Advancing an ethics of evidence: A critical appraisal of evidence-based medicine and feminist theories of evidence.

摘要

Evidence based medicine (EBM), the coveted standard of best practice in most areas of healthcare, holds the promise of systematizing clinical practice and improving patient care by making healthcare more responsive to research evidence. EBM's commitment to highly controlled experimentation and methods of statistical analysis previously used only for population-based research represents not only methodological innovation, but also a novel regard of the reliability of various forms of medical knowledge. The epistemic narrowing that results from the rigid hierarchy of evidence motivates my proposed new direction for critical analysis of EBM: an ethical analysis of the exclusionary and implicit normativity with respect to scientific knowledge in the context of EBM. By being framed as "better science", normative questions of meaning are reduced to technical questions of measure.; This mode of critique diverges from the familiar tactic among EBM critics of illustrating the untenable positivist construction of evidence underlying EBM. Advancing an "ethics of evidence" broadens the current scope of the ethics of EBM by demonstrating the ethical significance of the epistemological challenge to EBM's objectivist account of evidence and science. I also further the epistemic challenge to EBM by drawing on the work of feminist philosopher of science Sharyn Clough to promote an alternative configuration of evidence that avoids the objectivism-to-relativism slide common to postpositivist science studies. I argue that while the critics rightly challenge EBM's objectivist account of evidence, they are unable to offer a decisive alternative. Once the fallibility of empirical evidence and the underdetermination of theory are properly recognized, the critics cannot offer guidance for adjudicating between the competing subjective and interpretive filters that inescapably enter into clinical decisionmaking. Clough's critical reading of postpositivist science studies offers an intriguing explanation for this difficulty in her indictment of representationalism, which, she claims, necessarily leads critical epistemologies of science to relativism. I recast the EBM critiques in light of Clough's Davidsonian analysis, and while I reject Clough's prescribed abandonment of epistemic pursuits in favor of critical empirical science, I support her effort to reinvigorate the normativity of evidence found in objectivist epistemology without the objectivism while avoiding the relativism of evidence thought to accompany contextualist theories of knowledge.