) was impossible, instead proposing that logic and mathematics were the new foundation of knowledge. This marked the end of 'psychologism' and positivism of Comte and led directly to the development of logical positivism of the Vienna Circle, which supported the idea that a conclusion is true only when it can be 'verified', ie the true value is on the set of specific operations that allow such verification.
soon became clear that the 'systematic operational checks' were impassable and forced to make changes to make them feasible through softer definitions of `truth', 'test' and `knowledge '. A new opportunity arose with the development of statistical techniques, most of which were developed in England by such men as Fisher, Pearson, and Kendall. What came to be called 'probabilistic revolution' describes the import of probabilistic thinking in biology and social sciences. The change came supported by the Newtonian paradigm crisis where time and space were considered fixed and objective dimensions. From the work of Einstein, Heisenberg and Gödel's definition of reality needed to be corrected or completed by the viewer's perspective or the information was not included in those definitions. At the end of this period the 'objectivity' and 'truth' had been reclassified as probabilistic concepts' captured through statistical analysis and determined by an (arbitrary) level of 'significance' statistics.
The probability reaches
Psychiatry probabilistic proposals were quickly accepted by all without appreciating the important epistemological and ethical implications that would have this change in the scientific Weltanschauung. An immediate consequence of this change was that the rights and duties fundamental epistemological (the sense of responsibility that all 'scientific' should have in relation to their narratives) were canceled. In some ways, knowledge was now determined by impersonal mathematical mechanisms, was neutral, and science was the only generator of knowledge. Personal experience and wisdom, the noble concept of Sophia was obviated by being seen as a source of bias and distortion of the truth. First the probability
came to the basic natural sciences, and later reached the medical and social sciences and humanities since the Second World War. Psychiatry is resisted until the 60's but through the Trojan horse of drug clinical trials were allowed to enter the statistical analysis. I remember vividly that this change happened while I was Assistant Professor Max Hamilton of the University of Leeds, the man who introduced medical statistics in psychiatry. Initially, the analysis was only used for testing drugs and most psychiatrists were wise enough to believe that once the test results were obtained, Sophia (wisdom) and Empeiria (experience) took the helm and the psychiatrist could negotiate freely in the privacy of the doctor-patient what was best for that person.
The birth of the MEB
But always happens, greed won. Research groups and institutions which were originally created to collect information on cancer clinical trials believed that their activity could be extended to all areas of medicine including psychiatry. To do this we needed a new 'philosophical justification. " Meta-analysis, a statistical technique faint old was chosen as the best candidate to be the 'ideal pattern' and all mathematical and statistical weakness was minimized when compared to his amazing ability to synthesize. The magic word 'evidence' was dusted off and imported into the medicine a shocking disregard for their meaning and utility, and medicine-based 'evidence' was born as a conceptual post-hoc justification for the new business of creating and selling information clinic.
not surprising that the pharmaceutical industry to support these moves because they soon realized that the drugs' pasar'el could acquire meta-analysis review of a new legal and ethical strength, particularly if governments were persuaded on the issue of prescribing guidelines . They saw clearly that such guidelines in practice would destroy the therapeutic spontaneity of psychiatry and change the ancient art of prescribing, which happen to be creative and flexible mechanical and uniform. Finally not even require psychiatric prescribers were medically qualified. Summarizing
To summarize, the nonsense, and the damage caused by the MBE is not derived from the semantic ambiguity of the word in question or the fact that the court of philosophers who built not observe its historical peculiarities. Your problem stems from a much deeper epistemological perversion resulting from the reification of the fact prescribe and care for people with a mental disorder. This identification is closely related to the demands a neo-capitalist economy that needs open new markets and create new consumerist needs.
First, it is a perversion epistemological proposes a vision of medical activities as inappropriate and harmful. This view is related to verification, and outdated, and that is an epistemological approach abandoned even by physics, mother of the basic natural sciences. Since no one knows almost nothing about the causes of mental disorder, the idea that it is possible to create an evaluation system based on speculative etiologies is ridiculous, dangerous and unethical. Throughout history, all proposed treatments in psychiatry seem to work according to the law of thirds Black, (one-third recover, a third recover partially and one is not recovered, a good percentage of 66% recovery rate - the same that we get today) and still know little about the nature and role of the placebo effect in these results. It would be irresponsible to hide all these doubts behind the meta-analysis and related techniques have low sensitivity for detecting mathematical details in the lower levels (eg at the level where people actually take the pills).
is also a parody epistemological psychiatrists are asked to accept the SEM without further evidence that blackmail moral created by those who claim that mathematics is the highest form of science and therefore it is mathematically demonstrable `'than anything else. No advocate of EBM has never explained why we have designed a large-scale trial to show that prescribe and make decisions based on the SEM is significantly better than making decisions based on knowledge and experience of physicians.
is a moral perversion to quantify, evaluate the costs and govern the prescription (which should be considered as a minor component in the patient-doctor relationship) the need to implement a modified SEM complete the essence of that relationship including negotiating deep emotional and elusive placebo response containing inter-subjective elements. In this context 'reify' means to turn human relationships in an inanimate object or thing desinvistiendola all dynamic, personal value and meaning. Once these are reified human relations can not explain the change for themselves, and any change that is measured by `prospective 'has to be attributed to the` active ingredient' call it the drug in question. That the changes are well handled by the fact that drug trials are 'controlled' and are 'double ciego'etc, etc, is not enough and that interactions between dynamic factors and the effect of the chemical may occur at a level not aware and remain beyond the scope of controlled design.
can even ensure that the `reificación'no is the product of wrong-doing of a few philosophers of fashion. From the classic writings of Marx and Lukacs is known that these changes come from the depths of the heart of the economic system prevalent in the Western world. See health as another commodity to be bought and sold is part of the process. It has been cleverly sold to the public. We have the right to choose when and where to buy health with our own money, as a witness to this is the current U.S. debate to try to create a national health system minimally free and general. The language in which health services are currently sold mimics the language of the supermarkets. There are no longer patients but buyers' health ', doctors' sell health and therefore as a pair of shoes products should come under strict regulations and perfect.
The illusion of having a supermarket of health has been destroyed forever the doctor-patient relationship. It has become a business contract subject to all the legal trappings of a market place and the press and Internet have ensured that the 'consumers' health aware of their rights to achieve perfect health. Assuming that the clinic will always be imperfect art, in parallel we have developed a defense industry to protect doctors who sell defective products thereby increasing the bloated spending that generates health. The MBE thrives in this context because it sells 'evidence' to the lawyers working for both consumers and sellers of health.
And in the midst of this madness, where everyone wants to do business the old doctor-patient relationship, and patient suffering, are gone forever. That is really what is wrong with the SEM.
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