Continuing the evidence‐based health care debate in 2006. The progress and price of EBM

摘要

In Volume 12, Part 3 of the Journal of Evaluation in Clinical Practice, we committed to the international medical literature a deposit of considerable scholarship on the evolution of the evidence-based medicine (EBM) debate and on the nature of evidence for clinical practice (Borry et al. 2006; Couto 2006; Dewhurst 2006; Djulbegovic 2006; Dobre et al. 2006; Geanellos & Wilson 2006; Gupta 2006; Leung & Johnston 2006; Lipman 2006; Loughlin 2006a,b; Kemm 2006; Maier 2006; Malterud 2006; Miettinen 2006; Miles et al. 2006, Porta 2006; Roddy et al. 2006; Sandars & Heller 2006; Stevenson et al. 2006; Tanenbaum 2006; Tonelli 2006; Upshur 2006a; Upton & Upton 2006). In the current issue, Volume 12, Part 4, we publish those articles that for practical reasons of space could not be included in Volume 12, Part 3, but where editorially judged urgency of publication precludes their being delayed until the 10th thematic edition on EBM in early 2007. This Part II of the ninth thematic edition on the progress of the EBM movement therefore augments Part I (Miles et al. 2006) and the previous eight (see Miles et al. 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004). This opus having now been achieved, we again invite contributions to the 10th thematic edition for publication in 2007. Recurrent themes in the contributions to this and previous thematic editions concern the apparent failure on the part of many advocates of EBM to explain and justify their most fundamental assumptions – about the nature of science, rationality and evidence itself, and how these key concepts may be put to work in the formulation of any defensible view about proper medical practice. We believe that it is necessary for any intellectually serious analysis of the phenomena associated with EBM to explore and, if possible, attempt an explanation of this surprising omission on the part of defenders of so influential and pervasive a doctrine. Even the attempt to characterize EBM as a ‘doctrine’ may be challenged (Lipman 2006), but this difficulty in finding any consensus about what EBM is can itself be seen as one of the more puzzling of the phenomena crying out for explanation (Loughlin 2006c). Any author attempting such an analysis must be driven to consider not only contributions to the EBM literature, but also the processes that produce that literature – he must effectively take the debate itself as the object of his study and ask causal questions about how it comes to take the form it does. What forces drive the debate about EBM? What assumptions or interests give rise to or frame that debate? Why are some questions regarded as apparently unworthy of serious consideration and banished to the margins of debate by organs that (by general consensus) may be regarded as defining the ‘mainstream’ in medical discourse? To address these questions, it will be necessary to consider the processes which affect publication practices in certain influential medical journals. In this context, it is therefore appropriate for us to discuss openly the processes which led to the publication of the first two papers in the current issue. One of these (Upshur et al. 2006) poses in our view a necessary and, it would certainly seem, overdue question: ‘Can scholarly journals be in financial conflict of interest situations?’ Readers might imagine such a question to be purely theoretical, even somewhat ludicrous, given the level of trust built up over long years by periodicals of international stature. Recent events at the Journal of the American Medical Association, at the Canadian Medical Association Journal and elsewhere begin, however, to make questions relating to conflicts of interest in general, more than topical and essential to pose. In order to explain the Editor’s rationale in commissioning and publishing such a paper, we would invite the reader to study, firstly, the juxtaposed paper contributed by Buetow et al. (2006). It is now possible to document here that the substance of that parti